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Reimagining the UK’s shortage of GPs

Dr G Richard Olds

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Anyone with even a casual interest in current affairs will tell you that the UK has a serious doctor shortage. While it’s true to say that the UK needs more doctors in absolute terms, far more serious is the UK’s maldistribution of doctors, both by specialty and by geographic area. Simply producing more doctors will not remedy the problems facing the NHS.

Between 2012 and 2017 the number of specialists working in emergency medicine increased by 25%; in paediatrics by 16%, radiology by 9% and gynaecology by 7%. Over the same period, general practice saw a rise of just 3%; below the UK’s population increase during those five years.[1]

Similarly, the ratio of doctors to patients is unevenly distributed throughout the UK. The BMA reports that vacancy fill rates are lowest in the North East, Yorkshire and the Humber, and are decreasing in the East of England and the West Midlands. London and the Southern regions fare better.

That the number of medical school places in England is to increase should be welcomed, but it will not solve these fundamental problems. The current system is producing doctors who disproportionately avoid general practice and who don’t want to work in areas with the greatest need.

The biggest determinants of where a student will ultimately practice are where they finish training and where they are actually from

In the short-term, recruiting from overseas may help to plug the gap – and the easing of UK visa restrictions for doctors will certainly help. In the long-term, however, countries must increase domestic capacity in an effective way for the outcomes desired.

Currently, medical schools themselves introduce a bias for specialisation over general practice being attached to university teaching hospitals with faculties comprised mostly of specialists. This means students spend little time in outpatient settings, with role models unlikely to work in primary care. It is encouraging that some UK medical schools are taking steps to address this – with Anglia Ruskin reported as looking to increase students’ exposure to general practice early in their education with the hope of reducing the severe shortage in Essex by partnering with local GP surgeries. This will help, but we must also consider other factors known to drive a doctor’s career decisions if the number of physicians working in primary care is to rise significantly.

We know that where a student goes to medical school is not a good predictor of where they ultimately practice. The biggest determinants are where a student finishes their training and where they are actually from. So creating more postgraduate general practice training places in the geographic areas of greatest need, and recruiting medical students from these areas in the first place, will improve outcomes in terms of getting GPs practicing where they are most needed.

Outcomes could be improved further if medical students were more likely to become GPs from day one, which comes down to how universities design their selection criteria. Those going to medical school must be qualified to do so, and a high minimum threshold must be set – but once a pool of qualified students has been identified, it makes more sense to recruit based on characteristics that predict the likelihood that an individual will go into general practice.

When I founded a new medical school to address the chronic shortage of doctors in Inland Southern California, we selected from the pool of qualified candidates those who had done community and voluntary work, spent time in the Peace Corps, or who had travelled furthest relative to their peers in terms of the their schooling – all of which are good predictors of how likely it is that a graduate will end up practicing primary care in their community. This has proved remarkably successful.

We employ similar measures at St George’s University (SGU), my current institution. Among those who are qualified to enrol, we look for the qualities that make for highly skilled medical professionals with a propensity to work in underserved areas and specialties.

As a result, around 70% of SGU graduates go into primary care. Crucially, because they were chosen based on their likelihood to want to work in these kinds of clinical environments, they are more likely to be fulfilled in their careers and less likely to leave – another issue facing general practice in the NHS.

In the UK, the current model of medical training is not producing both necessary and desired outcomes in terms of the proportion of graduates going into general practice in underserved areas. Simply increasing the overall number of students going through this system is not the answer. If we want to redress this imbalance, we must seize the opportunity to do things differently.

Dr G Richard Olds is President of St George’s University in Grenada, West Indies. Dr Olds is a tropical disease specialist and is former Vice Chancellor for Health Affairs and Founding Dean of the School of Medicine at the University of California, Riverside.

References

1. GMC. The state of medical education and practice in the UK. 2017.

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Readers' comments (12)

  • All very true BUT the working life of the GP needs to improve if young graduates are to be attracted and retained in meaningful numbers.

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  • Dependant on working conditons,if the Job is s**t with no joy in it and no real benfits trying to fill it up will not work.You also need to look at hospital junior dr post.There are a lot of holes in the rotas now my friend.A decade + long pay freeze/cut will no aid your effort either.Add to the the establishment ready to handg the nearest proffessional out to dry for its failures tis doomed to failure.The whole mess is alot more complicated tha the feeding in at the bottom.Now dont get me on the decade it will get medical student to become useful GPs.Sadly this all should have been done in 2004.Only 15yrs late.

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  • Interesting. Would be good to know the stats on state vs private education on career outcomes as well.

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  • David Banner

    Once GP sinkholes open up, and GPs desert these areas, then no young doctor will want to join these failing practices. The only practical solution is to financially incentivise them to join and stay.

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  • GP has been transmuted into ordure and no matter how you polish it the smell lingers on.

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  • Interesting,if not unique,in presenting an alternative narrative to that presented by the college,bma,lmc, deanery ,politicians etc.

    Unfortunately,thereafter it breaks down somewhat.

    It is not the number going into practice that is the concern,rather the number happily successfully and lucratively practising 10,20 years down the line.

    The claim that they are less likely to leave,why ?

    There needs to be some substantiation,have you no data,no measures, no supporting evidence.

    A British deanery most certainly would not have,they do not gather the data,they do not make any effort to find out,they do not consider the question,nobody has ever required them to do so.

    There has never been any evidence,ever to show they are achieving anything other than collecting their pay and gongs.

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  • Make General Practice as a profession more attractive and the workforce will follow. Whilst GPs are over-worked, under-paid and with no clear plans for the future of General Practice then you can't blame trainees for staying away.

    It can still be a great choice as a career but it has lost its way currently - we need leaders to step up and demand change for the better. Without that I see the profession dying a death over the next 10 years, being replaced by a salaried service with a propensity for GP associates, Paramedics, Nurses and Pharmacists.

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  • Deprived areas are full to the brim of heartsink patients. Language and cultural barriers make your day job unbelievably stressful. Worried well are a problem of affluent areas but nothing compared to the depressive polypharmacy of the inner city and sink estates

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  • Interesting reading in the comments here. Ponder this- could some of your comments re: retention, managing the adversities of working in GP today, and even descriptions of ‘heartsink patients’ reflect your own backgrounds, where you came from, where you saw your careers and lives going when you first embarked on your paths?
    You are all so fixed on the’shit hole’ that is General Practice here and now, but changing that in the long term is about a hell of a lot more than making our own beds more comfortable, it’s about engaging and encouraging the people who will be most contented and prepared to work in future GP. Addressing the issues from all sides.

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  • This article is full of pompous self-congratulatory nonsense, almost overflowing in quantity.

    1.Do you honestly believe that university medical schools and their close relationship with specialists, inadequate as it is in some ways, could readily be replaced by having more GPs doing more of the teaching? We learn, we pass exams, and then knowledge withers away unless one remains very motivated (beyond the bullsh#t of "doing ones appraisal"); to be taught by the mediocre to establish ones baseline knowledge is a sure-fire way to produce low quality practitioners.

    2. Doing voluntary work in the UK, or Peace Corps service where the author resides, are just a means of making the right noises ("I want to help people" without using the words) and these days seems to be something pretty much expected from those applying to study medicine. With regards to the UK, I fail to see how this can then be used as a predictor of ending up in primary care.

    3.The author also appears to have no firm notion as to why general practice is unattractive as a positive career choice these days. If he believes that the kind of person who has done voluntary work would be blessed with an enlarging blindspot towards the reality of the job then he should consider the view from the ground instead of the vista from his ivory tower.

    4. He claims that his medical school has produced "highly skilled medical practitioners"; perhaps he could tell us of the assessment procedure his outfit makes to have reached this conclusion. Are the doctors actually tested on patients with clinical signs, or is it like that inadequate joke called MRCGP which assesses one for a seasons work at the Royal Academy of Dramatic Art?

    And to Catherine Welch- can you perhaps expand on "the people" who need to be engaged with and encouraged to a life in general practise where they will be contented and still grafting 20 years later? Who are they? What are their characteristics?

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