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Analysis: ‘The end of GP training as we know it’



‘We don’t do training to earn money,’ says Dr Alistair Howitt, a GP trainer in Tonbridge, Kent. ‘We see it as part of our professional commitment. It is training the next generation.’

But he and other GP trainers are reeling in shock at Department of Health plans to make practices pay for the ‘benefit’ they get from a trainee.

A ‘tariff’ system being introduced by Health Education England (HEE) – exclusively revealed by Pulse – could see training practices having to contribute to the salaries of trainees, as ministers look for ways to help fund the sharp increase in GP numbers needed to meet rising demand in primary care.

The plan has prompted GP programme directors to warn that the system could collapse, with dire implications for the future of general practice. The GPC has also reacted angrily, claiming the plans could ‘spell the end of GP training as we know it’.

The move towards a tariff was included in the business plan published in July by HEE, the new body responsible for NHS workforce requirements.

Although HEE is still considering how the tariff will be applied, in secondary care – where similar plans are due to be rolled out from April 2014 – the Government’s favoured option is that the training hospital pays 50% of a trainee’s basic salary plus a placement rate.

A figure for GPs has yet to be set, but HEE says it is ‘considering all options’ for how any potential levy will work.

Practices are currently reimbursed for 100% of trainees’ salaries by local education and training boards. They are also given a £7,600 annual trainer’s grant. But the DH believes having a trainee available gives practices an advantage they should pay for.

A DH impact assessment of the plans says: ‘The current arrangements for postgraduate medical training in primary care provide funding for 100% of the trainee’s salary, taking no account of whether the trainee provides any service (benefit) whilst they are training.

‘Introducing tariffs, based on the costing exercise, will allow us to address this and remove any advantage there may be to a practice who takes trainees.’

A special relationship

But GPC negotiator Dr Beth McCarron-Nash, who is a partner at a training practice in Cornwall, says any attempt to impose charges for the service provided by GP trainees will be the ‘straw that breaks the camel’s back’. 

She says: ‘It’s mad. Although training practices, such as mine, value training young doctors, there comes a point where the workload is so high and the impact on practices so significant that unless it is remunerated properly, they will throw in the towel.’

The DH is trying to apply a system that can work in secondary care to general practice, where it is inappropriate, Dr McCarron-Nash argues.

‘The training we give is completely different to that received in hospitals. That one-on-one relationship is absolutely fundamental to the quality of the trainee that comes out at the end of that process.’

Other GP trainers have pointed out that hospitals rely on the services provided by junior doctors to continue functioning, whereas hosting a GP trainee is at best cost-neutral for practices.

Dr Krishna Kasaraneni, chair of the GPC trainees subcommittee, worries that payment will fundamentally alter the special relationship between trainee and trainer. He says: ‘It’s no secret that practices are struggling financially, and asking them to pay for the privilege of training is not going to go down well and could spell the end of GP training as we know it.

‘At the moment, I can go to my trainer and say “I am lacking experience in ENT, I would like to practise in an ENT clinic soon” and they will say “fine, off you go”.

‘But if they are paying for my services, and I say I want to go to ENT, they are likely to say “you can’t, because we won’t have enough GPs that day. I’m paying for you, I expect you to be in the practice and do work”. So how do I get trained?’

A ‘collapse’ in training

The plans come as the NHS determines how to pay for the planned introduction of a fourth year of GP training.

Pulse reported last year that the Committee of General Practice Education Directors was in talks with the DH over a national tariff for service provision by fourth-year trainees, in a bid to offset the extra cost and persuade ministers to approve the longer GP training period.

The NHS already has a huge job on its hands to meet Government targets for 50% of all medical graduates – 3,250 each year – to go into general practice by 2015. This year, the number of recruits for the August intake was 2,787 – an increase of just 95 on 2012 figures.

An HEE taskforce is developing plans to meet the targets, which it says will be published in ‘due course’.

But GP vocational training scheme programme directors agree that a recent 20% rise in GP trainers could be kicked into reverse if the plans to charge for trainees go through. Dr David Griffiths, programme director of the Oxford District GP training scheme, says a number of practices will stop training ‘immediately’ if they have to pay trainees’ salaries.

 He says: ‘We can’t afford to lose any training places; we already get complaints that the grant is insufficient. There is also quite a big retirement time-bomb with trainers and this could tip a lot of them over the edge.’

Dr Stuart Calder, programme director for the York GPVTS team, says: ‘It is likely that training would collapse in the York area. Training places demands on practices, which receive recognition appropriately with a grant.’

But he concedes there could be a rationale for practices paying for a trainee in their fourth year of training. ‘If a fourth year of training came in, a case could be made for some payment, as this would be equivalent to taking on a salaried GP who has just finished training.’

A looming shortage

Professor Bill Irish, chair of the GP National Recruitment Office, declined to comment on the proposals to charge practices because, as director of education and head of school at the Severn Deanery, he is also an employee of HEE. But he admits there is a looming shortage of training practices given the need to increase places.

He says: ‘The degree of the problem depends on the area. Areas with high workload, deprivation and isolation generally have less capacity. HEE and its regional offices are working hard to develop the necessary training places.’

But this is of little comfort to Dr Howitt: ‘To be a GP trainer, you have to get a postgraduate certificate in education and that takes a long time. If we effectively had to pay to have a trainee and we looked at the implications, the obvious thing would be to have a salaried doctor come in and do the work – that is a million times easier.’

Additional reporting by Bethan Eynon and Madlen Davies

Case study: ‘We will stop or cut down on training if we have to pay’