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At the heart of general practice since 1960

GPs need extended training to be fit for the future

Placing GPs in their extended training in a range of primary care and community/outpatient settings is definitely a ‘win – win’ solution for workforce planners, training bodies, service providers and the trainees themselves.

The Royal College of General Practitioners (RCGP) is currently preparing the educational case for extending GP training to four years for submission to the Department of Health's medical programme board in the spring. A previous submission was unsuccessful – so why are the RCGP and its partners, in deaneries and the BMA, submitting again?

The educational case is strong. There is a constant pressure from politicians, the public and other specialty colleagues for GPs to ‘do more/be better at/take responsibility for…' a whole range of clinical and transactional processes without understanding or appreciating our generalist skills. Prominent amongst these are care of children, care of the elderly and care of those with mental health problems.

These are all within the RCGP curriculum for GP training and beyond – but never the less, time to experience these facets of care in general practice, and further develop the skills to deliver care in these areas, are both crucial components in the case for extended training.

Add to this the emerging responsibilities of GP commissioning in England, and the general leadership competencies required of all UK GPs, and it is easy to demonstrate the inadequacy of our short specialty training programme.

In Europe GP trainees all have longer periods of training:

European Country

Total duration of GP training (years)

Duration of training in a General Practice setting  (years)

Duration of training in a hospital or other setting (years)

Finland

6

4-6

0-2

Norway

5

4

1

Sweden

5

2.5-3.5

1.5-2.5

Denmark

5

2.5

2.5

Iceland

5

2

3

Slovakia

5

1-2

3-4

Switzerland

5

0-3

4.5-5

Ireland

4

2

2

Poland

4

2

2

Portugal

4

2

2

Slovenia

4

2

2

Spain

4

2

2

Greece

4

1

3

UK

3

1.5

1.5

Source:EURACT (2011)

The role of a UK GP as the key generalist clinician and first port of call across all health related issues, exceeds that of any of our European counterparts in breadth and depth and complexity.

This role has expanded over the last few years and research has shown its developments in terms of health service leadership and management (not only in the rapidly evolving systems in England but across the whole of the UK), alongside the management of chronic conditions previously managed in hospitals.

Implementing an extended period of training will be a challenge to postgraduate deaneries and their GP schools. There is a common feeling that any additional training should be delivered based in general practice.

There have been several ‘pilot' schemes that have looked at GPST4 and GPST5 years, and the process of delivering them in conjunction with curriculum coverage and appropriate assessments.

In North Western Deanery, our ST4-5 pilot gave interesting and valuable feedback on all of these areas.

Trainees meeting to review their experience and personal development made a range of statements to summarise their ‘gain' from adding two years to their training whilst expressing, at the end of year 4 and then at the end of the programme, the ‘waypoints' of these gains

Responses included the following:

·          Looking back on it now I am a markedly more confident GP in actually practising the stuff that we've learned in the first years

·          There's a massive advantage [of extended specialty training] in that I'm 100% certain that I am now actually ready to start being an employer and an employee rather than a trainee

·          My clinical skills are much more confident, that I have really started to master them rather than just being good enough to go out and work

·         I do think we give better care and more cost effective care than our colleagues would do.

·         My broader skills are now integrated with the core clinical skills developed in Foundation and 3 years training

Recent and current graduates of GP training are competent in the key clinical areas, and graduates of extended training will be more confident ‘rounded; practitioners able to ‘step up to the expected mark' earlier in their post training career than most do now.

This will make them more attractive to recruiting practices, whether as a partner or salaried practitioner.

We have a workforce crisis in GP. Large areas of the country are ‘under-doctored' when measured as whole time equivalents per capita.

Taken alongside a parallel deficit in other members of the primary care team, especially practice nurses, we cannot continue to deliver the level of clinical services expected of us without increasing our workforce.

Placing GPs in their extended training in a range of primary care and community/outpatient settings within a locality will encourage them to stay in the area after graduation from training whilst giving them experience of integrating care across the services they have worked in – definitely a ‘win – win' solution for workforce planners, training bodies, service providers and the trainees themselves.

We cannot afford not to grab this opportunity for general practice and make it work.

Dr Barry Lewis is a GP in Rochdale, Lancashire, director of North Western Deanery and chair of Committee of GP Education Directors (COGPED)

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