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Analysis: ‘The end of GP training as we know it’

Plans for training practices to pay trainees’ salaries could cause the whole system to collapse, the GPC is warning. Jaimie Kaffash looks at the implications

‘We don’t do training to earn money,’ says Dr Alistair Howitt, a GP trainer in Tonbridge, Kent. ‘We see it as part of our professional commitment. It is training the next generation.’

But he and other GP trainers are reeling in shock at Department of Health plans to make practices pay for the ‘benefit’ they get from a trainee.

A ‘tariff’ system being introduced by Health Education England (HEE) – exclusively revealed by Pulse – could see training practices having to contribute to the salaries of trainees, as ministers look for ways to help fund the sharp increase in GP numbers needed to meet rising demand in primary care.

The plan has prompted GP programme directors to warn that the system could collapse, with dire implications for the future of general practice. The GPC has also reacted angrily, claiming the plans could ‘spell the end of GP training as we know it’.

The move towards a tariff was included in the business plan published in July by HEE, the new body responsible for NHS workforce requirements.

Although HEE is still considering how the tariff will be applied, in secondary care – where similar plans are due to be rolled out from April 2014 – the Government’s favoured option is that the training hospital pays 50% of a trainee’s basic salary plus a placement rate.

A figure for GPs has yet to be set, but HEE says it is ‘considering all options’ for how any potential levy will work.

Practices are currently reimbursed for 100% of trainees’ salaries by local education and training boards. They are also given a £7,600 annual trainer’s grant. But the DH believes having a trainee available gives practices an advantage they should pay for.

A DH impact assessment of the plans says: ‘The current arrangements for postgraduate medical training in primary care provide funding for 100% of the trainee’s salary, taking no account of whether the trainee provides any service (benefit) whilst they are training.

‘Introducing tariffs, based on the costing exercise, will allow us to address this and remove any advantage there may be to a practice who takes trainees.’

A special relationship

But GPC negotiator Dr Beth McCarron-Nash, who is a partner at a training practice in Cornwall, says any attempt to impose charges for the service provided by GP trainees will be the ‘straw that breaks the camel’s back’. 

She says: ‘It’s mad. Although training practices, such as mine, value training young doctors, there comes a point where the workload is so high and the impact on practices so significant that unless it is remunerated properly, they will throw in the towel.’

The DH is trying to apply a system that can work in secondary care to general practice, where it is inappropriate, Dr McCarron-Nash argues.

‘The training we give is completely different to that received in hospitals. That one-on-one relationship is absolutely fundamental to the quality of the trainee that comes out at the end of that process.’

Other GP trainers have pointed out that hospitals rely on the services provided by junior doctors to continue functioning, whereas hosting a GP trainee is at best cost-neutral for practices.

Dr Krishna Kasaraneni, chair of the GPC trainees subcommittee, worries that payment will fundamentally alter the special relationship between trainee and trainer. He says: ‘It’s no secret that practices are struggling financially, and asking them to pay for the privilege of training is not going to go down well and could spell the end of GP training as we know it.

‘At the moment, I can go to my trainer and say “I am lacking experience in ENT, I would like to practise in an ENT clinic soon” and they will say “fine, off you go”.

‘But if they are paying for my services, and I say I want to go to ENT, they are likely to say “you can’t, because we won’t have enough GPs that day. I’m paying for you, I expect you to be in the practice and do work”. So how do I get trained?’

A ‘collapse’ in training

The plans come as the NHS determines how to pay for the planned introduction of a fourth year of GP training.

Pulse reported last year that the Committee of General Practice Education Directors was in talks with the DH over a national tariff for service provision by fourth-year trainees, in a bid to offset the extra cost and persuade ministers to approve the longer GP training period.

The NHS already has a huge job on its hands to meet Government targets for 50% of all medical graduates – 3,250 each year – to go into general practice by 2015. This year, the number of recruits for the August intake was 2,787 – an increase of just 95 on 2012 figures.

An HEE taskforce is developing plans to meet the targets, which it says will be published in ‘due course’.

But GP vocational training scheme programme directors agree that a recent 20% rise in GP trainers could be kicked into reverse if the plans to charge for trainees go through. Dr David Griffiths, programme director of the Oxford District GP training scheme, says a number of practices will stop training ‘immediately’ if they have to pay trainees’ salaries.

