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Independents' Day

How to ease the recruitment crisis? Turn back the clock on GP training

Professor Clare Gerada says GP training has become too cumbersome and may deter experienced doctors who might otherwise have opted for general practice

In times of stress and adversity it is always worth revisiting the past, not least to see how we can learn from it. Often we make small changes, which at the time seem sensible, but over the years have the cumulative effect of creating a stifling environment like the overcluttered homes of our grandparents.

We’re locking doctors in and removing flexibility

We now need to declutter. Begin to tidy out the overpowering, burdensome flotsam and jetsam – and in the context of general practice, this is the training processes for GPs. Despite the recent good news about increased funding in the General Practice Forward View we are still finding it hard to recruit to our GP training posts.

There are obviously well-rehearsed reasons for this, but I also wonder whether we need look beyond recruitment of medical students and retention of established GPs and examine whether our training regulations and the rigidity of the systems we have to qualify as a GP are acting as barriers to doctors already in training.

Diverting from hospital jobs

This is especially pertinent given the junior doctors’ dispute. It might be that many will rethink a career in hospital practice and will jump out of hospital into general practice. Their loss will be our gain and we should be ready to welcome hospital refugees into our fold. And before anyone shouts at me, I am not talking about ‘dumbing down’ our profession or making it the specialty of last resort – far from it. General practice will be strengthened by doctors trained in other branches of medicine, just as it was in the past.

Compulsory vocational training has been the single most important aspect of improving the quality and standards of our profession – and I was one of the first beneficiaries of this. But from a flexible process where the young (or not so young) medical graduate could meander through different specialties, gaining experience, competence and knowledge along the way, we now shoehorn doctors who are barely out of medical school into training programmes that will determine their entire professional lives.

Deep down I always knew I wanted to be a GP (influenced by my late father, himself a singlehanded GP) but I also knew I was excited by what I had seen and learned during medical school and house jobs. As with many newly qualified doctors, I wanted to show off my newly acquired skills. I wanted to prod and poke and stick tubes into patients and run for cardiac arrests and tell stories of medical heroism. After training in accident and emergency, then completing a senior house officer (SHO) medical rotation I decided to do psychiatry, for no better reason than I was interested in Freud. Finally, after realising how much I enjoyed every job, it dawned on me that my vocation was generalism.

But instead of having to start from scratch and take entry examinations just to be allowed to restart training as a GP (as medical students have to do today), I was able to fill in the gaps. I completed six months in obstetrics and gynaecology and then 12 months as a GPR (having my first baby in between).

No flexibility

The negative effect of the removal of the SHO role, which allowed experimentation and individually structured training, and its replacement with the Medical Training Application Service, means we’re locking doctors in and removing flexibility. This will be compounded by the new junior doctors’ contract, which risks removing pay related to duration of training and will require those who want to change specialty, potentially to come to general practice, to drop down the pay scale and takes no account of what they already know or have done.

In addition, GP training should be extended, something I fought hard for as RCGP chair. Three years might be enough to become competent, but it’s not long enough to become confident. Freeing up routes of entry and accreditation criteria, allowing for transferable skills, knowledge and experience into general practice and allowing longer and more personalised training should only be a good thing. It would (re)grow the pool of additional expertise in general practice.

This can only be positive for GPs, for patients and for the NHS.

Professor Clare Gerada is a GP in south London and former chair of the RCGP

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Readers' comments (32)

  • After 20+ years working as a partner in one practice then deciding to leave and continue as a locum it was sobering to see the speed with which all visible traces of a career were removed. The Practice Website was updated the following day and the NHS Patient website the day after. After 12 weeks off, not engaging in locum work my account was removed without notice. I wasn't expecting a carriage clock nor a portrait in the waiting room. What matters is the knowledge that it has been a privilege to work in a job where you can touch the lives of others, even make a difference and learn so much in the process. Locum life does not bring such rich personal rewards and has many other challenges. If I wasn't able to hold on to that sense of personal achievement there would be nowhere in the NHS that I could look to, to remind myself of the 30+ years service to that organisation. I am tempted often not to take on further work, not that practices are not extremely greatful if I do, but it is the enduring sense of lack of a appreciation by the organisation as a whole. I know if I did not work for more than 2 years it would be hard to return. The reason I mention this here is to highlight the the NHS does not value the experience you bring to a post. It lacks trust and requires you to regularly prove you are competent when you are fully engaged in a post. It doesn't care if or when you leave and will never remember anything you did. It will make it difficult for you to return. It will not offer you a single 'perk' or staff benefit, not even one free prescription a year. Sometimes it can be difficult to access even the same level of care as your patients as some colleagues are so anxious to ensure you are not treated differently you can feel you are being ignored even when you make so little call on the system. If you ever feel you are undervalued or unwanted from the day you start to the day you finish, you are probably right

