The future integrated care workforce

This toolkit brings together those with first-hand experience of designing, delivering, evaluating and participating in a Longitudinal Integrated Clerkship (LIC) within a UK Higher Education Institution and those working closely on programmes focussing on Health Education England (HEE)’s and NHS England’s national priorities. In August 2022, a collaborative workshop was held for students and tutors participating in a London-based LIC in 2021–2022, faculty with prior experience in running LICs, and HEE representatives. The aim of the workshop was to co-produce a toolkit to guide undergraduate institutions, who may wish to introduce an LIC within their medical school curriculum that aligns to these national priorities. Although this toolkit primarily focuses on a UK audience, we anticipate that other health systems facing a need for similar educational reform may also find use for this toolkit.

In August 2022, a collaborative workshop was held for students and tutors participating in a London-based LIC in 2021-2022, faculty with prior experience in running LICs, and HEE representatives. The aim of the workshop was to co-produce a toolkit to guide undergraduate institutions, who may wish to introduce an LIC within their medical school curriculum that aligns to these national priorities. Although this toolkit primarily focuses on a UK audience, we anticipate that other health systems facing a need for similar educational reform may also find use for this toolkit.

| BACKGROUND
The NHS Long Term Plan, 1 the HEE Future Doctor Report 2 and The Enhance Programme 3 have outlined key national priorities for the future of health and social care (Figure 1), including how we can train our workforce to deliver these aims. These priorities include embedding generalist skills in early career doctors, so they can better provide person-centred care in the context of complex multimorbidity, while considering the impact of deep-rooted health inequity and social determinants of health.
They can better provide person-centred care in the context of complex multimorbidity, while considering the impact of deep-rooted health inequity and social determinants of health.

| WHO IS THIS TOOLKIT FOR?
to meet their local and national health and workforce priorities. This document may also enable health and social care providers and third sector organisations, who are partnering up to support educational programmes, to better understand how longitudinal courses may benefit their health priorities.

| WHY IS THIS TOOLKIT NEEDED?
Currently, undergraduate and postgraduate training is fragmented in its provision of educational supervision and patient care. The lack of continuity of relationships with patients, supervisors and peers, can make it harder to effectively address the increasing complexity of multi-morbidity at an individual and population level. Because this fragmentation continues in the educational experience of postgraduates, it has a domino effect on undergraduates placed within those fragmented clinical settings-it becomes easy to see how this cyclical lack of continuity could perpetuate workforce burnout and poor retention. 4,5 This cyclical lack of continuity could perpetuate workforce burnout and poor retention.
There is also a need for the future workforce to better understand the effects of health inequity, both at an individual and community level. It is well-recognised that certain groups of patients have poorer health outcomes than others. 6 However, a deeper understanding of local population health priorities is difficult to achieve within our current, fragmented teaching and training programmes and instead requires being embedded into a community over a period of time.
A deeper understanding of local population health priorities is difficult to achieve within our current, fragmented teaching and training programmes and instead requires being embedded into a community over a period of time.
LICs ( Figure 2) are an ideal educational model to address the issues of fragmentation of the student experience, and the need for students to have a better grasp of local population health. LICs place a greater emphasis on continuity for students and patients, 7 greater responsibility for patient care, with more rewarding outcomes for students/trainees, and their patients and communities. 8 Furthermore, many of the LICs in the United Kingdom are based in primary care, 9 which provides a fertile ground for students to develop meaningful longitudinal patient relationships, and allows students to be embedded within a local community.

| THE CURRENT LITERATURE
The discussions within our workshop were informed by the existing literature on LICs which provides an international lens on how to develop LICs, what benefit they can provide, and their pitfalls. [10][11][12] This toolkit builds on this literature with our lived experience within a UK health care and higher education environment, and aims to

| Identification and co-production with key stakeholders
To ensure an LIC that is sustainable, it is important to identify and consult with key stakeholders from the outset. Consideration of your institution's culture will also be important to ensure the success of an LIC, particularly with regard to the assessment process and how the LIC will be perceived within the hidden curriculum. 14 Stakeholders might include the following:

| Establishing the purpose of your LIC
A co-created mission statement for your LIC can help to ensure that all stakeholders are on the same trajectory. The overarching aim of your LIC is likely to depend on your local context. For example, in your local area, a main driver may be the need to address workforce recruitment and retention. Alternatively, addressing health inequity within underserved communities in the local area may be your main driver.
When considering learning outcomes for your LIC, these can be considered under the headings of educational and health outcomes to ensure mutual benefit for those served by health systems and educational institutions. Similarly to a programme's mission statement, LIC outcomes are best defined with input from educational, health and community stakeholders. Investment at this stage from all stakeholders will be important as there may be conflicting priorities that will need to be worked through. Educational outcomes should align with the broader priorities and values of your institution, as well as national priorities, such as the Medical Licencing Assessment and those from HEE. Creation of a curriculum blueprint will be useful at this stage. Health outcomes would consider NHS policy documents (such as the Five Year Forward view), as well as local policies relevant to health context.

