Nigel Praities (NP) Pulse editor (chair)
Dr Fiona Cornish (FC) GP trainer in Cambridge
Professor Simon Gregory (SG) GP and Health Education England lead for general practice
Dr Heather Ryan (HR) GP registrar in Liverpool, medical leadership fellow at Health Education North West
Dr Shamila Wanninayake (SW) GP tutor in Oxfordshire and chair of RCGP First5 committee
Dr Chris Williams (CW) Sessional GP in the Highlands and a clinical educator for NHS Highland
There is no doubt that the UK needs more GPs. Pulse recently revealed one in eight GP positions is currently unfilled, causing crippling effects on practices that are already struggling and forcing more and more to resign their contracts. It is therefore more crucial than ever to have a new generation of GPs entering the profession.
In England, the Government has set a punishing target of 5,000 additional GPs by 2020. But across the country – perhaps excluding Northern Ireland – education leaders are struggling to boost the number of training places filled. In Scotland, two in 10 training places were left vacant last year.
Although Health Education England has increased the number of GP training places it struggles to fill them. Applications for 2016 GP training slumped by 5% on last year, which does not bode well for the Government target. HEE has begun to reverse the tide with £20,ooo ‘golden hellos’ and a major review of the culture that pervades within medical schools.
But what more can be done? Pulse convened a panel of experts to discuss the issue in depth.
NP – Why do you think GP training placements are unfilled and how can we boost the number of graduates who are choosing general practice?
CW You could sum it up in one word – ‘perception’. For a long time general practice hasn’t been promoted in the same way as some other specialties. People who are coming through medical school form opinions fairly early about what interests them and how they see their future, and I think we don’t do enough to challenge some of those perceptions and make people stretch to what they can be. Giving them reliable information earlier will help and again show the diversity of the options that are available to them.
HR I helped to set up a GPs’ society at Liverpool University, and one of the first things they did was research on what affects students’ career choices and what medical students think about general practice. A lot of students said that their own personal inward perception of general practice was very positive, but they heard relentless negative comments from secondary care clinicians in particular. One quote was that students were afraid and ashamed to admit they wanted to be a GP.
SG What we’ve heard consistently is negativity. I bet every single one of us can remember being told – I certainly can – at medical school, ‘why are you giving up being a doctor to be a GP?’ [and] ‘you’re too clever to be a GP’.
FC And the comments can be throwaway remarks from hospital colleagues – ‘Oh, are you only going to be a GP?’ All really denigrating. It’s a shame, because when students come into our practices, a lot of them are really enthusiastic and they like it and they have a great time. You can tell the ones who clearly think it’s all pointless and are going to go into their labs and do PhDs – and that’s fine; some people are destined for that. But it is a shame that all these dynamic, fantastically energetic students are being put off general practice.
SW It is denigration from the media, denigration from secondary care, but actually there’s also a lot of negative feedback from GPs themselves. That also puts off medical students. But one of the fundamental things that encourages them into general practice despite this is having solid GP placements as medical students. That can make an immense difference, as it did for me. When you’re a young doctor, you always fancy yourself as doing all the acute medicine on the acute shop floor, but actually, I had such a fantastic experience as a medical student in both my GP practices that I thought ‘This is something that I could do’.
SG We’ve got students, trainees, everybody around the table and we’re visiting medical schools … they’ve heard the bashing of us for years, but they used to see GPs who said it’s fantastic. Now, we’re not feeling like that. They say ‘what we hear on Twitter, websites and in the medical press’ – all of it’s true. We mustn’t criticise ourselves or our colleagues for saying how bad it is, because it is – but students say, ‘you no longer tell us it’s a good job. You no longer tell us that you want to do it.’ I now say: ‘I love being a GP; I just don’t like general practice as it is at the moment.’
