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At the heart of general practice since 1960

Debate: Will restricting hospital training places encourage more medical students to become GPs?

Dr Katie Bramall-Stainer and Dr Phil Williams discuss

Dr Phil Williams

YES

Last month, Health Education England published its report, Securing the Future GP Workforce: Delivering the Mandate on GP Expansion, that it been holding since March. It neatly summarises the shocking state of UK general practice at the moment. There are now fewer GPs per head population than five years ago and not enough GPs are being trained. Increasing numbers of GPs are working part-time (both men and women) and there is an exodus of retiring GPs.

The most controversial recommendation in the HEE report is to remove 2,025 hospital training posts to create 450 more general practice posts - and I agree this must be done.

One popular solution proposed by others is to look for alternative models of care instead. I agree with the report’s authors that there is a crisis now in the workforce. We can’t fulfil the current demand for GPs so this requires immediate action. We cannot afford to wait until new models of care are developed, piloted and implemented.

We don’t even need to increase the total number of medical students. A report in 2011 showed that, if current training rates continue, there would be an oversupply of consultants and an undersupply of GPs.

In short, without removing training places from hospital specialties we will see medical unemployment in secondary care.

But would the recommendation to remove hospital training posts work in practice? Would ‘wannabe surgeons’ change their minds and become GPs?

In Northern and Mersey deaneries there were 10 posts for every 11 applicants to GP specialty training. Now 20-30% of applicants to general practice have it as their sole top choice. General practice is the most popular second choice for those applying to other specialties. If the likelihood of getting a job in cardiothoracic surgery is reduced, suddenly their ‘back-up choice’ becomes important. It will force medical students to closely examine a career in general practice.

It wouldn’t take a lot to show applicants to other, more competitive, specialties (such as the acute common care stem) that general practice shares the same attributes. I don’t believe we risk having a population of disgruntled ‘failed’ surgeons filling up the GP workforce.

In any crisis, strong leadership is required and bold actions must be taken. And during the current crisis in the GP workforce, we must not be afraid to remove the excess hospital training places.

If we don’t, we will be cosigning the next generation of secondary care doctors to the risk of medical unemployment whilst those in primary care continue to be overwhelmed by an impossible workload.

Dr Phil Williams is a GP in Lincoln is the RCGP’s national lead for First5.

 

Dr Kate Bramall-Stainer -LMCs conference 2013 - online

NO

Health Education England expressed surprise earlier this year at a vacancy rate in GP specialty training programmes of up to 40% in some parts of the country, which forced them to run an unprecedented third round of recruitment. Junior doctors aren’t stupid, quite the contrary. They read the papers, and they witness the pressure cooler environment first hand in their training placements - daily fire-fighting and frazzled tutors. They see colleagues emigrate or forced into early retirement due to burnout. They see practices in financial ruin and a continued disinvestment compounded by an inexorable rise in complexity and quantity of workload. No wonder they think, ‘No thanks’.

It has taken years of reduced investment for GP morale to hit rock bottom - but that’s where we are now. Ten years ago, the nGMS contract led to thousands of trainees actively choosing general practice - I was one of them. GPs were a contented lot and that shone through in every teaching or training placement.

But it will take years to turn this around again. The proposal for GP training to take junior doctors who don’t want to be GPs, and to place them in surgeries where GPs don’t want to be trainers, is optimistic to say the least. Presumably, this will push even more junior doctors away from the profession.

To suggest taking funding away from fallow GP specialty training programmes and use it to fund yet more hospital placements for failed GP applicants is simply madness. Why not ring-fence the funding to get returners back into practice? They’ll be back in their surgeries seeing patients quicker than it will take a F2 embarking on ST1 to qualify, and at a fraction of the cost. The political will is there to make this happen.

It’s not so long since the MTAS wrecked careers that were in full bloom. At least this policy proposal is looking to nip them in the bud. By all means, temper career expectations and streamline training programmes to meet society’s demands, but this is not the sort of moulding that responds to a blunt instrument. If you want the child to swallow the medicine, you’d better make it taste nice.

Today’s prospective trainees have eye-watering student loans to pay off and will receive an NHS pension no better than others on the high street. They will need a serious set of incentives to come on board. Address the chronic lack of investment, the rock bottom morale, the workload imbalance. Give GPs back their autonomy and increase our funding to a 12% slice of the NHS pie - that will improve recruitment.

But don’t restrict hospital training places in the vain hope it will make everyone want to be a GP. You’d be better off rearranging the deck-chairs on RMS Titanic.