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  • Lipstick on a pig
    GP is overwhelmingly disappointing. However horrible the training is or isn't you're still presented with a turd pie at the end.
    The only time I saw competition for GP was when the money was too good to turn down. This isn't difficult. If you want someone to do a job no one else wants to you have to pay them more.
    I don't know why this is so difficult to understand.

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  • Few years ago did my own GP training scheme made up of my choice of SHO jobs and then got accepted onto a GP registrar year with KSS. As one of my SHO jobs was a 'clinical fellow' job (but actually same teaching etc as the SHOs) RCGP tried to block my eventual training sign-off. Had a nightmare year trying to get it all through PMETB - it was also extremely expensive. Worked for a couple of years in the UK, but now much happier in Australia. Have no time for the RCGP now, felt that they stabbed me in the back, and I stopped paying their fees as quickly as I could.....

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  • Before I entered VTS, I had extensive acute medical and general medical training- approx 6 years worth.

    Paediatrics should be compulsory if not done previously
    General medicine or Geriatrics necessary for a good foundation
    Gunae, ENT, Derm, Psych all helpful.

    Extended training recommended for inexperience doctors i.e. those straight from Foundation training.

    Bring back the flexibility of the past.

    Promotion of the posotoves of GPing!

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  • If flexibility is introduced into GP training, we may end up with GPs who may never have had any passion to become a GP but forced to take it up as their career i.e. those doctors who cannot become consultants for one reason or the other then jump into General Practice. We dont want such failed individuals into General Practice, and sadly we already have plenty of them.

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  • There are immediate needs and long term needs.

    The immediate need is to get doctors back to being willing to be GPs.
    - end time wasting - unproductive screening exercises, approving consultant appointments, using computers for things that are simpler by hand.
    - persuade GMC and RHAs to offer direct inquisition and mentoring of doctors who make a mistake, rather than the legal process
    - government pays for medical indemnity
    - bring CQC and NHS Improvement to realism
    - sanction on patients who waste NHS time or bring about their own ill-health - community service, suggested donation, undertake mentoring and keeping a log, or adverse publicity and public shaming.
    - admit doctors to GP who pass MRCGP regardless of training.
    - bring back and increase seniority allowance
    - include language skills of the local population in calculating deprivation allowance and increase deprivation allowance
    - NHS no longer to be responsible for prescribing over the counter medicines and pharmacy list items.

    Long term -
    - re-integrate GPs and hospital doctors by having more routine secondary care provided by local GPs with staff grade accreditation in the specialty.
    - OOH community care to be provided by co-ops of local GPs.
    - base social workers and community nurses in general practice.
    - enhance democracy within practices - allowance for mutual management and wide-ranging partnership agreements
    - base some payment to both secondary and primary/community care on approval ratings from patients.

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  • I fully agree with Clare Gerada, but what can we do about it and how quickly?

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  • There is another option dear colleagues: Work directly for the people to whom you owe your devotion- Your patients!
    Leave the government out of the equation. Charge a reasonable fee like any person who provides as service. The people who want and appreciate your service will pay it...and those who do not....will leave you time to smell those roses.

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  • Flexibility of training is a very small fraction of problem.
    The disregard, not valued by the public and the government; a GP is not a doctor attitude towards GPs does not help.

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  • Am I wrong = did Shaba Nabi not find GP partnership intolerable and rightly so ?
    So, why are we advocating this branch of medicine.
    Pev and Kevin have gone.
    I am leaving. This practice is intolerable, physically and mentally dangerous to us GPs in exhaustion and stress, and financially unviable for many following a 40% reduction in share of NHS funding.
    Why oh why are we promoting General Practice? Are we not being disingenuous and deceitful?
    Should we not be saying 'Please stay away' instead?

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