HR We can’t authentically promote general practice as a career when students come into GP surgeries and see people at breaking point or going off sick with stress. I think we need to make the profession more attractive. As a trainee at the moment, when I look at my cohort of GP trainees at VTS lots of people enjoy seeing patients, they enjoy consulting with patients, but an awful lot of trainees don’t enjoy the peripheral elements – the management, the resource allocation. And actually, out of my VTS group of 20 I’m the only one who’s even talked about looking for a partnership. People are increasingly looking to find a locum or perhaps take a salaried post. So I worry that the pressures on general practice are not only putting people off coming into general practice, but they’re shaping the way the general practice workforce is going to go. If we don’t get new partners, partnerships are going to fail.
SW We have a pretty good idea of the problems that we’re dealing with on a day-to-day basis. There was an online survey done last year of roughly 300 First5 GPs and 250 AiTs and they all cited similar things – increased workload, increased bureaucracy, admin and what is a crucial element of stress and burnout, the fear of litigation. That really is driving a lot of GPs out of these roles because we have 80 or 90% who feel that their workload is unsafe, and they don’t have the time to deal with patients in the way that they’d like to. A lot of early years GPs have said to me they feel they’re just a step away from a court case. And that burden is just too great for them to continue.
NP – I’d like to come back to Simon’s point – when he said ‘I love being a GP but I don’t like general practice at the moment’. Does it not behove medical schools to get the point across about the benefits of a general practice career?
SG I think it does behove medical schools. I think it behoves all of us. I think the campaigns to get more resource and to address the issues are vital. We have got to work on the current medical students, but we as a profession have got another challenge. [Medical students] can’t get placements in general practice when they’re sixth formers. So they don’t see a positive role model of a GP before they apply. My local hospital organises placements for any sixth former that wants to go to medical school, but it begs for practices [to take part]. We’ve been talking with the RCGP about putting an information pack out there about what the legal issues are and confidentiality and how to do it.
But if, for example, a federation, a super-practice or a CCG were to co-ordinate it, each practice might get one or two [sixth formers] a year. But at the moment, I sit on medical school interview panels and [when] I ask: ‘Have you visited a practice?’, [they say] ‘I’ve tried.’
dr chris williams 330x330px
CW In the Highlands, we’ve had a medical school mentoring scheme, where we’ve tried to cater for people who wish to apply for medical school. Work observation is a vital part, and helping them towards a selection process that’s been skewed towards academic performance. We’ve tried to sustain a scheme where we can place some of these school pupils in GP surgeries within their immediate area and try to provide a structure to the practices that host the student. I think the earlier you start to give people opportunities to see behind the surgery doors, to see what happens without the television cameras and glamour, to see the day-to-day reality of general practice, and to have somebody talking them through it and explaining some of the intricacies, people can start to believe in general practice as a career – an interesting, diverse, rewarding, person-centred career.
NP– A wonderful video from the Royal Australian College of General Practitioners shows general practice as all about the relationships developed with patients and their families.1 But it contrasts with HEE’s skydiving video, which featured someone ticking a box. Don’t we need to get across what it actually means to be a GP?
professor simon gregory 330x330px
SG I don’t disagree with you at all. That HEE video was out for two weeks and it was only to start [the campaign]. The thing that’s worked is the near peers, the ambassadors and people talking about why they wanted to be a GP. If you look at the research, less than half the universities have got an academic department of general practice. In some of those universities for your GP placement you’re [only] taught consultation skills, and what you see is this stereotypical GP who teaches you how to talk to people. What we need is high-quality teaching in general practice of the discipline of general practice. We need inspirational people.
CW There are different ways we can use general practice as an education. These students aren’t there to learn general practice; these students are there to cover their fourth year undergraduate medical curriculum. There are different ways that we can use general practice as an environment to support learning. We need to think more about how we can support practices to become teaching practices so that we have practices of different shapes and sizes being able to take on teaching commitments and develop their potential.
FC I think a big issue with that is the funding, because it’s very arduous to teach if you’re a small practice. You need the space and you need a mass of doctors’ time. And people just can’t absorb anything extra, and shouldn’t have to without funding. We haven’t usually taken on locums [to cover for teaching time], but a lot of people get a locum in if they’re doing teaching. But you can’t just get a locum any more.
