In the first part of our investigation on the recruitment crisis, Anna Colivicchi looks at how an increase in medical school places will translate to a rise in the number of fully trained GPs, and why trainees might not want to pursue a career in general practice
Tackling the workforce crisis in general practice will require looking at every stage of the career. But it is unsurprising that the focus has been mainly on educating and training the next generation of GPs, including in last week’s workforce plan.
But in fact, this might be the area where health authorities have had the most success. Health Education England has managed to increase the number of medical graduates starting GP specialty training, up from 2,769 in 2015 to 4,000 this year.
Pulse has mapped the progress of about 7,800 medical school students who started medical school in the UK in 2012, as they are the latest to have qualified as fully trained GPs. While there are several caveats around non-linear progression – with gap years, career breaks, exam failures and other factors all playing a role – our analysis reveals that roughly around a third of this cohort had gone on to become fully trained GPs as of August 2022.
‘One in three medical students going into general practice is a reasonable figure’ says Professor Azeem Majeed, head of the department of primary care and public health at Imperial College London.
‘But it’s also important to focus on retention. Many GP Registrars do not go into roles as salaried GPs or GP partners at the end of their training, or work only a small number of clinical GP sessions. The NHS needs to make the role of being a frontline clinical GP more attractive to rectify this.’
Both main political parties are committed to increasing medical school numbers, and the workforce plan commits to doubling the number of newer medical schools that have a GP focus, which bodes well for the number of fully trained GPs by the middle of the next decade (if we can wait that long).
From medical school foundation training
Currently, there are around 9,500 places to study medicine in the UK each year. Around 7,500 are in England, and the workforce plan commits to doubling this to 15,000 – a measure backed by the Labour Party and the Medical Schools Council, which represents UK medical schools.
Although for the majority of medical students who enter medical training, it is not a vocational degree and some end up in research or a different career altogether. ‘There are so many other opportunities now, for people with a medical degree to get involved in other sectors, sometimes offering better pay or working conditions, for example in AI and technology or within the private sector and pharmaceutical companies which compete with the NHS,’ says Dr Tzortziou Brown, ‘I suspect this may be one of the reasons.’
There has been what the RCGP described as a ‘toxic anti-GP culture’ in some academic institutions, leading medical school deans to warn medical school intakes not to ‘fail and become GPs’. This view of the profession is something GP trainees still experience today.
Dr Annabelle Machin, a portfolio GP in Staffordshire, says that as a medical student she experienced negativity towards general practice from clinicians, particularly while on secondary care placements. ‘We need to push back against the labels “Just a GP” and “Jack of all trades”’ she says. ‘General practice is intellectually stimulating; we deal with many complex problems and we have expertise just as hospital specialists do.
‘Our distinct expertise is in generalism. Perhaps on placements, students aren’t getting to see this complexity, so I think it needs highlighting as it could make careers in general practice more attractive.’
The Government has done its part to discourage this narrative, increasing funding for medical schools that aim to boost GP trainee uptake by exposing students to general practice, in the hope of making the career path more attractive.
Newer medical schools have been encouraged to focus on general practice, as the Department of Health and Social Care believes ‘giving students additional exposure to high-quality placements in general practice will improve recruitment into these specialties’.
Five medical schools were set up in 2018 – Sunderland, Edge Hill, Anglia Ruskin, Lincoln and Kent – alongside an expansion of places at Aston, and they all had to show a GP focus to get GMC approval. This year, Anglia Ruskin and Aston won approval after demonstrating ‘a focus on the prioritised specialties of general practice, psychiatry and any other shortage specialties’. All universities who want to establish a new medical school or programme are subject to a period of ‘quality assurance’, and Sunderland, Kent and Edge Hill are currently on the list of schools being reviewed to award UK medical degrees, while medicine at the Lincoln Medical School is fully accredited by GMC as part of the University of Nottingham’s medical courses programme.
The workforce plan says the Government will look at setting up more medical schools in areas of the country where there is the greatest staffing shortfall, with similar plans for postgraduate medical training places.
During the foundation programme, approximately 55% currently have the opportunity to do rotation in general practice lasting four months. Those spending time in general practice are regarded by the RCGP to be more likely to enter general practice. Under the workforce plan, all foundation programme trainees will do a rotation in general practice by 2030/31, which ‘will give doctors in foundation training an understanding of work in primary care’.
‘The evidence so far shows that the more exposure trainees get to general practice, the more likely they are to pursue it as a career,’ says RCGP vice chair Dr Victoria Tzortziou Brown.
