‘The situation remains as serious as ever,’ says Dr Simon Plint, the GP proposing a radical shake-up of postgraduate training to address the current crisis. And his ideas could not come at a more opportune time.
Health education bosses have overseen the worst GP recruitment round for seven years, meaning that they are further than ever from their goal of ensuring at least half of training places are for general practice.
Dr Plint leads a taskforce set up specifically to look at ideas on how to boost the number of GP trainees. Its recent report recommends radical solutions, such as incentivising medical schools to increase the proportion of their graduates selecting general practice, and funding practices up to £20,000 to expand and take on more trainees.
But the most contentious proposal is the recommendation to reduce the number of secondary care places to fund an expansion of GP trainee numbers.
The taskforce report was submitted to HEE in March this year, and was only made public following pressure from the GPC, amid rumours that HEE bosses were unhappy with the recommendation to limit hospital training posts.
But Dr Plint, Wessex Deanery postgraduate dean, says that since the report was written the need for a radical restructure of training has become even more urgent.
‘This was a year when we did manage to expand the numbers of places to try to address the problem, but unfortunately we have not been able to fill them,’ he says.
The training figures this year were disastrous, with only 2,630 graduates entering training in England, the lowest number since figures were collected in 2007. In some areas, vacancy rates were as low as 40%.
This led to HEE introducing an unprecedented third round of recruitment last month for 200 places across England. But the scheme is aimed at graduates who haven’t already applied and training experts are dubious that such an untapped vein of potential trainees exists.
In this environment, training bosses are left with the difficult reality that to boost GP numbers, with a limited pool of graduates and flat funding for the expansion of general practice, money has to be diverted from other sources.
Reducing hospital places
For the taskforce, this meant raiding the budget for secondary care training places. The report says: ‘Funding the training posts required for GP training expansion could be cost neutral to Health Education England if 2,025 specialty training posts are decommissioned.’
Dr Plint recognises that this will not be an easy sell. He says: ‘The big catch there is, by closing down other career opportunities, we cannot necessarily assume that everybody will say “OK we’re going to go into general practice”.’
He adds: ‘Political sensitivities could prevent any move towards disinvestment in hospital training.
‘Almost everywhere in the NHS is under the most incredible strain at the moment.
‘Were we to talk about having to take medical posts out of hospitals, particularly acute medical posts, the response would be absolute incredulity. They are under such incredible pressure. But the catch is that they’re under such pressure partly because of the crisis in primary care.
‘This is a real catch-22. We have to be able to increase the capacity of primary care, to meet the growing demand and to protect the hospitals so that we can bring about this shift. It’s the horse and the cart.’
‘The last thing we want to do in the NHS is to lose doctors overseas’
Dr Krishna Kasaraneni
Dr Krishna Kasaraneni, chair of the GPC trainees subcommittee, warns of the unexpected consequences of meddling with intake requirements: ‘The last thing we want to do in the NHS is to lose doctors overseas because we tried to socially engineer which specialties doctors go into, and end up losing doctors from the NHS all together.’
And trainers themselves are worried about the effects of herding graduates into primary care.
Dr Kamal Sidhu, a GP trainer in Blackhall, County Durham, fears the move could create tensions between trainers and their trainees.
He says: ‘I can envisage some trainees who will have “had” to take up general practice as a career specialty. This has the potential to lead to some strain in the relationship with their trainers and the practices…if their heart is not in general practice, they are potentially more likely to drop out.’
Although the suggestion to reduce places for other specialties has undoubtedly caused the most controversy, the report offers 24 further ‘essential’ proposals to help solve the training crisis that have been welcomed by GP leaders.
Some of these, such as making returning easier for GPs who have left to work overseas, are already being tackled. Pulse reported in June that the RCGP was in conversation with HEE and NHS England about ways to keep overseas GPs on the national performers list, and to provide back-to-work training schemes for returners.
It also recommends incentivising medical schools to increase the number of students entering general practice. This follows on from comments from Professor Bill Irish, now chair of the Committee of General Practice Education Directors and a member of the taskforce, who last year told Pulse that the top universities were not doing enough to promote general practice.
Elsewhere, there is a recommendation for local education and training boards to fund general practices to expand their premises to enable them to take on more trainees.
Dr Plint has already implemented such a move in his Wessex deanery – which was welcomed by local GP leaders.
The taskforce report is in favour of such long-term measures, alongside a professional marketing campaign, for doctors and the public, to boost the image of general practice as a career.
But there is also an admission that the short-term targets for GP trainee numbers may have to be revised.
The report calls on HEE to reduce the target of 3,250 trainees entering general practice by August 2016 – a target that has already been delayed by a year.
But there is no guarantee that these recommendations will be implemented.
Pulse has reported that the reason for the delay in the publication of the report was HEE leaders’ reluctance to implement the recommendation to reduce secondary care places, while the GPC wrote to the body accusing it of ‘burying’ the report.
HEE gave only a lukewarm reception to the ideas and when the report was finally published, it was done without fanfare, tucked away on the publications section of the HEE website and with no media announcement. HEE is keen to emphasise that it did not exist when the GP taskforce was convened in 2012.
It has declined to commit to implementing the taskforce’s recommendations, and a spokesperson would only tell Pulse: ‘The GP Taskforce Report was commissioned prior to the establishment of Health Education England.
‘However, although it takes a very GP-specific view, it contains some useful research and will be helpful information to consider as part of our workforce plan for England alongside other evidence and suggestions, while many of the recommendations have been acted upon through commitments in our mandate.’
But this perhaps fails to address the urgency of the crisis, which is exacerbating the huge shortfall in GP numbers. For Dr Plint, the recommendations are vital for the NHS as a whole.
He says: ‘In very broad terms, a 1% downward shift in general practice’s capacity to handle demand could result in a 10% increase in secondary care, which would be absolutely overwhelming.’
‘This is why it’s so important that the report is seen as looking after the whole system.’
What does the report say?
The GP Taskforce was convened by the DH in December 2012 specifically to recommend how the system could achieve the Government’s target of 3,250 trainees a year.
It is comprised of GP representative bodies, Health Education England regional boards, DH representatives, lay members, GP trainees and representatives from the Centre for Workforce Intelligence, which published a report on GP workforce in conjunction with the taskforce report published in July. Its report listed 25 essential recommendations, including the proposal to reduce secondary care training places. Other recommendations included:
• A GP workload survey must be urgently recommissioned, along with a more effective vacancy survey.
• NHS England and HEE should work to provide and fund a GP returner programme.
• Consider incentivising medical schools to increase the proportion of their graduates selecting general practice.
• HEE to review why 25% of applicants to GP training are considered unappointable.
Source: GP Taskforce report, published July 2014.