Workforce and Organisation of Care (old)

Communities living within remote and rural areas of Scotland face difficulties in accessing quality healthcare. One of the largest challenges in providing healthcare to such communities is the ability to recruit and retain healthcare staff. While there is some evidence that people born or brought up in remote and rural areas are more likely to want to work there, there is little evidence about how to attract in and keep people from more diverse backgrounds.

This Chief Scientist Office funded project, will use qualitative interviews to better understand the experiences and motivation of doctors with respect to remote and rural medical positions within Scotland. The findings from this qualitative phase, led by our sister Unit HSRU, will then inform the development within HERU of a discrete choice experiment to value the factors which influence career decision making in relation to remote and rural working.

HERU researchers involved in this research project: Diane Skåtun and Verity Watson

External collaborators: L. Locock, Z. Skea (Health Services Research Unit (HSRU); J. Cleland (Nanyang Technological University, Singapore); P. Wilson (Rural Health, Institute of Applied Health Sciences, University of Aberdeen); P. Murchie, R. Hollick (Institute of Applied Health Sciences, University of Aberdeen).

There is very little evidence about how business risk affects a practice’s prospects, and GP’s decisions to become or remain a practice partner or not. We aim to address this gap in the literature using primary data collection to study the business organisation of general practice.

Our main interest is how practices and partners within practices operate and organise themselves in the current system. A better understanding of how practices react to current contracts and circumstances should provide evidence to inform future changes. We will gather data on the way practice operate through semi-structured interviews with GPs who work within independent contractor practices.

HERU researchers involved in this research project: Verity Watson

External collaborators: Schulz, R. (University of Aberdeen Business School); Dickey, H. (Queens University Belfast); Murchie, P. (Academic Primary Care, University of Aberdeen); MacLeod, J. (Aberdeen City Health and Social Care Partnership

There is a perception of geographic disparity in access to general practice care. Government and local health boards can intervene and provide practices in underserved areas. Nevertheless, it is important to understand what factors influence the location choices of General Practitioners (GPs) who are independent contractors. This study analyses the factors that influence where GPs choose to locate their practice in response to spatial factors.

HERU researchers involved in this research project: Verity Watson and Attakrit Leckcivilize

External collaborators: Schulz, R. (University of Aberdeen Business School) and Videau, Y. (Université Paris-Est Créteil)

Medical training is a long-term investment for both trainees and the government. Changes in behaviour in terms of the flow through the training pathway can have severe implications for workforce planning and service provision. This project seeks to understand better the movement of medical trainees at a critical point in their training pathway where choices are made in terms of progressing to speciality training.

This project follows on from a broader PhD research project, led by Medical Education at the University of Aberdeen, entitled ‘A mixed-methods study of career-decision making in Foundation Programme doctors’.

HERU researchers involved in this research project: Diane Skåtun and Attakrit Leckcivilize

The role of pay competitiveness and nurse agency staffing

This research will provide evidence on the use of alternative staff configurations and in particular of the use of agency staff to fill gaps in staffing by health providers to resolve staff shortages.

HERU researchers involved in this research project: Diane Skåtun

External collaborators: JB Combes (Aix-Marseille Université)

Nurses form the largest group within the NHS workforce and understanding how they react to monetary incentives in terms of attracting them to jobs is a key challenge for policy makers. In this project we will consider how workforce characteristics act as a moderating or magnifying influence on behaviour in the presence of economic incentives.

HERU researchers involved in this research project: Diane Skåtun and Attakrit Leckcivilize

This project will investigate what factors doctors consider when deciding when to retire, the relative importance of these factors and how doctors might trade-off between them.

Continuing HERU’s collaboration with the Centre for Healthcare Education Research and Development (CHERI), this research will identify the push-pull factors related to the intention to retire, and will employ a discrete choice experiment (DCE) to examine which of these factors are most valued by doctors nearing the end of their careers. The research will use qualitative face-to-face interviews along with a Scotland-wide survey; distribution of which will be facilitated by the British Medical Association and NHS Education for Scotland.  

