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CAMHS won't see you now

GP workforce strategies must focus on medical school culture

Dr Ahmed Rashid writes

In the time between the publication of the Five Year Forward View last October and David Cameron’s outline of plans to launch seven-day NHS service after the Conservatives’ election win, talk has focused on the huge expansion of GP numbers that will be needed to fulfil these ambitions.

But let’s forget the future visions for a moment. Even if practice opening hours are not extended and GPs are not asked to take on more work from hospitals, there will still be a huge shortfall in GP numbers across the NHS.

In short, even if we ignore the fact that we’ll soon be asked to swim the channel, we can’t ignore the fact that we’re already drowning.

A number of solutions to the general practice workforce problem have been put forward. Many have argued that improving the working lives of GPs across the country is the only way to attract new doctors.

Some have suggested alternative primary care systems are needed such as the community health worker model where each GP leads a team of allied staff. Others, meanwhile, have proposed the slightly more controversial approach of trying to ‘control’ patient demand.

All of these suggestions are probably valid to some degree. But the elephant in the room, for me, is the fact that UK medical schools continue to demean general practice as a career choice.

The best way to transform the workforce would be to radically increase the number of qualifying GPs. Although we can’t force doctors to apply to GP training, we can endeavour to provide positive and balanced experiences to drive these choices and the responsibility to do this must rest largely with the institutions that build and shape doctors in the first place.

It is important to acknowledge that almost all medical schools have increased the proportion of curriculum time spent in general practice in recent decades. But although a recent study suggested this has been a positive move, time spent on general practice is now in decline at some schools. Although exposure to the GP environment is undoubtedly important, it’s actually only one piece of the jigsaw. The reason that GP placements were so short in the first place is theThe longstanding culture of idolising specialism, which generally lives on despite that prevails in most schools across the country is arguably the increase in GP curriculum timemost fundamental piece of all.

We know from countless national reports of the NHS in the last decade that culture and leadership are enormously important to all organisations. Medical schools are no different and have long been steeped in a culture defined by the scientists and hospital consultants that run them.  From their induction week onwards, medical students are exposed to negative attitudes about general practice and are trained with a philosophy that values highly specialist and technical knowledge over human skills. Although communication training is now well established in all medical schools, most distinctions and prizes are still awarded to students who can memorise facts about rare, eponymous diseases.

Time for a review

Medical schools should start looking GP role models to show how important and interesting the specialty in their own primary care research centres.

I find it incredible, for example, that Oxford produces less GPs than most other UK medical schools despite having some truly inspirational GP professors. What is the medical school doing to showcase these world-famous, charismatic GPs who could be incredible role models to undergraduate medical students? Not enough, it might seem.

Of course, it isn’t just Oxford that this applies to. There are amazing GPs across the country in a variety of exciting roles from pre-hospital emergency care to global health. Medical students are generally exposed only to local teaching hospitals and practices and may not appreciate the enormous influence and authority that GPs have in regional and national roles.

Although medical schools may slowly be starting to get the message that they need to promote general practice, I’m not convinced that this will lead to the dramatic culture change that is needed.

One solution might be to establish a national review of UK medical schools to determine exactly how GPs are currently involved in aspects like admissions, pastoral care and designing assessments. This report should help to inform an overarching national strategy and in turn, each school should outline a ‘personal development plan’ that describes the steps they will take to help nurture the future workforce of GPs that the NHS so desperately needs.

Dr Ahmed Rashid is an academic specialty registrar in general practice in the East of England LETB.

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Readers' comments (22)

  • Oh, boring.
    Good luck with that one.

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  • Has anyone actually asked the medical schools why they cut the time spent in general practice. Was it poor feedback from students, poor learning outcomes, financial pressures or the pressure of the curriculum, much of which is externally mandated. I really doubt it was because they couldn't be bothered. It might help to know what the explanation is ...

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  • Load of old rubbish. Drs aren't stupid clones. In 2005 my cohort of surgical shos in rotation all went to gp after seeing it was a relatively good specialty. 10 years later things have changed and people are leaving.
    Have more respect for doctors' intelligence. This is the same line of thinking as Pollyanna and her video.

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  • Improving the job will improve recruitment, sure.

    But constantly being told from day one that its a soft option and for the least talented doctors doesnt help either.

    Need to tackle all areas INCLUDING medical schools.