| Curriculum design
The success of an LIC will depend on how the principles of the longi- Consider the overarching outcomes of your LIC. Use this to decide what stage of medical school it is best delivered in.
Early years E.g., Key LIC outcome = deeper understanding of the health inequity and preventative care for your population. You may wish to introduce these foundational concepts via an LIC at an early stage of clinical training, when there may be more curriculum space to dedicate to these concepts, and students are establishing their values around health equity. Later years E.g., Key LIC outcome = enhancing preparation for practice in line with national priorities In this case, the LIC may be better suited for those who are about to graduate How many students?
New medical schools or those undergoing curriculum review may wish to implement an LIC for an entire cohort Medical schools with an established curriculum could pilot an LIC with a small group of students, with a phased roll-out in future years, allowing for improvements in your model if you fully roll out. Or there are many LICs that are small cohort studentselected programmes. If do you choose to run a pilot LIC, consider how you will advertise and recruit prospective students.
LIC curriculum structure?
The format of an LIC can vary internationally. Within the United Kingdom, LIC structure can range from a full time LIC to 1 day a week. Also consider the balance between • 'service-led' learning (students actively learning through interactions with patients during service provision) • Timetabled classroom teaching • Community-project work • 'White space' (students defining how they learn during un-timetabled curriculum space) Consider if your original LIC outcomes can be achieved in your chosen format and whether you can evaluate and assess these outcomes (see below for evaluation and assessment) within the constraints of your given structure.

Setting?
LICs can take place in a variety of settings with one setting usually acting as the main base for student learning • Primary or secondary care • A mixture of both primary and secondary care • Also consider the third sector as potential placement providers, e.g., nursing homes, hospices and day care centres

Supervision?
Adequate supervision ensures clinical and educational safety for students and the patients they care for. This is an important consideration across all clinical settings. Also consider how undergraduates and postgraduates, and students from different health professions within the same learning environment can be brought together to enhance learning for both groups, e.g., through group supervision, tutorials or patient care.

Patient interactions?
Supervisors should facilitate student-patient partnerships so students can navigate their patient's journey through the health care system. This may be done by • Supporting students in taking ownership of their patient caseload under supervision • Identifying areas where students can add value to patient care • Building flexibility into the timetable so students can advocate for their patients, e.g., when they attend appointments in different care settings

Assessment?
Assessment should be considered from the outset of LIC planning to ensure there is alignment with learning outcomes, as well as medical school and national assessments. Consider • The balance of formative versus summative assessment • Overall assessment burden across the whole curriculum-is it achievable for students? • If service-led assessment alleviates some of this burden, e.g., a formative community quality improvement project? How and when these assessments will be reviewed should also be factored into the timetable for students and supervisors.
Abbreviation: LIC, Longitudinal Integrated Clerkship. literature, an LIC should be long enough for students to establish meaningful relationships, and Worley et al. suggest that an appropriate length of time should be from 6 to 12 months. 15 We would suggest the length of time should be conducive to students having repeated encounters with the same patients, educators and peers to maximise relationships.
There is no formal consensus on how 'repeated encounters' should be defined but the aim is for students to experience patient care over time in different settings with different health care practitioners. Facilitating sustained patient-student partnerships across the course of an LIC lies at the heart of this educational model.
It is through these partnerships that mutual benefit can be garnered.
The aim is for students to experience patient care over time in different settings with different health care practitioners.

| Provision of support
LICs are likely to require a shift in mindset and logistics from the existing culture of learning at your institution, not only from the perspective of students, but also placement supervisors and central faculty.
Adequate support for all relevant groups will help to identify early teething problems and ensure smoother transitions during implementation (see Table 2).

| EVALUATION AND RESEARCH OF AN LIC
With any educational intervention, particularly one that is new to an institution, there will be multiple reasons to collect data. When deciding what data to collect, it is worth looking back at the primary LIC objectives, and planning from the outset how evaluation will be conducted and data collected, alongside the design and development of the overall LIC. This will help make early decisions regarding why the data are being collected, when and from whom, and ensures timely ethics and funding applications. Reviewing the existing literature at this stage will help shape both the LIC and your evaluation and research questions.
Kirkpatrick's hierarchy can be a useful heuristic when considering what type of data to collect-for example, collecting qualitative data from different stakeholders on their perceptions and experience of the LIC. You may also choose to collect specific quantitative student or patient outcome data.
When deciding who to collect data from, consider the whole range of stakeholders. For example, if a key aim of your LIC is to improve patient access to health care in your local area, it would be important to hear from patients themselves on their experiences. When deciding who to collect data from, consider the whole range of stakeholders.
While data are often collected to look at what additional value an intervention provided, it is equally important to ensure no harm has inadvertently been inflicted on stakeholder groups in the process. This is also something to consider when deciding what parameters should be evaluated.
The timeframe of data collection is also an important consideration. In keeping with a longitudinal process, some research questions may be better answered by looking at different points across the course, to capture how data change over time.
When writing up and presenting data, consider involving all stakeholders in this process. It would be worth looking at presenting and publishing avenues that reach a broad audience-for example, health care arenas, patient and community facing publications, and medical educators.

| CONCLUSION
The future health workforce will require new complex skills to manage increasingly complex population needs. Current undergraduate training needs to consider how it is preparing future graduates to develop the skills needed to adapt to the rapidly changing health care land- scape. An LIC places continuity and integration at its core and is an ideal educational model to embed these key skills within the curriculum. This, in turn, could help prepare our future workforce in providing person-centred integrated care that meets population need. This toolkit can be used to guide those considering educational reform in line with population need. Finally, it is the collaborative partnerships with students, policy makers, educators, and health and social care providers that will help ensure alignment between population priorities, workforce needs and medical education.
Current undergraduate training needs to consider how it is preparing future graduates to develop the skills needed to adapt to the rapidly changing health care landscape.