NP – How do you manage the teaching?
dr fiona cornish 330x330px
FC So far it’s been built into the staffing so we’ve had two trainers, and now we have F2 doctors and medical students. We’ve also now got a salaried doctor two days a week. One of the reasons for that was to accommodate the teaching, otherwise we just can’t do it. You have a whole week of teaching and you’ve got to have one doctor [dedicated to it]. We have four students sometimes, two students at a time seeing their own patients. So they see them for 20 minutes, then the doctor goes in for 10 minutes and keeps it all in sync. Basically a lot of doctor time is taken up.
HR When we talk about the quality of GP placements as well, I think the worst thing you can do is just get medical students to sit in the corner. One of the big factors for me in my final year was that we had a separate consulting room, and we could see patients and start to develop. Actually, despite the stereotype that all GPs are stupid, it’s tremendously intellectually challenging to have to just use your history and examination to make a diagnosis. I feel much more awake and engaged in primary care than I did in my hospital job. What we need is to get medical students to experience that, particularly towards the end of their training when they’re more competent. I think the best advert for general practice – the good aspects of it – is to allow them to simulate doing the job.
NP – The generation now coming into GP training – are they a different breed and do they have different expectations from the old dinosaurs?
CW People who leave medical school now have a huge amount of debt – the same size as a mortgage already. It ups the pressure, and that is something we have to deal with. When this group who are now becoming doctors are making their choices, [they encounter] very different pressures from those who were graduating as doctors 10 or 15 years ago. I think we need to have sympathy to that debt and we don’t want them to make choices that are in response to this enormous burden that they’re carrying.
NP – It must be quite frightening becoming a partner.
FC There’s this huge mish-mash of what role you have. And the appeal of sinking a whole lot of money into a building and committing long term [has gone]. I don’t think anybody of Heather’s generation is so keen to commit to a long-term life plan.
dr heather ryan 330x330px
HR There’s a huge expectation and a desire now for flexible careers and portfolio careers. I don’t know anybody who just wants to work full time, eight or nine sessions a week. Portfolio career is the phrase on everybody’s lips, and there is a general ethos that people look for more of a work-life balance now. It’s not just women – males are also looking at family-friendly careers, ways to work to live rather than live to work. My generation are aware that we will probably work until our early 70s so it needs to be sustainable. Certainly, the state of full-time general practice at the moment is not sustainable, and if you become a nine-session partner you’ll burn out and get ill in your 40s probably. I suppose that’s a factor that pushes people away from general practice or certainly from a full-time partnership.
NP – Also, the complexity of what you’re seeing every day is so different. I’m not surprised that young doctors are thinking now, ‘Gosh, I can’t do this’.
SW We know the complexity has gone up. The workload has gone up, by 16% or something, in real terms of what we’re doing. And of course when you’re coming into a practice and seeing what the partners are doing and the salaried GPs also… There are positivities and negativities and there are lots of conflicts within those groups. I don’t think that’s necessarily helpful. [For example] if you have a locum at your practice and that locum doesn’t feel as welcome as they might want to, it might put them off becoming a partner. It’s almost denigration within our own profession, which I think needs to be equalised more. We are working together and there are lots of different models of care that we can deliver and all these different opportunities, so let’s see if we can be more on an even footing.
What one thing would you change to encourage more people to go into general practice?
CW Exposure to general practice at an earlier point in your medical career. We need to evidence that and show what this exposure looks like and what effect it’s going to have.
FC Change the medical schools’ attitudes to encouraging students into general practice.
HR Make GP training more attractive and increase funding for more trainees so they are introduced to a portfolio career that will sustain them through a long career.
SW More GP champions in the media, who are doing positive things in general practice.
SG Authentic ambassadors [to say] why they chose to be GPs, why they are still GPs and why general practice is a good career, so that people aren’t dropping out of other specialties into general practice – they are being GPs by choice.