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Getting involved in teaching and education is one of the most rewarding experiences for a clinician and his/her practice.
There is, however, a process to be followed and a period of hard work is required to develop the practice to the stage where it is capable of achieving training status.
As more work flows into primary care, and the commissioners of healthcare education – Local Education and Training Boards (LETBs) – test new models of community-based education, GP trainers and their practices could well be in great demand.
This article describes the process of becoming a training practice as it currently stands, in five easy-to-understand steps.
1 Understand why you want your practice to take on training
This is perhaps the most important step in the journey towards becoming a training practice. No two general practices have the same ethos and drivers. Some are driven by financial considerations, while others work towards a certain work-life balance thus sacrificing high incomes; others still are motivated by experimenting with innovation and change in the workplace. The different motives are not necessarily exclusive as a single practice could be at the forefront of innovation, be altruistic to a degree and yet be financially stable.
It is therefore critical before starting out to have a clear understanding of the primary motivation for becoming a training practice. By encouraging internal dialogue and conversation throughout the practice team, the partners and members of staff can share their experiences and concerns. Such dialogue also makes the process an inclusive experience for all concerned.
2 Make sure you’ve weighed up all the advantages and disadvantages
There are advantages and disadvantages in becoming a training practice and a GP trainer. It is important to weigh these up carefully before arriving at a decision. I have listed a few for consideration though this list will not cover all the potential issues for every practice.
On a positive note, becoming a training practice:
- encourages professional and practice development.
- gives a sense of achievement and makes your practice stand out from the crowd.
- keeps partners stimulated and up to date through regular contact with learners.
- can improve your patients’ experience of healthcare.
- offers motivation to develop practice policies and procedures.
- helps partners learn with your fellow trainers locally.
- offers another potential revenue stream for the practice.
However, being a training practice has its disadvantages too:
- the approval process is time-consuming and requires perseverance.
- there are employment and human resource implications associated with being a trainer and a training practice.
- training can take up a significant amount of time and emotional energy, especially with trainees who struggle to make progress.
- doctors in training initially require lots of support and supervision to ensure that patients are not put at risk.
- most schools of general practice require trainers to undertake a postgraduate certificate in education – this can be expensive and time-consuming.
- patients may be dissatisfied with seeing doctors early in their training.
- training can occasionally have a negative impact upon continuity of care.
3 Consider the financial implications
The financial impact is not as easy to assess as one would like to believe. The practice will need to invest substantial resource before it can be approved as a training practice.
- Doing a training course: the potential trainer will have to do a course in postgraduate training and education. This can take up to a year. Different courses attract different fees and the practice needs to factor in both the fees and the locum costs to cover the time lost in attending the training days. This could well be in the region of a few thousand pounds.
- Structural changes: The practice needs to have adequate space to accommodate the trainees. Some practices may need to invest in creating extra consulting rooms (subject to the availability of space and planning regulations). This in itself can run into thousands of pounds.
There are also miscellaneous expenses to cover, like purchasing of video camera/ screen, doctor’s bag and its content, and books for a small in-house library. All this should cost around £1,000-2,000 as one-off expense.
Different practices will therefore need to factor in different budgets for investment depending on their individual circumstances.
There are too many variables in the equation to allow precise calculations of the net financial gain. The partners should ask specific questions about what kind of training they want the practice to undertake, such as:
- Is the practice going to train a foundation year trainee or GP specialty trainee?
- Will the GP specialty trainee be an ST1/2 trainee or ST3/4 trainee?
- Will the GP specialty trainee be an able trainee or a learner who will need remedial action?
- Will the trainee be full-time or part-time?
The practice needs to consider both best and worst case scenarios to make an informed decision.
In the best-case scenario, the two main potential sources of income are:
- the trainer’s grant: this currently stands at around £7,000.
- service delivery: this depends on whether the practice is going to get a foundation year trainee (commonly known as FY2) or a specialty trainee (ST1/2/3/4) or both. A full-time trainee is expected to do seven clinical sessions in a week.
Typical FY2 students are normally placed in a practice for four months. They go through an induction for one to two weeks, following which they will initially start seeing patients at 30-minute intervals.
They will progressively increase their consultation rate depending on their ability and confidence. By the end of their term, most FY2s will be seeing patients at 15-minute intervals. In essence, an average FY2 may see about 10-25% of the number of patients seen by a full-time GP. In financial terms, it equates to having a resource equivalent to roughly £8,000 -16,000 per year.
Specialty trainees in their first or second year (ST1/2) are placed for six months in general practice. They normally start seeing patients at 30-minute intervals, moving to 15 minutes in their final few months.
Registrars (ST3) are normally placed for 12 months. They normally see patients at 15-minute intervals by month two or three of their placement and at 10-minute intervals in the final few months. There is no agreed timetable of when a trainee should be consulting at what rate, as it is very much guided by their competence. However, on average an able registrar will see about half the numbers of patients over the year compared to a typical full-time GP. This equates to almost £40-50,000 per year of service delivery for an ST3 trainee, and approximately £20-30,000 per year for an ST1/2.
This may be too simplified a way of assessing the financial gain as a best case scenario. Other factors to consider are whether the trainee is full-time or part-time and whether they are an able or slower learner.
Nor does my summary take into account the increase in work generated by the trainees and this can come from two sources. Firstly, trainees’ inability to deal with uncertainty can result in much higher rates of follow-up appointments and investigations, and secondly, there will be higher than average rates of re-attendance by patients seeking a second opinion after having seen the most junior member of the team.
Against this income we need to look at the four main expenses:
- Teaching session: One session per week is dedicated to formal teaching, which means that a trainer loses a clinical session per week. The trainer session’s worth depends on the income of the practice but on average will be £10-20,000/year.
