British NHS

This article analyses the representation of the British National Health
Service (NHS) in Government communication and news media in Britain
as a crucial discursive figure of British national identity both during the
months preceding the Brexit referendum of June 2016 and in the early
months of the diffusion of the Covid-19 pandemic in 2020. We focus
on a number of issues regarding the ways in which the NHS has been
portrayed in the public arena. Both during the Brexit campaign and at the
onset of the coronavirus pandemic, the NHS was adopted as a powerful
unifying national symbol to be protected, thanks to a populist language
based on the adoption of quasi-religious tropes and mythical themes, war
metaphors, and praise for heroism. This populist language was charged
with rhetorical messages and slogans which turned the NHS into an image
of Britishness, as emerges especially from an analysis of the leading frontpage articles from the right-wing newspaper Daily Mail in the early phases of the pandemic.

In recent years, the healthcare sector has adopted the use of operational risk assessment tools to help understand the systems issues that lead to patient safety incidents. But although these problem-focused tools have improved the ability of healthcare organizations to identify hazards, they have not translated into measurable improvements in patient safety. One possible reason for this is a lack of support for the solution-focused process of risk control. This article describes a content analysis of the risk management strategies, policies, and procedures at all acute (i.e., hospital), mental health, and ambulance trusts (health service organizations) in the East of England area of the British National Health Service. The primary goal was to determine what organizational-level guidance exists to support risk control practice. A secondary goal was to examine the risk evaluation guidance provided by these trusts. With regard to risk control, we found an almost complete lack of useful guidance to promote good practice. With regard to risk evaluation, the trusts relied exclusively on risk matrices. A number of weaknesses were found in the use of this tool, especially related to the guidance for scoring an event's likelihood. We make a number of recommendations to address these concerns. The guidance assessed provides insufficient support for risk control and risk evaluation. This may present a significant barrier to the success of risk management approaches in improving patient safety.

Background
UK general practice faces a workforce crisis, with general practitioner (GP) shortages, organisational change, substantial pressures across the whole health-care system and an ageing population with increasingly complex health needs. GPs require lengthy training, so retaining the existing workforce is urgent and important.

Objectives
(1) To identify the key policies and strategies that might (i) facilitate the retention of experienced GPs in direct patient care or (ii) support the return of GPs following a career break. (2) To consider the feasibility of potentially implementing those policies and strategies.

Design
This was a comprehensive, mixed-methods study.

Setting
This study took place in primary care in England.

Participants
General practitioners registered in south-west England were surveyed. Interviews were with purposively selected GPs and primary care stakeholders. A RAND/UCLA Appropriateness Method (RAM) panel comprised GP partners and GPs working in national stakeholder organisations. Stakeholder consultations included representatives from regional and national groups.

Main outcome measures
Systematic review – factors affecting GPs’ decisions to quit and to take career breaks. Survey – proportion of GPs likely to quit, to take career breaks or to reduce hours spent in patient care within 5 years of being surveyed. Interviews – themes relating to GPs’ decision-making. RAM – a set of policies and strategies to support retention, assessed as ‘appropriate’ and ‘feasible’. Predictive risk modelling – predictive model to identify practices in south-west England at risk of workforce undersupply within 5 years. Stakeholder consultation – comments and key actions regarding implementing emergent policies and strategies from the research.

Results
Past research identified four job-related ‘push’ factors associated with leaving general practice: (1) workload, (2) job dissatisfaction, (3) work-related stress and (4) work–life balance. The survey, returned by 2248 out of 3370 GPs (67%) in the south-west of England, identified a high likelihood of quitting (37%), taking a career break (36%) or reducing hours (57%) within 5 years. Interviews highlighted three drivers of leaving general practice: (1) professional identity and value of the GP role, (2) fear and risk associated with service delivery and (3) career choices. The RAM panel deemed 24 out of 54 retention policies and strategies to be ‘appropriate’, with most also considered ‘feasible’, including identification of and targeted support for practices ‘at risk’ of workforce undersupply and the provision of formal career options for GPs wishing to undertake portfolio roles. Practices at highest risk of workforce undersupply within 5 years are those that have larger patient list sizes, employ more nurses, serve more deprived and younger populations, or have poor patient experience ratings. Actions for national organisations with an interest in workforce planning were identified. These included collection of data on the current scope of GPs’ portfolio roles, and the need for formal career pathways for key primary care professionals, such as practice managers.

Limitations
The survey, qualitative research and modelling were conducted in one UK region. The research took place within a rapidly changing policy environment, providing a challenge in informing emergent policy and practice.