HERU researchers involved in this research project: Diane Skåtun, Ourega-Zoé Ejebu, Terry Porteous and Mandy Ryan

External collaborators: Cleland, J, (CHERI)

This research is based on the GP contract; Phase 1 of 3 was introduced in April 2018 by the Scottish Government and British Medical Association. Phases 2 & 3 will be implemented in the coming years.

In the UK, general practices are generally small businesses that contract with the NHS, but which are owned and managed independently by a single GP or a partnership of GPs. The new contract changed practice funding to better reflect workload. Funding is based on adjusted capitation.  Across Scotland, independent GP partnerships are concerned that the contract does not adequately address the challenges they face.

This studentship will investigate how contractual arrangements impact on general practice partnerships as businesses in Scotland. A theoretical model of contracts will be used to predict how contractual changes will affect practices. These predictions will be tested using administrative data on practice income; and qualitative interviews to understand the perceived impact of contracts on general practice activities. 

PhD Student:  Pauline Ogilvie

Supervisors: Verity Watson (HERU), R. Schulz (Business School, University of Aberdeen) and P. Murchie (Institute of Applied Health Sciences, University of Aberdeen)

There are wide variations in clinical practice despite the increasing use of clinical guidelines. Whilst a wide range of potential determinants have been examined including patient, physician and system characteristics a relatively large part of the variation remains unexplained.

This PhD will examine the role of the physician’s risk and time preferences and personality in clinical decision making. There is a small literature on the impact of physician’s risk preferences on medical decisions but most studies are small in size. The role of time preferences and personality is not well understood. A better understanding of these factors can help reduce practice variations by taking these factors into account within training and professional development.

This PhD will draw on a large panel survey of physicians in Australia called "Medicine in Australia: Balancing Employment and Life (MABEL)". This survey includes measures of risk preferences and personality. Variations in clinical decisions such as prescribing of new drugs, provision of certain types of care in rural areas and also litigation can be examined.

A blog post from the project, focusing on the impact of shocks on doctors' risk attitudes, was published on the HERU website in June 2020. 

PhD Student:  Xuemin Zhu

Supervisors: Marjon van der Pol (HERU); Scott, T. (Melbourne University); Allan, J. (Health Psychology, University of Aberdeen).

The project aimed to investigate changes in the patterns of regional wage differences in the UK in the period since the global financial crisis. Regional differences in wages are an important element of the formula which underpin the distribution of monies to Central Commissioning Groups (CCGs) in the NHS in England and to fund local authority activities.

Annual Survey of Hours and Earnings (ASHE) and Labour Force Survey (LFS) data were used to detail changes in spatial wage differences since 2008. The project explored the drivers of  these differences and the consequences of the observed changes for the distribution of funding to CCGs.

Outcome and Translation

Regional differences in wages are an important element of the formulae which underpin the distribution of monies to CCGs in the NHS in England and the funding of local authority activities. Understanding changes in the underlying patterns of spatial wage differences and how this impacts on funding streams are of interest to both the Government who allocate the funds and to those who receive the funding.

HERU researchers involved in this research project: Bob Elliott, Diane Skåtun and Daniel Kopasker

A period of pay restraint had been in operation within NHS Scotland since 2011. Following a  previous multi-year settlement that took effect in 2008/9, 2009/10 and 2010/11, there was no general pay uplift for two years (2011/12 and 2012/13), followed by a further 5 years where a 1% pay uplift was awarded with additional flat rate increases for lower spinal points. This research analysed and assessed the effect of this pay restraint on NHS Scotland staff on Agenda for Change Pay Scales within the wider economic situation in Scotland. The research was undertaken within a very short timescale and focused on the collation and where necessary the adaption of existing evidence.

Outcome and Translation

This research was commissioned by the Scottish Terms and Conditions Committee (STAC) the body which negotiates terms and conditions issues relevant to NHS Scotland. The findings will support submissions to the NHS Pay Review Body.

