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Are registrars worth it?

As debate rages over whether practices should be made to pay for their GP registrars, newly-qualified GP Dr Matt Doyle gives his verdict

As debate rages over whether practices should be made to pay for their GP registrars, newly-qualified GP Dr Matt Doyle gives his verdict

The straight answer is more from necessity than practicality. Yes, GP registrars have to be worth it if we wish to continue to produce newly-qualified GPs – which we most definitely need (unless there is to be a sudden and dramatic change in the practice of medicine in this country).

A couple of months ago it became clear that the Department of Health was questioning the cost of GP training and specifically whether it should continue funding the salaries of GP registrars. Surely, if a qualified doctor, at least three years out of medical school, is working at a practice then they are providing an extra pair of hands and lessening the workload. Would it not make sense to allow the practice to pay for this service rather than effectively getting a free doctor from state coffers?

Let's face it, GP registrars are not cheap. Let's look at the current pay structure and see what happens when a second-year SHO becomes a GP registrar. The SHO has a basic salary of £27,022, assuming average hours and duties. If they were to step up to a third-year SHO post that would increase to £28,720. If the jump were to a first-year SpR the salary would increase to only £28,307 (assuming they've worked through their chosen postgraduate qualification within that two years). If they become a GP registrar their salary leaps to £44,5871.

Cheap specialty

It gets better; let's now suppose that our registrar has come from a non-career grade post, or from outside the NHS (for example, HM Forces). These registrars will be entitled to an allowance not less than their previous salary. If that salary was lower than the last hospital post worked they would be entitled to an allowance based on the current salary for that post. In addition there are allowances for travel to visits, London weighting, payment of medical insurance subs and even for removal and house-buying expenses. GP registrars are not alone in these allowances; SpR posts attract similar benefits.

It's not hard to see why the department has identified the possible savings from ceasing to fund GP registrar training. Hospital doctors perform a function for the hospital, funded within the NHS budget. GP registrars are working in the same way, except that a GP surgery is essentially a private business performing publicly funded health care. Why shouldn't they foot the bill?

Why indeed? Are GP registrars, to quote the advert, 'worth it'?

The first key issue is the point of training. To become a good GP, you have to work and learn in general practice. Like all different specialties it has its own varied skill base and necessary abilities. This training is also markedly shorter than for other specialties; one year instead of five. If you consider the salary costs above, one should bear in mind that this financial burden is only for 12 months; an SpR will normally take five years to train with an annually increasing salary (costing the NHS about £160,000 over five years in basic salary alone).

For the practice

What about the contribution the GP registar makes to the training practice? They will see patients, take on audit or projects and contribute to emergency rotas. Initially the recommendation is that a registrar starts seeing patients at 30-minute intervals (instead of seven to 10).

But as their ability and confidence improves they can end up seeing patients alone at 10- to 15-minute intervals, which is surely a massive contribution to a typical practice. Depending on their previous experience this change may happen relatively quickly.

This process is overseen by one trainer to every registrar, in contrast to hospital training. This relationship is at the heart of GP training; if it fails there is unlikely to be a keen new GP at the other end of the process.

Clearly this requires a great deal of input from the trainer. As Dr Richard Stevens said in Pulse 21 September: 'If you get a good registrar they are a joy and an asset, but you might have one that needs remedial training.'

Tutor commitments

In addition to filling in the (often massive) gaps of primary care knowledge they must also help the registrar prepare for both summative assessment and the MRCGP, which each have four components. This will shortly change with the new exam, though the workload is unlikely to be lessened for the trainer.

This is a substantial amount of work for both parties; videoing consultations alone can take a couple of months. In addition, though most GP registrars will have completed two years in hospital medicine at SHO level, each trainee has a slightly different skill and knowledge base.

The self-construct registrar is now a less frequent occurrence, but they can potentially have an even more diverse history of medical training. Some try other specialties before deciding general practice is the right choice. The result of this is that no two GP registrars will have the same exposure as clinicians prior to the practice-based year.

There is also a change in workload for other members of the practice. Nursing staff, receptionists and other staff will have to work alongside a new doctor every 12 months, obtain consent from patients to see the registrar or to be used on video for training.

I finished my GP training in August. I hope I was an asset to the practice rather than a burden. Though I was expensive to train, I was no more so than any other specialist. I have no fear of becoming time-expired or that I will need to head off to Australasia to find a post in my chosen field. I will hopefully continue providing NHS services for many years to come; a short-term investment with a long-term view.

Matt Doyle passed the MRCGP this year and is now a full-time partner in Huntingdonshire

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