Conclusions
This research identifies the basis for current concerns regarding UK GP workforce capacity, drawing on experiences in south-west England. Policies and strategies identified by expert stakeholders after considering these findings are likely to be of relevance in addressing GP retention in the UK. Collaborative, multidisciplinary research partnerships should investigate the effects of rolling out some of the policies and strategies described in this report.

Study registration
This study is registered as PROSPERO CRD42016033876 and UKCRN ID number 20700.

Funding
The National Institute for Health Research Health Services and Delivery Research programme.

We report a test of an influential theory of employee turnover: the unfolding model . We describe and critique this classificatory model, and propose both theorybased and empirical refinements. The two extant tests of the current version aussi ce modèle n'a pas pu être généralisé. Nous présentons les résultats obtenus en utilisant le "unfolding model" auprès de 352 infirmières du service de santé national du Royaume-Uni qui sont sur le départ. Contrairement aux résultats obtenus par , le modèle n'a pas permis de classer un nombre substantiel d'infirmières sur le départ et certaines hypothèses découlant de ce modèle ne reçoivent qu'une validation partielle. Ces échecs de classification ont été analysés tant quantitativement que qualitativement. Il ressort que les sujets étaient plus facilement classés si ils n'avaient aucune personne à charge et si ils décrivaient leur départ comme évitable. Bien que le "unfolding model" incorpore plus de formes de turnover que les modèles traditionnels, un échec de classification aussi systématique questionne quant à sa revendication à offrir une approche complète du turnover. Nous expliquons ces échecs par: (i) des imperfections dans la mesure principale (ii) les caractéristiques du groupe de salariés étudiés (iii) un marché du travail extrêmement difficile pour ce groupe de personnes sur le départ.

The Centre for Workforce Intelligence (CfWI) was commissioned by the Department of Health (DH) and Health Education England (HEE) to undertake an in-depth review of the GP workforce in England. This is a medium-term, strategic review looking ahead to 2030.

This report presents our preliminary findings for consultation purposes. Please note that as some data and assumptions will be updated for our final forecasts, the analysis and conclusions in our final report may differ from those presented in this report.

Emerging recommendations

We reaffirm our previous recommendation (CfWI, 2011a) that there needs to be a substantial increase in GP training phased in over several years. We consider that achieving and maintaining 3,250 GP trainees per annum is necessary to address future demand, and should be the top priority. A substantial share of this workforce increase should go towards improving support for under-doctored areas to help achieve more equal access to GP services across England.

Given the rapidly changing nature of healthcare and the inherent uncertainties about future demand, however, we also recommend there be periodic reviews of future GP workforce supply and demand every 3–5 years, supported by a stronger evidence base.

Action is also needed to improve the attractiveness of general practice as a career, including promotion among medical students (and possibly earlier). We see merit in seeking to retain the existing workforce, for example ‘retainer schemes’ – particularly in areas where GPs are under most pressure – and providing support for returners through return-to-practice schemes. The GP Task Force is reviewing these areas.

Note: The final GP report was published by CfWI in July 2014 and can be found at: www.cfwi.org.uk

Typical responses to a confrontation with failures in authority, or what Lacanians term 'the lack in the Other', involve attempts to shore it up. A patient undergoing psychoanalysis eventually faces the impossibility of doing this successfully; the Other will always be lacking. This creates a space through which she can reimagine how she might intervene in her suffering. Similarly, when coronavirus forces us to confront the brute fact of the lack in the Other at the socio-political level, we have the opportunity to discover a space for acting rather than continuing symptomatic behaviour that increasingly fails to work.

In this paper we examine why risk-based policy instruments have failed to improve the proportionality, effectiveness and legitimacy of healthcare quality regulation in the National Health Service (NHS) in England. Rather than trying to prevent all possible harms, risk-based approaches promise to rationalise and manage the inevitable limits of what regulation can hope to achieve by focusing regulatory standard-setting and enforcement activity on the highest priority risks, as determined through formal assessments of their probability and consequences. As such, risk-based approaches have been enthusiastically adopted by healthcare quality regulators over the last decade. However, by drawing on historical policy analysis and in-depth interviews with 15 high-level UK informants in 2013-5, we identify a series of practical problems in using risk-based policy instruments for defining, assessing, and ensuring compliance with healthcare quality standards. Based on our analysis, we go on to consider why, despite a succession of failures, healthcare regulators remain committed to developing and using risk-based approaches. We conclude by identifying several preconditions for successful risk-based regulation: goals must be clear and trade-offs between them amenable to agreement; regulators must be able to reliably assess the probability and consequences of adverse outcomes; regulators must have a range of enforcement tools that can be deployed in proportion to risk; and there must be political tolerance for adverse outcomes.