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At the heart of general practice since 1960

The junior doctors’ strike is not over for general practice

Prospective GP trainees will continue voting with their feet unless we change how we go about selecting and training them in general practice, write Dr Anwar Khan and Dr Sam Everington

dr everington and dr anwar

Nearly half of FY2s, having completed two years training since qualifying as doctors, are choosing not to sign up for specialist or GP training. Some are going part time, others are doing locums and many are tempted by opportunities abroad

The crisis in general practice is illustrated by the need to recruit 2,000 GPs from outside the UK. This is not just a problem for England: similar problems are found in the other four nations, with headlines such as ‘Brain drain as Scottish doctors abandon NHS in their thousands’.

Lack of continuity of care both of patients and doctors is a major part of the problem, with junior doctors describing how they have to move on every few months and have little continuity of mentorship from trainers.

Like many areas of the country, the East End of London is struggling to recruit GPs. This, we believe, is in large part because we are not able to engage in selecting GP trainees who will be committed to staying on once they are qualified.

We should be far more interested in ensuring a GP trainee is likely to commit to an area

Evidence shows that if a doctor has been born and brought up, or trained for a meaningful period in one area, they are much more likely to stay.

Yet in discussion with junior doctors, we heard that those wishing to enter GP training are allocated a place dependent on their ranking in the entry exam. This means they might end up anywhere in the country.

Exception can be applied after selection, if a junior doctor can show good grounds to stay in the same place, though this seems to be adjudicated harshly. We heard from a junior doctor who wanted to be near his mother who was frail and had to prove this in a manner that can only be described as demeaning. It involved getting a letter from his mother’s GP and her hospital consultant.

Some argue the selection process is intended to be an academic one, a process to distribute doctors throughout the UK. In order to be ‘fair’, high scorers get the areas they want.

But the whole process means trainees – through no fault of their own, as they seek to find the ‘best’ training practices and experiences – may effectively be imposed on areas even though they may have no intention to work there in future.

We should be far more interested in ensuring a GP trainee is likely to commit to an area, shares our values and has the key attributes needed in general practice such as emotional intelligence, communication skills and a wider understanding of their role in improving the health and wellbeing of their population. This in turn would ensure a focus on key issues for junior doctor, stability, family and continuity of patient care and mentorship.

Furthermore, four out of five years’ training to be a GP are usually spent in hospital. Where is the logic in that? No specialty would accept that.

Some FY2s spend four months in primary care. If you know you want to be a GP, why not bypass the Foundation programme and spend five years training in a GP surgery – living in one place and working at one training practice with continuity of training by senior GPs.

We are left in no doubt that the present system is damaging to junior doctors in relation to their health and wellbeing and is now having a serious impact on patient care. The process is not fit for purpose for training per se; it needs buy-in from the new generation if we are to get improved retention of doctors and trainees.

Juniors need to be valued and supported throughout their training with continuity of patient and trainer care. Until these issues are sorted, the ‘strike’ continues. The battle might be over, but the peace has not been won.

Dr Anwar Khan is chair of Waltham Forest CCG and Dr Sam Everington is chair of Tower Hamlets CCG

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Readers' comments (7)

  • Juniors are not valued looks at last year climb down by the BMA.There are massive hole in roots and training schemes all over the country, there are shortages in key specialities.The damage done to the profession by the government and establishment(inc BMA+RCGP)done over the last 10 years will take a generation to repair,if at all.Pure vandalism and destruction which is costing the country dear.The only way to deal with it is withdraw services provided,RELP,stop useless subscriptions to the organisations that let us down.Look after yourself and your family, beacause the various arms of the establishment are sacrificing you on the altar of the cult of the NHS,and reorganisation, your life and career doesn't matter to them.

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  • The issues are far deeper than just how the system works. The whole profession needs to have a look in the mirror as to how we treat each other. The 'good old days' where doctors who were not thought to be capable of becoming a consultant, went out and became GP's under the apprentice system. They had to buy into practices and work up to parity, which still exists today in some partnerships. Junior doctors in hospital had to keep their noses clean and be seen to be a good sort, in order to be considered to join the ranks of consultants, usually waiting for dead men shoes. To counter the old boys network approach these training schemes were devised,but the flaw was balancing training with the service element requirements. The rivalry between colleges compounds the problem which goes back centuries and is in the DNA of doctors. It is not one noble profession because we don't treat each other as equals. I believe we all went into medical school the same, came out the same and it is our choices after that differentiate who we are, not our branch of medicine. Clearly there are those who choose to become super qualified in their field but they should appreciate those that chose not to go down similar paths. Juniors will be seniors one day and until we start treating each other as equals and a united profession the issues or recruitment and retention will persist. I have counselled my children not to follow me into the profession, not that they will listen.