 He says: ‘We can’t afford to lose any training places; we already get complaints that the grant is insufficient. There is also quite a big retirement time-bomb with trainers and this could tip a lot of them over the edge.’

Dr Stuart Calder, programme director for the York GPVTS team, says: ‘It is likely that training would collapse in the York area. Training places demands on practices, which receive recognition appropriately with a grant.’

But he concedes there could be a rationale for practices paying for a trainee in their fourth year of training. ‘If a fourth year of training came in, a case could be made for some payment, as this would be equivalent to taking on a salaried GP who has just finished training.’

A looming shortage

Professor Bill Irish, chair of the GP National Recruitment Office, declined to comment on the proposals to charge practices because, as director of education and head of school at the Severn Deanery, he is also an employee of HEE. But he admits there is a looming shortage of training practices given the need to increase places.

He says: ‘The degree of the problem depends on the area. Areas with high workload, deprivation and isolation generally have less capacity. HEE and its regional offices are working hard to develop the necessary training places.’

But this is of little comfort to Dr Howitt: ‘To be a GP trainer, you have to get a postgraduate certificate in education and that takes a long time. If we effectively had to pay to have a trainee and we looked at the implications, the obvious thing would be to have a salaried doctor come in and do the work – that is a million times easier.’

Additional reporting by Bethan Eynon and Madlen Davies

Case study: ‘We will stop or cut down on training if we have to pay’

Readers' comments (20)

  • Is general practice going to survive?Doesnt feel like it at the moment

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  • Hazel Drury

    I am a single hander. Not through choice, I kinda ended up here locuming 12 years ago and stayed. The geography of my locality is that we have small towns strung out along the coast of North Wales. These towns are populated by many elderly retired who are unable to drive. We generally have poor public transport and taxis are expensive due to large distances involved. Most are unable to get to super surgeries in the big towns so we have many single handers in the county. Alas we are treated the same financially as big practices. 2 of us have no MPIG as we were set up after 2004.
    What will happen with these elderly communities if we are driven out of business?

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  • Hazel Drury

    There again, in Wales there is no CQC or CCG. Having said that though, there are precious few GPs the way things are going.

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  • The harsh reality is that deprived areas of all types are being neglected be it rural poverty or inner city. the obsession with competition means people will suffer.

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  • I think the future of general practice is that anyone with any sense will quit. I am amazed that so many GPs still plug away at a job that becomes more untenable each year. I left years ago when all this stuff was starting.

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  • I think you're right.Most single handed practices are run by first generation immigrant doctors from the Indian subcontinent who are now close to retirement age.These practices are usually based in deprived inner city areas.The likelihood is that they will end up becoming branch surgeries of larger federated practices

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  • Amazing comments to make, large organisation eg nhs England apparently can't sort out payments even though its bigger, so no idea why small practices have to fail or be made to fail.
    Most community services , social service budgets do not come under general practice at all so economy of scale is meaningless.
    The real success came under fund holding back when there loads of small practices and when gps had 24 hour responsibilities as well and could commission community service directly,
    The only reason to federate is more a work force issues ie to have enough holidays, sick leave etc for cover and that's about it.

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  • GP'S become trainer because it is free to have extra pair of hand after initial few weeks and they learn and we have some help. symbiotic relation.trainer need to do a lot to stay being a trainer. i would never had a trainee registrar if i have to pay a penny from my pocket . we are self employed and have no obligation to teaching free of charge. does maths teacher work for free??

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  • A GP trainee adds to the work load unless they are exceptional and sadly our recent trainees with a few exceptions have been a real challenge. We have already got very to withdrawing from being a training practice due to the poorly remunerated extra work trainees cause. Clearly NHSE is completely out of touch with general practice.

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  • Pipin Singh

    If the government continue their current form, they will drive out committed dedicated doctors to other countries and possible other specialities (as is already happening) There is no way I think they will increase the number of entrants into GP currently! The mood is shifting in our proefession. They are making it undesirable and it's such a shame! I speak as a new partner, intending trainer and someone heavily involved with GP recruitment. I thoroughly enjoy my work and the variety/challenge it brings but the demands are now starting to border on unrealistic and I really hope the government act soon to change the direction of things. I suspect a recruitment crisis is not too far off.

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