‘We need urgent action to support general practice so that trainees are excited about becoming a GP, rather than being daunted by the extreme pressures we’re currently under. When general practice is properly supported and resourced, there is no career quite like it.’
Under the current foundation placement process, applicants are ranked based on how they performed against peers at their own medical school, combined with their situational judgement test (SJT) scores, which evaluates their decision making. The highest-ranking applicants are then allocated their preferred foundation school first.
This process has been labelled as ‘unfair’ and ‘stressful’ for applicants, who have pointed out a ‘lack of standardisation within and across schools’. In response, HEE changed the programme to make it easier for graduates to navigate the process, including a new computer-generated ranking that will be used to allocate graduates to foundation schools, as part of a move to make the process ‘fairer’. The SJT is being removed, too. The new process will allocate as many applicants as possible to their first-choice foundation school; if there are no remaining vacancies, they will be allocated their next highest available preference. This is unlikely to have much effect on GP training, however.
According to the GMC, around one in 12 doctors leaves the UK workforce after foundation training.
For those who stay, almost exactly half of foundation trainees enter GP specialty training – in line with HEE targets.
To attract more doctors to GP speciality training, HEE brought in initiatives including a campaign called ‘Choose GP’ and the Targeted Enhanced Recruitment scheme, a national incentive programme funding £20,000 salary supplements to attract trainee GPs to work in areas of the country where training places have been unfilled for a number of years.
Since 2019, there has been even greater success in increasing GP training. The latest figures from August 2022 show 4,000 GP training places filled across the UK.
The GP training model is also undergoing reform to support better training for GPs and ‘a more balanced distribution of trainee capacity across the NHS’, according to the Department of Health, with HHE creating place-based pilots to test educational models and prioritising training capacity expansion to areas of deprivation, including urban estates and remote and rural areas.
As part of the workforce plan, the Government is promising to increase GP training places by 50% to 6,000 by 2031. GP registrars have traditionally spent around half of their three-year specialty training working in general practice, but as part of changes included in the plan, they will now spend their full training in general practice.
The GMC’s National Training Survey found 41% of trainees in GP posts last year rated the intensity of work as heavy or very heavy, and 16% of GP trainees also reported working beyond their rostered hours daily. London GP registrar Dr Sammy Luney says one of the main challenges is that there is a lot to fit in to a relatively short training scheme, adding that trainees can be discouraged by the workload that seems to be growing by the day, on top of preparing for exams. He says: ‘Trying to get all of that done while the workload noticeably escalates – each month is more difficult than the last as you take on more responsibilities.’
The cohort of fully trained GPs
|Entering GP specialty training in 2019||3,450|
|Passing MRCGP in 2022||approx 2,700|
The RCGP said it believes that data on CCT rates is a more accurate way of measuring GPs entering the workforce, with 3,180 candidates passing in 2021/2022 and roughly 85% being from the UK (2,703).
Around 92% of UK graduates who take the final component of the MRCGP exam – the recorded consultations assessment (RCA) – pass. The pass rate for international medical graduates is infamously lower, at 45%.
The RCA was brought in during the pandemic to replace the clinical skills assessment (CSA), which required candidates to simulate consultations face to face with actors, and is to be replaced in November by the Simulated Consultation Assessment, which will see GP trainees assessed virtually in their own practice, with actors playing the role of patients.
Problems later on
While the conversion rate from medical school students to fully trained GPs is good, it is not all positive and problems are seen later down the line.
According to RCGP chair Professor Kamila Hawthorne, GP trainees see the workload faced by their trainers and other GPs in the practice, and they don’t want a lifetime of working in this way.
Despite all the efforts to encourage young doctors to choose general practice, a BMA survey found that 13% of trainees say they don’t expect to work as GPs in future, which, if extrapolated, represents a loss of 433 potential GPs in England alone ‘before they even start working’, the union says.
And the RCGP has predicted that nearly 19,000 GPs and trainees will exit the profession in a ‘mass exodus’ over the next five years, unless workforce and workload issues are urgently addressed.
According to data from the Institute of Government, 21.6% of fully qualified GPs aged aged under 30 left in the 12 months leading up to December 2022 – up from 6.8% in March 2021.
The report also suggested the increase in the youngest GPs leaving could explain ‘why higher GP trainee numbers are not translating into more fully qualified, permanent GPs’.
But Dr Luney says: ‘When I’m talking with my colleagues, not everyone is excited to get through the door. Lots of people are thinking about doing out of hours and locum, because of everything that is happening and all the pressures that are everywhere, no one is jumping with joy that we are coming to the end.’