HERU researchers involved in this research project:  Diane Skåtun, Attakrit Leckcivilize

External collaborators: Skåtun, J.D. (Department of Economics, University of Aberdeen)

Reducing ‘avoidable unscheduled attendances and admissions to hospital’ is recognized as one of the eight key areas of improvement NHS Scotland’s 'Shifting the Balance of Care Improvement Framework'. The Improvement Framework identifies a variety of approaches to achieve shifts in the balance of care, two elements of which include the identification of patients who are most at risk of hospital admission, and the development of patient care plans.  Such care plans are built on the understanding that a substantial proportion of individuals who arrive in A&E Departments, or have other forms of unplanned hospital admissions, do not require, or want, acute hospital care, suggesting that it may be possible to reduce acute care costs by providing alternative approaches to acute care. Furthermore, a small number of individuals account for a large proportion of such hospital admissions (often termed “high demand” patients). In 2014, NHS Lothian initiated a service to identify and manage “high demand” patients, by implementing a system of Anticipatory Care Plans (ACPs) amongst those at high risk of future hospital admission. We conducted a comparative before-and-after study of hospital admissions, emergency department visits, length of hospital stay and hospital costs, to estimate the overall service impact.

Outcome and Translation

The results suggest that introduction of ACPs led to a statistically significant reduction in the number of unplanned hospital admissions and emergency department (ED) visits. There was also an associated reduction in length of hospital stay for unplanned admissions, and lower hospital costs for ED visits and inpatient care. These outcomes suggest that ACPs are a promising intervention to consider if hospitals wish to reduce the number of unplanned hospital admissions. The findings have been highlighted in the Chief Medical Officer for Scotlands’ Annual Report in 2019.

HERU researchers involved in this research project: Paul McNamee and Attakrit Leckcivilize

External collaborators: R. Steel (NHS Lothian)

HERU Postdoctoral Fellowship

This project investigated the role of job satisfaction and mental illness on work absenteeism in the public healthcare sector.

Using secondary data-sources, the project explored sickness absenteeism variations within the public sector. Distinctively, the public sector was segmented into vocational and non-vocational sectors, assuming that vocation leads to differing degrees of job attachment and hence alter sickness leave.

Outcome and Translation

Increased absenteeism is costly for NHS employers and may compromise the quality of care to patients. It is important to understand the role of non-pecuniary organisational factors, as well as health-related factors as determinants of work absenteeism. Results provide more insights on the role of organisational and health-related factors on work absenteeism in the public healthcare sector.

HERU researchers involved in this research project: Ourega-Zoé Ejebu and Diane Skåtun

We will link the Annual Survey of Hours and Earning with the Business Structure Database to form a large matched employer-employee dataset. Using this dataset, we aim to advance the understanding of insecure employment and productivity by identifying characteristics of the employers which could potentially benefit from reducing insecure employment. This project complements our ongoing research which values the benefits to employees, in terms of health-related quality of life, of limiting exposure to insecure employment.

Outcome and Translation

Our analysis indicates a causal negative relationship between insecure employment and labour productivity. The results predict that for each 1% reduction in insecure employment, the growth rate of labour productivity will increase by 0.7%. However, these effects are only observed within industries in the bottom half of the economy-wide labour productivity distribution - i.e. industries with relatively low productivity. Previously, we established a causal effect between insecure employment and mental health. The findings from these two pieces of research combine to indicate that by reducing insecure employment, employers can increase productivity and provide a health benefit to employees.

HERU researchers involved in this research project: Daniel Kopasker

External Collaborators: C. Montagne (University of Aberdeen Business School)

Health Care Reform: the iMpact on practice, oUtcomes and costs of New roles for health pROfeSsionals

This project is undertaking a systematic evaluation of the impact of these ‘new professional roles’ on practice, outcomes and costs in a range of different healthcare settings within European Union and associate countries. It details the nature, scope and contribution of the new professional roles, evaluates their impact on clinical practice and outcomes, and identifies their scope to improve the integration of care. It conducts economic evaluation to identify the cost-effectiveness of the new professional roles, identifies optimal models for delivery of healthcare and the consequences of these for management of human resources and workforce planning. Study design is cross-sectional and multi-level. A mixed methods approach combines analysis of routinely collected data and primary data generated through interviews and questionnaires to health professionals, managers and patients. Data analysis employs multi-level modelling techniques.