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  • Vinci Ho

    (1)As I am growing older accumulating more long term memories which clearly stick , the recently acquired short term memories become less influential for my mind. This is the naturally occurring risk of turning into a stubborn , grumpy old man , in candid language.
    (2)While we complained about the establishment being lost in touch with us , I keep reminding myself of becoming an 'establishment' of my own device in front of our youngsters. What so often happens is the risk of forgetting I was like them many years ago , filled with passion and hope but fear and uncertainty of what my future would be .
    The passion and hope are there because one believes one can make a difference to his/her own life(perhaps the 'world' as well), going up the ladder to a 'better place'. The word dream may be naive and aspiration more practical. But I do not think that matters because the passion and hope is where the energy we need to sustain a profession like ours which in eyes of other people are pillars of the society and hence , can make a difference. If our youngsters have this belief, we need to help them to carry on believing by all our might and means . As I wrote recently; an ordinary doctor heals a disease ,a good doctors heals a person , a perfect doctor heals a society . Although none of is a perfect doctor, our youngsters will love to be good doctors, at least.
    (3)Then it is the fear and uncertainty which arguably has been affecting ALL of us . The
    political shortsightedness and shallowness of our leaders in the hierarchies have simply treated us like toy soldiers ignoring what we believe. The economic approach of squeezing out the most 'results' by using the least amount of resources, is well proven to have backfired.Traditionally, we are trained in such a way that we want to stay away from politics , the notion of which is what one should respect . But if politics has stepped out of its line and invaded into our freedom from fear creating more uncertainties , this is battle time and I disagree the saying 'the battle is over' in this article. In fact , it is only the beginning of the battle.
    (4) The simple truth is we need to ask what our youngsters believe and still believe. Do they believe in NHS and general practice in this current form and principles or it should be something else altogether? Do they believe this is a career(in certain format) worth their next 30 years plus long lives to fight for ? I am humbled by their answers and only on receiving end with full respect.
    (5) Any definitive answer of these questions should be met with our efforts to fight for them against our manipulative enemies who only want toy soldiers or AI robots with no emotions to fulfil their political goals.

    We are not here to just chase against some target of reaching so many GPs in such period if time , we are only here to fight for what our youngsters believe for their future. And if they believe general practice can still make a difference, let's make a difference for them in this everlasting battle against our common enemies.
    ''It is not about deserve ; it is about what you believe .''
    Dianna Price

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  • Vinci Ho

    Correction
    .....so many doctors in such period of time,.....

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  • Vinci Ho

    Correction
    Although none of us is a perfect doctor,....

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  • As someone who has recently finished GP training and as accepted a Salaried Post in a place where I finished my training I feel I can contribute a little bit to this discussion.

    In my practice I was allowed to choose my "study day," and the day I was allocated an on call day (I chose monday). I was not expected to do extended hours and my practice respected my decision to support the strikes.

    Other trainee's did not get this flexibility. They were told they were doing the friday on call, that they would be staying late on tuesday evening to do the GP surgeries extended hours surgery. They are now locuming, feeling that what they have learnt what there training is that you need to make sure you are your own boss.

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  • Vinci Ho

    Confucius’ advice to intelligentsia in Analects was ,
    ‘‘ Do not enter a dangerous nation ; Do not live in a chaotic nation . Make yourself available if the nation has the conditions to sustain the WAY . Hide away if the nation has lost the WAY completely.’’ (危邦不入,亂邦不居。邦有道則見,無道則隱。)

    One can argue that this also applies to those educated , skillful European citizens who are leaving post Brexit.
    At this age of 52, do not have any more ambition. The only ‘ambition’ perhaps , is the fight to ensure our youngsters have the ‘conditions’ to be ambitious themselves.......

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