Dr Katie Bramall-Stainer is a GP in Hertford and a member of the GPC.

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Readers' comments (6)

  • Ludicrous to try and micromanage people into General practice.

    Young medical graduates are bright and often over burdened with debt and without notions of loyalty to the NHS.

    I've seen many who are interested in general practice but cannot afford to enter our profession. After all they want to be able to afford to have homes, reasonable schools etc
    Of course hospital medicine may also not allow them that either. So what I am seeing is increased emigration or at least planning.

    I've had sev F2's sitting USMLE exams - planning to go to UAE or Australia on a permanent basis. This is unheard of but above proposals will accelerate this.

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  • Vinci Ho

    To have this debate seems meaningless without realising what is the origin/root of the crisis while this measure is only scratching the surface to fire fighting the consequence(s).
    The origin is the way government(s) has been treating general practice , the gatekeeper of NHS, full stop.

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  • Perhaps if GP's were treated like responsible adults highly skilled to do their jobs without someone standing over their shoulder be telling them how to apply a sticking plaster might help!

    It is appalling the way GP's are being treated, without any other issue, that in itself would deter anyone from joining this profession.

    GP's are grossly undervalued and any new doctors will not be around for another five years so what will bridge the gap?

    Roll on the next election!

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  • Yes, GPs in Australia, Canada etc

    Let the exodus begin

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  • As the parent of two NHS doctors, one of whom is in GP Training, and both of whom have sizeable student loan debts, and would like to get on the housing ladder one day, it is imperative that the proportion of the NHS budget that is allocated to Primary care - specifically ring-fenced - be increased to the 2004 levels, or higher.

    Though not a statistically valid sample by any means, 3 of the 6 housemates that one of these doctors roomed with for the last 6 years are currently in Australia. Around 60% of doctor graduates are female these days, and statistically this means a lower proportion of career-work-days from this medically qualified personnel "stock".

    And with the currently planned extension of GP Training from 3 years to 4 years, there are icebergs ahead, and the "Good Ship NHS Primary Care" had better start to change course NOW! All Politicians, please take note.

    It is also well past time for the general public to stop expecting "24/7" medical care as if these highly specialised and life-critical skills were the same as it takes to run a 24 Hour petrol station or fast-food restaurant.

    For the vast majority of UK citizens, it would be a terrible shame for them to find out too late just how good they have had it with the NHS care they receive. Yes, continue to keep a reasonable level of pressure on NHS staff at all levels, in order to maintain and improve the delivery of clinical care. But the funding proportion allocated to Primary care must be reinstated to earlier levels.

    Playing off Primary and Secondary care against each other will doubtless continue, not to mention the Social Care contributors. But any implosion of these collaborating partners must be avoided.

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  • GP trainee recruitment crisis + GP retention problem and mass GP exodus + early retirement = GP workforce crisis.

    During the last six years for which records are available 12,486 GPs have left the profession. It costs £247,000 to put a family doctor through post-graduate training- (12,486 GPs X£ 247,000 = £3,084,042,000) (RCGP publication dated: 04 July 2014). Let’s suppose a bank lose over 3 billion pounds, then what would happen. Forget about depriving patients form the care these GPs could provide or the time spent on their training.

    I think asking GPs to come from Australia or Canada is a fantasy and over optimism. Make conditions better here, then it could be a possibility.

    Those GPs who already left medicine for more than 2 years, I don’t think they would come back due to dropping confidence in practising medicine. In addition, conditions for practising medicine are not better now in comparison when they left, so why should they come?

    Asking foundation doctors to spend time in general practice is madness as general practice is a very broad- based specialty. Poor newly qualified foundation doctors may be overwhelmed in general practice and there is a risk that they would leave medicine all together. They can’t work independently and where would you get the trainers from in supervising them in seeing every patient?

    Restricting hospital training and forcing trainees and forcing them to general practice is not a good idea. Then you would have a problem in retaining them in general practice. Looks at the above, already alot of money wasted on training, and don't wast it.

    Lastly, one good source doctors and readily available is ex-gp trainees who failed are role player CSA exam, but RCGP mostly turns a blind eye to it. Most of them have several NHS hospitals experience and work back at the NHS hospitals after failed CSA exam. Make CSA exam fairer for IMGs and it could help a lot towards the GP workforce crisis. There is no need in arguing for fairness in CSA exam by looking at the statistics for a very high discrepancies in failure rate for UK and non UK graduates. If you don ‘t believe in statistics, stop practising evidence-based medicine now.

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