Outcome and Translation

The project demonstrated that across the nine countries and three conditions studied there is variation in the extent to which the wider health care team is involved in patient care. Where the extended team is involved patients are satisfied, clinical outcomes are similar to more traditional care and there are potential cost savings. The results have been disseminated through a variety of approaches (e.g. invited talks, contributions to complementary projects, conference presentations, briefing papers) and are informing policy development at the highest level, at the OECD, EC and individual countries.

The MUNROS Project conference was held on the 6th February 2017.

HERU researchers involved in this research project: Robert Elliott, Hanne Bruhn, Daniel Kopasker and Sebastian Heidenreich

External collaborators: C Bond (Centre of Academic Primary Care, University of Aberdeen); A de Bont (Erasmus University); R Busse (Technische Universität Berlin); M Ruggeri (Università Cattolica del Sacro Cuore); M Mijal (University of Warsaw); H Svobodová (Charles University Prague); G Okem (Economic Policy Research Foundation of Turkey); JE Askildsen (Uni Research Norway) and M Sutton (University of Manchester).

• for further details visit Munros website

Emigration by doctors is of increasing concern given the high training costs and the shortage of doctors in the UK.  It is crucial to increase our understanding of emigration decisions.  This paper focused on the role of risk preferences.  Emigration is fundamentally a risky decision and evidence suggests that risk seeking individuals are more likely to migrate.  However, it is unclear whether this can be generalised to doctors.  It could be argued that there is less financial risk associated with emigration and some destination countries have lower rather than higher levels of risk associated with career and clinical care.  The aim of this paper was to compare risk preferences of GPs who qualified in the UK and emigrated to Australia with those who are currently practising in Scotland.  We used data from Australia's national longitudinal survey of doctors (MABEL) which included 275 GPs who qualified in the UK and data from a survey of 295 Scottish GPs.  Risk preferences were elicited for financial risks, career and professional risks and clinical risks on a scale from 1 to 5.  

Outcome and Translation

This research showed that UK trained GPs who migrated to Australia were more risk averse than GPs in Scotland.  This suggests that outward migration of GPs may be reduced by reducing risk and uncertainty within the UK NHS.

HERU researchers involved in this research project: Marjon van der Pol and Alastair Irvine

External collaborators: A. Scott (University of Melbourne), O. Bezannier (Université Paris-Est Créteil)

Existing research indicates factors such as the perceived benefits of particular specialities, wish for quality of life, and demographic factors, such as gender, are influential. However, we do not know the most important ‘push-pull’ careers-decision making factors for the current generation of UK medical students and trainees. What drives medical students and trainees away from a place or a speciality? What draws them to a new location or a different speciality? To what extent are specific factors important at different transitions?

This project used anonymous, online surveys to gather contemporary UK data on these issues from medical trainees and students. A Discrete Choice Experiment was used to identify the most important push-pull factors in medical careers-decision making.

Outcome and Translation

Our results suggest organisations could focus on improving working conditions for trainees to a minimum standard, promote linked training positions for medical couples, and provide access to career support for non-medical partners. Alternatively, organisations might provide monetary incentives to trainees for accepting posts that do not meet their preferred conditions. Medical students were also found to value good working conditions more than they value geographical location. 

HERU researchers involved in this research project: Diane Skåtun, Verity Watson and Nicolas Krucien

External collaborators: J Cleland (University of Aberdeen), C Rees (University of Dundee), K Mattick (University of Exeter) and P Johnston (NHS Education for Scotland (NES))

With increasing demands on health services policy is looking at alternative ways of providing healthcare. Examples include extending the role of pharmacists and nurses in the management of common ailments, promoting self-care of symptoms indicative of self-limiting illness, and extending the roles of specialist nurses and physician associates in some clinical areas. We use discrete choice experiments (DCEs) to investigate preferences in the management of different illnesses.  

