Title: Mapping underdoctored areas: the impact of medical training pathways on NHS workforce distribution and health inequalities
Funder: Department of Health and Social Care

Abstract: Background: NHS workforce recruitment and retention is a longstanding concern for patients and policymakers, and impacts on capacity to deliver services. Access to care is not equitable across the UK and some areas struggle more than others to recruit doctors. Previous research has examined workforce distribution, but has not fully considered the impact of medical training pathways on unequal access to care, or related workforce distribution to health inequalities. Discussion with PPIE representatives highlighted that NHS workforce was a concern because lack of access to care leads to longer waiting times and cancelled appointments which have a negative impact on outcomes. Aim: To identify the impact of medical training pathways on workforce distribution, considering health inequalities, and proposing how, when and where interventions might be facilitated to improve outcomes. Research questions: How do medical training pathways impact on recruitment and retention in socio-economically deprived areas? What is the impact of policy on workforce distribution? What geospatial patterns about training pathways when mapped to socio-economic inequalities? What factors influence decisions about career specialism and geographic location? How, when and where might interventions be facilitated to improve workforce distribution? Methods: We take a cross-disciplinary theoretical approach, bringing historical, spatiotemporal and sociological insights to healthcare problems. Multi-method empirical analysis is key to our approach, using a multiple case design that contrasts three underdoctored areas and one oversubscribed site, selected to represent real-world boundaries. Using iterative explanation building as a tool for integrated synthesis specifically designed for case studies, we will focus on how our research findings can be used to support decision-making and intervention design. The research will be delivered by four linked work packages. 1: A longitudinal analysis of archival data focused on identifying critical decision points about recruitment, retention, specialisation and rationalisation. Looking across historical data will help to demonstrate how training pathway design has shaped service provision. 2: A geospatial analysis of existing datasets about medical students, doctors, training and health inequalities. Understanding the patterns across the UK will highlight similarities and differences across areas. 3: An interview study with 100 doctors. Working with doctors at various career stages will allow us to identify potential temporal points for intervention. 4: An integrated synthesis based on WP1-3 that explains how medical training pathways impact on workforce distribution and affect health inequalities. The overall outcome will be concrete recommendations, co-produced with key stakeholders, patients and the public about interventions for improving medical training pathways that will influence unequal provision of care across the UK. Timelines: The study will be conducted over 30 months. Interim outputs will be made available via steering groups and engagement events. Anticipated impacts and engagement: Working with key stakeholders including our PPIE group from the outset, we will inform future healthcare practices and consider how changes to training pathways can be leveraged to reduce healthcare inequalities. Our participative approach will deliver co-produced, implementable recommendations for intervention design.

Lay abstract: Access to healthcare relies on there being enough doctors in an area to treat patients. There are fewer doctors in some areas, despite the greater healthcare needs of the population, and it affects people’s health because they cannot see a doctor when they need to. The problem of not having enough doctors is known as ‘underdoctoring.’ Some areas struggle to recruit doctors to serve the local population, especially in areas where there are other inequalities, such as people having low incomes, there is high unemployment, poor housing and an unhealthy environment. These inequalities also affect people's health, and we call them the 'social causes of poor health'. When we spoke to patients and the public, they agreed that underdoctoring was a concern for them because they had struggled to get appointments with doctors, experienced long waiting times, and travelled long distances for healthcare. How medical training programmes are organised is important, because we know that where doctors train is a big influence on where they end up working. Several studies have looked into doctors’ careers, often using questionnaires to find information, but we think that there are a lot of factors that influence where doctors work which have not yet been looked into, including how this relates to the social causes of poor health. We aim to make a major contribution to addressing underdoctoring. Our study will investigate why doctors work where they work, thinking about how the healthcare system as a whole is organised as well as individual choices. We will conduct case studies of three underdoctored areas, and one site that does not struggle to recruit. By looking in detail at these areas, we will be able to understand the differences between places, which will have lessons for other areas in the UK as well as the areas we are focusing on. The project has four parts: 1. We will use historical records from medical schools and the NHS to understand how services are organised and how this may have affected how many doctors there are in an area. 2. We will use existing statistical sources to map a) where doctors work and b) which areas have high levels of inequalities, to see if we can understand if there is a relationship between the two. 3. We will interview doctors about why they work in certain locations, to try to explain the reasons behind the unequal distribution of care. 4. We will bring together the data gathered in parts 1-3 to work with medical schools, the NHS, and patients and the public to design new solutions that encourage doctors to work in areas that struggle to recruit enough doctors. We want to understand what doctors think about when they are choosing a job, (e.g. location, career progression) so that we can make changes that mean that more doctors want to work in underdoctored areas. We think that by recruiting more doctors who are committed to underdoctored areas, this will provide better quality care and have health benefits for local populations. By examining medical training in this project, we will suggest changes that can be made throughout the NHS to improve numbers of doctors in areas that struggle to recruit. Throughout the research we will work with patients and the public to develop priorities, reflect on research findings and consider how best to share these findings widely and creatively. We will share our findings with relevant national organisations including NHS England and the General Medical Council.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE