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At the heart of general practice since 1960

Future GPs shouldn't be trained in hospitals

We must stop the nonsense of making future GPs spend most of their time training in hospitals, argues Dr Sam Everington

There has to be a complete review of the training of GPs. It just does not make sense to hand four years of GPs’ training to a hospital while we give them only one year in general practice.

If a junior doctor wanted to train as an anaesthetist, and was told to spend four years in general practice and one year training as an anaesthetist, how would we expect that doctor to feel?

I believe medical graduates should have the option to be GP trainees right from FY1. Five years’ training based in general practice for newly qualified doctors would offer many advantages. As GPs, we could provide personalised training; they would have the same GP training practice/mentor for five years. They would also have continuity of care with patients – impossible when they are moving around every four to six months.

And the training would be comprehensive from day one. Seeing 20 patients in a morning provides a concentration of learning. Similarly, if a student wanted to learn about a specific condition, I could find four patients with it and ask one of them if they are willing to have a chat with the student.

If they need training in hospital specialty areas, they should do it from a general practice perspective. In dermatology, for example, a trainee could sit in on an outpatient clinic for a week or two. If they needed training for maternity, they could spend a week in the labour ward.

As well as this, allowing trainees to live and work in the same place for five years would create great support and stability. This is a major positive. In 1989, I led the junior doctors’ campaign to reduce the working week to 72 hours from 84. So I was surprised when the recent junior doctor contract became a dispute. Juniors told me stories of moving house and job frequently, feeling unsupported and generally demoralised.

The option of primary care-based training for newly qualified doctors could be one of the solutions to a stressed junior doctor workforce.

Such a change would also be a meaningful move to parity between generalist and specialist training, at a time when an ageing population means a far greater need for generalism in primary and secondary care.

At the same time, it will make sense for the taxpayer. Health Education England estimates training in general practice is a third cheaper than in hospital. A huge amount of work has shifted into primary care – the majority of diabetes and heart disease is handled in that setting now, as is basic paediatrics. Most consultations take place in primary care, making it easier for trainees to learn in general practice.

Also, we need to ask if our graduate and postgraduate training is fit for a world where the internet can equip patients with medical knowledge, complex care is expanding, and technology – such as online GPs or remote monitoring – will take over many of our tasks.

But most importantly, it is time to show confidence in ourselves as trainers of future GPs and base the five-year training in general practice rather than hospital.

Dr Sam Everington is chair of NHS Tower Hamlets CCG

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Readers' comments (10)

  • I'd probably chuck ED in there, nothing quite like ED to teach how to spot a sick person.

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  • I think you need Obstetrics and Gynaecology as well.

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  • Vinci Ho

    I see where you come from.
    Arguably, a job of GP training in the same place for 5 years from day one is attractive to avoid being exploited as work labour in hospitals. Cheaper or not , not sure .The caveat is being used as another way of clandestine austerity , given the situation of funding in HEE.
    But clearly, this ideology needs a very thorough thinking and organisation so that trainees can truly acquire skills from different specialties to survive in general practice nowadays and at the same time , they can enjoy the training ........

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  • I agree, although I think longer periods of time should take place in hospital outpatient clinics and ED. None or little time should be spent on the wards. It would also provide some help for overworked GPs, but how would hospitals cope without junior doctors training to become GPs? Hospitals are already finding it very difficult to recruit. Mind you that would be a hospital problem. Actually I think doctors in training to become consultants should all spend at least six months working in primary care.

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  • Plan to do the split week between Hospital OPD/ ED and GPs for the first year then divide the rest of the training between 2 practices to see the variety.

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  • Is rather concerning that GP trainees are regarded as a workhorse in most hospital posts with little if any training. I am in full agreement with this article. It is also of concern that despite repeated poor feedback in the gmc training report that these rogue departments do not have their GP trainees withdrawn. One has to wonder if GP deanery professors /TPD are actual frightened or subservient to hospital consultants.

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  • Azeem Majeed

    Thanks Sam. An interesting article.

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  • Healthy Cynic

    I think that the danger is to further foster the belief in GP registrars that they are 'learners' rather than 'workers'. We are all learners, even after 25 years at the coalface. A GP registrar (who may be 4 years post-qualified) needs to provide a service firstly (to justify that salary) and then to take the opportunity to learn from that job.
    I am also concerned about continued dumbing-down of new GPs. If you have not admitted acute abdomens at midnight and spent the small hours assisting in their laparotomy, will you be as capable of recognising an infarcted bowel or a pancreatitis?
    Or are we saying that the need now is to train GPs to do repeat prescriptions, fitnotes, and treat URTI, but to refer everything else to an expert?

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  • Could we turn this proposition on its head? All hospital specialty trainees should spend more time in community training, where appropriate. Or just, GP trainees should spend longer being supervised in the community.

    As a GP who trained first in a hospital specialty, I had the opportunity to manage very unwell patients on HDU and on the wards. Unfortunately I am not sure all GP trainees are given those sorts of opportunity. Perhaps, in fact, they don't spend long enough in any specialty, to be trusted to 'do' things. Or they are treated as not needing to get certain types of experience because they are the GP trainee. Rather, they are by-passed and relegated to doing ward admin 'service' tasks rather than more 'training' tasks.

    There aren't a lot of sick patients in the community. Being able to spot people who are progressing towards the knife edge is critical to being an excellent GP. That case type is much more prevalent in the hospital.

    Rather than shortening the in-hospital experience, extending the post-hospital apprenticeship is a better idea. Or setting up the conditions for supported life-long learning through Balint groups/action learning sets.

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  • silver surfer

    Sam I will have to sound a bit reactionary initially in my reply.You and I trained at the same time my training consisted of 6/12 rotations in numerous specialities which provided the backbone of my knowledge base and is something that i rely on everyday.I think that the problem is that medicine has moved on and young doctors dont think the same way as us anymore they expect a "life work balance" and quite right too.I feel that the first change to GPS is to bring us into line with our hospital colleagues ie SALARIED.This will then start to breakdown the idea of secondary/primary care.We will have medical care only doctors will be employed by Trusts/CCG/Federations whatever and will be trained/employed to provide that care in whatever setting.All doctors will have the same terms of service and can gravitate to which area/areas that they choose

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