Outcome and Translation

A general finding is that, whilst individuals often prefer to see a doctor or consultant, improvements in other aspects of care (reduced waiting time, continuity of care, longer consultation times) can compensate them for not seeing their preferred health worker. 

HERU researchers involved in this research project: Mandy Ryan, Verity Watson and Patrícia Norwood.

External collaborators: Terry Porteous, Christine Bond, Alison Elliott, Phil Hannaford and Peter Murchie (Academic Primary Care, University of Aberdeen)

The staff Market Forces Factor (sMFF) is the mechanism in England by which both funding allocated to commissioners of healthcare and the tariff that providers of healthcare can charge are adjusted to reflect the unavoidable costs of commissioning/providing health care across different geographical locations. The current sMFF is based on estimates of spatial wage differentials using 2007–2009 Annual Survey of Hours and Earnings (ASHE) data. The focus of this project will be on providing a new updated Staff MFF index based on the latest data available from ASHE. This ensures funding and pricing reflects the current labour market conditions faced by commissioners and providers of healthcare.

Outcome and Translation

The focus of this project was to provide a new updated Staff MFF index based on the latest data available from ASHE. This ensures funding and pricing reflects the current labour market conditions faced by commissioners and providers of healthcare.

HERU researchers involved in this research project: Diane Skåtun, Bob Elliott and Zoé-Ourega Ejebu

External collaborators: Alex McConnachie (University of Glasgow) and Nigel Rice (University of York)

Medical workforce training and planning are at the forefront of policy and practice discussions. Difficulties in recruiting and retaining trainees threaten the reliable delivery of care and have massive long-term implications for the NHS in Scotland. This project will employ a discrete choice experiment (DCE) to explore the factors influencing medical trainee career-decision making to better understand the flow of trainees through the training pathway. It forms part of a broader PhD research project led by Medical Education entitled ‘A mixed-methods study of career-decision making in Foundation Programme doctors’.

Outcome and Translation

The research undertaken within this PhD thesis provides important information to workforce planners and to the NHS on quantifying the factors that medical trainees find important in their training stages and thus provides the service with a better understanding the flow of trainees through the training pathway.

PhD Student: Gillian Scanlan

Supervisors: Diane Skåtun (HERU); J. Cleland (Medical Education, University of Aberdeen); P. Johnston, K. Walker (NHS Education for Scotland).

Population ageing has motivated policy makers around the world to focus on how best to organise health and social care services to meet an anticipated growing demand on services. Two popular initiatives are re-ablement and telecare. Re-ablement is an approach within homecare that enables older individuals with social care needs to improve their functional performance and live independently. Telecare, on the other hand, involves use of devices to monitor individuals’ health and safety, and provide response when needed. Evidence from the existing literature suggests that there are few economic studies investigating the effects of re-ablement and telecare, especially in Scotland. The generalisability of the existing studies is also questionable given that most of them have small sample sizes and high attrition rates. To this end, we undertook economic analyses of linked administrative health and social care data in Scotland. Our estimation strategy controlled for potential selectivity bias, endogeneity of key variables and unobserved heterogeneity in tandem. 

Outcome and Translation

The findings from this thesis informed the factors associated with better outcomes; helped identify the groups of people that are most likely to benefit from the interventions; and showed the relative importance of telecare in improving outcomes.  More specifically, it was shown that some of forms of telecare (community alarms) were associated with a reduced probability of admission to hospital in the emergency department, whilst other types of telecare had the opposite effect.  Further, those living in remote areas, and those living with multiple conditions, were also more likely to be admitted as emergency cases.  Finally, some form of telecare (community alarms) were associated with reduced length of hospital stay amongst some patients (those with physical disability).

PhD Student: Kevin Momanyi

Supervisor: Paul McNamee and Diane Skåtun