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At the heart of general practice since 1960

Hospitals are draining general practice of its new blood

Acute trusts require huge numbers of junior doctors just to run, says Professor Bill Irish, but they are making a looming shortage of new GPs worse

There simply aren't enough GPs in the UK. 

While perhaps not the most glamourous branch of medicine, there is extensive and compelling evidence that general practice is the lynchpin of medical care in this country.

Some 300 million consultations take place in primary care each year in England alone – 90% of all NHS contacts occur and 98% of all prescriptions are issued outside hospital. There has been a massive expansion in the number of hospital consultants during the last decade, but this has not been matched in primary care.

Such modest increases as there have been are offset by decreased rates of engagement among a younger generation who value part-time working and the opportunity for career breaks. One recent study suggests a need to train between one and a half and two new GPs for every retiring senior GP.

In addition, while there has clearly been a trend towards delivery of primary care by non-medical clinicians, there has actually been a surprising decrease in the number of trained practice nurses working in general practice. Has all of this work really been mopped up by healthcare assistants? This is an area desperately needing further research.

The Centre for Workforce Intelligence recently recommended a further 17% increase in the number of GP speciality trainees just to balance the anticipated retirement bulge over the next five years – something that will be certainly accelerated by the double whammy of revalidation and changes to the NHS Pension Scheme.

Where are all of these young doctors to come from? The harsh truth is that few newly qualified young doctors view general practice as an attractive job. 

Only about 20% describe it as their first-choice career, a finding reproduced in most developed countries across the world.  Deaneries outside London and the home counties consistently struggle to recruit competent trainees – particularly in areas of high socioeconomic deprivation and geographical isolation.

Bleak career prospects

Why should this be? Are medical schools selecting the ‘wrong' sort of student? Is the undergraduate experience of primary care inadequate or of low quality? Why is it that fewer than half of foundation rotations include general practice? Or is it instead simply an accurate reflection of general practice as an unfulfilling, undervalued and poorly remunerated career?

After a massive increase over the last decade, UK medical school output has increased from 4,000 to just over 6,000 graduates per annum. But the demands of European working-time compliance, and a model of hospital service delivery that still depends on trainees rather than fully trained specialists, has mopped up virtually all of this expansion. 

Somewhat cynically, acute trusts require huge numbers of young doctors simply to maintain service delivery. In the surgical specialities particularly, the career prospects of trainees are appalling. Many now face unemployment or re-training after seven or more years of hard work and study.

What is to be done? The bottom line is that a hospital acute medical service run exclusively by partially trained young doctors has surely had its day. We need a model of secondary health care that relies on far fewer junior hospital trainees.

If your father had a myocardial infarction this evening, wouldn't you want him to be immediately assessed and treated by a fully trained cardiologist?

The UK Departments of Health hope for a situation where 50% of all medical school graduates are trained as GPs, with far fewer going into hospital training programmes. To achieve this. however, they need to take on the might of large and powerful lobbies including large foundation trusts, the royal colleges and ambitious young doctors themselves – who see a career as a well-paid consultant as their birthright.

Professor Bill Irish is chair of the GP National Recruitment Office, director of GP education, at Severn Deanery and a GP in Radstock, Somerset

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