Summary
Most primary care physicians thought that there was a problem with recruitment and retention of GPs and FPs in Singapore. Strategies focusing on promoting general practice by emphasizing its advantages and enhancing its status, as well as by improving training through sub-specialisation and high-quality rotations were considered priorities for improving recruitment of GPs and FPs. For retention of GPs and FPs, improving working conditions such as an increase in salary, public recognition and varying or reducing time commitment were considered the most important strategies.
Comparison with the existing literature
Prioritization in primary care involving primary care physicians mostly focuses on resource allocation [23, 24]. Some studies involve diverse stakeholders including primary care physicians in priority setting in primary care research [25]. In addition to these important objectives, Decision-makers at the institutional, regional, and national level should harness front-line clinicians’ insight to improve the quality, safety, and efficiency of healthcare delivery. There are examples of similar initiatives through focus group discussions or surveys [26, 27]. To our knowledge, PRIORITIZE is the only approach to date that uses a systematic, priority setting approach to this end [17, 18]. In this study, we used a modified PRIORITIZE approach to identify local frontline clinicians’ views on recruitment and retention. We were unable to find a similar study prioritizing GP recruitment and retention strategy in other settings.
The literature on recruitment and retention of GPs, mostly originates from high-income countries, such as UK or the US, and is largely in form of qualitative research or surveys without prioritization [3, 28,29,30]. Marchand’s and Peckham’s systematic review analysed findings from 36 studies on recruitment and retention from diverse high-income, mostly English-speaking countries. In terms of recruitment, this systematic review extracted diverse strategies from the original studies but concluded that strategies addressing intrinsic recruitment factors such as receiving recognition and providing varied and continuous provision of patient care were more important than extrinsic factor such as loan forgiveness [3]. This is similar to our findings showing that local GPs and FPs considered recruitment strategies focused on enhancing status and improving the breadth of training rather than targeted financial support as more important. In terms of other local evidence, a recent qualitative study exploring medical students’ attitudes towards careers in primary care in Singapore identified several important and potentially detrimental factors [31]. These included limited professional opportunities, emphasis on lifestyle benefits rather than professional characteristics, need for business acumen, conflicts created by business in clinical care, mundane case mix, lack of continuity of care, limited consultation time, and specialists’ negative attitudes towards family doctors. Recruitment strategies such as “Emphasizing the holistic, community-oriented and patient-focused approach to family medicine” and “Enhancing status contribution of primary care practitioners”, which were prioritised by the respondents in our study, could help to address some of these concerns. Interestingly, Singaporean medical students felt that putting an emphasis on the life-style balance, which was the top recruitment strategy as seen by the local GPs and FPs, without focusing on the professional aspect or impact on care may deter some student from choosing a career in family medicine.
Retention strategies prioritised in this study are comparable with the other research in this area which mostly originate from high-income, western countries. A cross sectional study exploring motivation for career choice and job satisfaction among GP trainees and newly qualified GPs in seven European countries identified compatibility with family life and general practice being a challenging medically broad discipline as the main motivators for choosing a career in general practice [28]. It also showed a significant correlation between workload and mean income and the level of satisfaction. Correspondingly, our respondents felt that an emphasis on life-work balance and holistic, community-oriented, and patient-focused approach were top strategies to improve recruitment while increasing pay and varying time commitment were important for retention. Furthermore, a systematic review exploring factors determining GP satisfaction in clinical practice showed that flexible workload and receiving recognition, collaboration with colleagues from other specialities and engaging in other areas such as research were important [32]. Similarly, in our study strategies relating to recognition, flexible workload, and collaboration with colleagues from other specialities were ranked second, third and fourth, respectively. Furthermore, while emphasizing benefits of a GP lifestyle was seen as important for recruitment, for retention having more flexible working hours was seen as a top priority. This apparent duality may mean that the current working arrangement of GPs, although enabling greater work-life balance compared to other specialities, could be made even more flexible to improve retention.
Implication for future practice and research
Ranking of strategies for recruitment and retention of GPs and FPs as seen by practicing primary care clinicians provides important insights that can inform future policy making. Some of the top ranked strategies may be easily implementable and could be taken into consideration by educators and decision-makers in Singapore. A number of top strategies for recruitment focused on the promotion of a career in general practice. This can be achieved through initiatives that generate respect amongst doctors as well as society at large. Recruitment strategies that were ranked high and may be achievable in the local setting are those focusing on education at both undergraduate (e.g., ensuring high quality rotation and increased exposure to family medicine) and postgraduate level (e.g., a possibility of sub-specialisation). Notably, educational strategies which may be more difficult to introduce such as increasing length of general practice rotations or introducing educational tracks and programs focusing exclusively on general practice were not considered a priority. Retention-related strategies that were seen as important and could be considered for implementation are those enabling new ways of working through varying time commitment, enabling part-time hospital attachments and allowing for engagement in research or management, particularly by physicians working in public sector. In addition, we note some important differences between the private and public sector physicians in terms of priorities for recruitment and retention. For recruitment, private GPs felt found increase exposure to family medicine in medical school much more important than public sector physicians. For retention, both groups called for reduction of non-clinical responsibilities; administration-related among private GPs and management-related ones among public GPs. This seems to indicate a need for additional, specific non-clinical support in both sectors. Furthermore, social support from colleagues was seen as more important by private GPs, who mostly work in solo practices. Conversely, public sector physicians found involvement in research and additional training important for retention unlike private GPs who may have easier access to such opportunities.
Existing evidence on effectiveness of strategies for recruitment and retention is limited. To address this gap, it is important that the future implementation of such strategies is accompanied by robust evaluation. In addition, future research should explore additional strategies specific to Singapore which may have not been covered in the existing literature. It should also aim to investigate in more depth different priorities for private and public sector. Finally, to inform national strategy for requitement and retention of GPs in Singapore, there is a need for studies that would explore views form other stakeholders such as medical educators and policy makers.
Limitations & strengths
Our study included a diverse group of primary care physicians working in the private and public sector in Singapore. Our respondents were often involved in a number of other professional responsibilities and worked in different primary care settings. We used an established priority-setting approach which was previously used in other settings and disciplines. However, we modified it to minimize the burden on the clinicians an boost the rate of recruitment. This was done by extracting strategies for prioritization from a comprehensive systematic review instead of inviting physicians to volunteer strategies themselves. We aimed to avoid low response rates and an extension to the project duration observed in previous PRIORITIZE exercises. There are also some limitations to our study. While we extracted strategies from a comprehensive systematic review that collated evidence from diverse settings, there may be some additional strategies specific to Singapore context which were not mentioned. Our questionnaire did not include open-ended questions inviting additional suggestions for prioritization strategies from the clinicians. In addition, CHNRI simulation studies show that the ranking scores in this priority-setting approach remain similar upwards of 50 respondents. However, primary care physician workforce in Singapore is much larger and diverse. Future studies with a larger sample of primary care physicians would allow for more comparative analyses between the private and public sectors.