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  • I think the author has put forward some valid suggestions here although, from my own experience whilst at medical school, what universities promote was largely irrelevant. Undoubtedly as a student, consultants were idolised and seen as the "gold standard" and emulating their achievement and modelling their career path was an aim of some of the brightest students. However what the author has failed to mention is that students themselves garner experiences in specialities sometimes whether they are exposed to them or not.
    I remember around 2002-3 when I was half way through medical school talking to a bunch of friends 2 years above me sitting their finals. Several of this bunch were intent on becoming opthalmologists because they were led to believe at the time that it was by far the most prestigious speciality in terms of knowledge and pay. When probed further they would suggest that it's contained both medicine and surgery and also that at the time there was large waiting lists for cataract surgery which meant huge potential private income for very little effort. These conversations led a few of is younger naive and credulous students to also decide that opthalmology was the career path we should also follow!! I even went so far as to choose a special surgery block in the wretched subject and left after 3 days because all I saw was clinic and I couldn't get the bloody hang of the slit lamp and Everytime the consultant asked me to have a look through it would say "do you see that?" I would reply "yes" when in reality I hadn't the foggiest what he was referring to or what I should be looking at!! Nevertheless 2004 the year of my graduation also signalled a change in the gp contract and the culture shifted from working in a hospital under managers in a hierarchy, to working for yourself in a shorter training scheme and independence after 4 years with a hugely increased salary.......the smart choice therefore was general practice and loads of medics and wannabe surgeons were jumping ship.

    The reality is that no matter what medical schools or even workforce planning intend, medics talk amongst themselves and know where the action is. 2008 when I became a GP emigration was unheard of. I think Australia back then expected 5 years of experience before they would consider you. I believe their regulations loosened around 2010, and along with them the first trickle of new graduates made the move. Now we know that trickle has increased to a full blown flood and we're at the point where registrars know they can emigrate in August as newly qualified GPs and earn upwards of £150k whereas a salaried job in sunny England will perhaps earn them £60k for a lot more effort and hassle.

    As an earlier poster pointed out, students aren't stupid. They will figure out and modify there life choices based on pragmatism and practicality. If general practice is serious about attracting recruits then the whole package of good conditions, attractive remuneration, career progression, work life balance, control over workload, autonomy have to be put back into the equation. If not even the ones who enter training will leave for greener pastures abroad.

    The world is a village now, and uk qualifications are sought after worldwide. The world truly is your oyster even if the uk doesn't recognise this!!

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  • This rather patronising article assumes that medical students are brainless automatons who are incapable of making their own decisions.If they are indeed swayed away from general practice then all the better.It will spare them years of misery.

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  • Azeem Majeed

    Dr Rashid makes some useful suggestions about promoting general practice in the undergraduate curriculum One example is using GPs who have high profile posts in research, clinical practice, global health, management or health policy to lecture medical students.

    However, I like most other medical school academics feel that the onus remains on NHS England (and its counterparts in Wales, Scotland, and Northern Ireland) to improve the working conditions of GPs.

    One final point. When writing this kind of article, you are giving one side of the argument. Dr Rashid will be fully aware of the counter-arguments to those he expressed in his article. There is no need for personal attacks on him. His arguments can be argued against without using personal comments.

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  • GPs have more general medical knowledge than any other Doctor. So why shouldn't GPs be at the top of the medical hierachy, with the highest income and merit awards. All Consultants would be employed by GP run organisations. That would sort out recruitment overnight.

    Only kidding.....

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  • @ 11.24

    GPs are needing to be very competent general physicians with a huge amount of knowledge and expertise to handle the demands of the job. This, despite being looked down upon by specialists who prescribe a handful of drugs and deal with pre-triaged patients and who would be out of their comfort zone if presented with something a little different. (Cue the surgical ward round where a patient was referred to the med reg for athletes' foot, the patient with shingles who spent a week under general medics and was referred to dermatology before being diagnosed - actually heard these accounts from patients themselves).

    In the end, I feel, that generalists will be key and market forces will dictate better terms and conditions for those GPs left. The rule of business, 'last one standing', will prevail and come true.

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  • I suspect that a major factor is the size of medical student loans, and the difficulty of paying them off on a GP salary ( along with mortgage / buying yourself into partnership).

    The possibility of Private Practice / emigration makes hospital based training much more attractive.

    Ret' d GP.

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