- Debrief/supervision: It is normally expected that all trainees have protected time for debriefing at the end of their sessions. Most practices will have gaps in supervisors’ surgeries to allow time for advice and interruptions. This arrangement continues throughout the FY2 attachment and generally for three to four months in the case of ST3 (and much longer in the case of a remedial trainee). Again this could amount to a session of a GP’s work per week i.e. between £10-20,000/year.
- Management/admin time spent on arranging rota, pay and dealing with various queries.
- Trainers’ workshops and away-days: There are on average eight to 10 sessions lost each year for attending trainers’ workshops and away-days. This amounts to roughly £3,000/year, plus a session for being part of a visiting team to approve/re-approve other training practices.
In conclusion, the net financial gain in the case of an FY2 trainee could be minimal, if any. In the case of a full-time specialty GP trainee in their final year, the net financial gain might be cost-neutral in a worst case scenario through to a £10-20,000 net gain in a best-case scenario. This has obviously not factored in the impact of the extra work generated by the trainees.
I would like to caution here that the above assessment is based on the experience of a few trainers and practices will need to use their own judgement to make an objective assessment.
4 Preparing the practice
Once the practice has had an opportunity to debate the pros and cons, and made a decision to go down the route of seeking approval, I would suggest three key activities:
· identify a training lead
· familiarise yourself with criteria for practice and trainer approval
· apply to the local school of GP training.
The training lead will usually be the GP who is likely to become the educational supervisor/trainer and who, along with the practice manager, will oversee the progress of the application process. Any potential trainer should meet generic specifications like having the MRCGP, a good track record clinically and enthusiasm for training. It is worth liaising with your local GP school to enquire about the criteria they expect of GP trainers (this can vary from region to region). Some GP schools run their own courses and normally expect potential trainers to have done their course. Others will accept any recognised postgraduate masters educational qualification up to certificate level (60 credit points).
Before the completion of any trainers’ course, I would strongly recommend that you make contact with the local trainers’ workshop convenor to join the peer group. The local trainers’ workshop is an excellent way of being inducted and mentored in GP training. You will learn much about how to get started, and helpful advice on the potential pitfalls to avoid.
All local schools of postgraduate GP education have clear criteria for approving practices and trainers. Any approval process will cover the following domains:
- patient safety
- quality management, review and evaluation
- equality, diversity and opportunity
- recruitment, selection and appointment
- delivery of approved curriculum, including assessment
- support and development of trainees, trainers and local faculty
- management of education and training
- educational resources and capacity
Most practices will do a gap analysis, looking at where they are at present, identifying the gaps and working towards filling them.
Once the trainer has completed the relevant training course and the practice feels ready to be assessed for training practice status, a completed application form needs to be sent to the local school of general practice. It is usually helpful to access support from the local programme directors, trainer workshops convenor, and local trainers. Many workshops offer the opportunity for a mock assessment visit to the practice and trainer, with useful developmental feedback. Others offer mentoring schemes that assist potential new trainers and practices.
5 Prepare for your approval visit
It is a good idea to ask the local programme director, or trainer workshop convenor or one of the local trainers to visit the practice and talk through the nuts and bolts of the visit before the assessment itself. Practice and trainer assessment teams are led by a senior educationalist like an associate dean/director. Also attending will be a local programme director, together with a GP trainer from outside the area and their practice manager.
The structure and timetable for the assessment visit are available from your local school of general practice, and it is worth getting hold of this in advance. The visiting team will wish to meet and interview clinical and non-clinical staff members. They will also want to interview the trainer and watch a recorded patient consultation (get your patient’s consent before sharing this with the visitors) or teaching session if available. In essence what the team is looking for is adequate space, a safe and supportive environment for patients and trainees, enthusiasm and support for training and education across the whole practice team, and ample opportunities for multiprofessional learning within the practice.
If the trainer and the practice meet the essential criteria, the team will approve the practice and make recommendations for ongoing development. Normally the practice and trainers are approved for a maximum of two years in the first instance.
At this point, you deserve to celebrate the fact that you have led your practice on a difficult journey. Getting agreement and support from all your practice members to work towards training practice status, undertaking an arduous course in sometimes obscure educational theory, and getting through your first practice approval visit is challenging and rewarding.
Having a first postgraduate trainee in the practice will be another milestone. The practice and the trainer can expect to go through a steep learning curve alongside their first trainee. Important things you will need to have in place at an early stage for your trainee include:
- an educational and employment contract
- an induction pack with information about the practice profile, staff and their roles, important contact numbers, referral and other important policies, and where and how to get help
- an induction programme agreed with the approval team and the trainee
- the timetable for the trainee and the trainer
- clear and explicit ground rules for the trainee (rights and responsibilities with regard to training)
- clear process on who will supervise the trainee and when, with clear lines of responsibility
- a list of available equipment
- an initial needs assessment package.
Finally, put a mechanism in place to get feedback from trainees and practice staff so the system can be adapted and improved.
Dr Imtiaz Gulamali is a trainer and associate director with 18 years’ experience, and a GP in Harrow, north west London.
London Deanery. Trainer selection and re-approval procedures. April 2010.
COGPED. Delivering medical training in the fairness in procurement in primary care scheme. January 2007.
Houghton G, Wall D, Norton B and Wyatt S. Do GP training practices achieve higher QOF points? A study of the Quality and Outcomes Framework in Birmingham and the Black Country. Education for Primary Care 2006 17 (6) 557-571.
NHS East of England: Criteria for the selection and re-approval of trainers, associate trainers and their practices in primary care. Updated January 2012.