General practice continues to face a staffing crisis. There have been a number of failed attempts to bolster the size of the workforce – through international recruitment and retention of older GPs, among other initiatives.
But recently there has been reason for hope: last year, for the first time, Health Education England (HEE) met – and exceeded – its GP trainee recruitment target of 3,250. And it looks as though that will be bettered this year.
HEE’s deputy director of primary care, Professor Simon Gregory, believes this success can be sustained. Here, he tells Pulse about the changes to training that enabled the goal to be met and how HEE plans to tackle the workforce challenges still to be solved.
Pulse: HEE has met its target of recruiting 3,250 GP trainees in a year, after several failed attempts. How did you get there?
Professor Gregory: Initially, the challenge was trying to encourage people to join a specialty, a profession, when all they were hearing were negative stories. We needed to be honest about the problems there were – and still are – in general practice and encourage these incredibly bright doctors to realise they could be part of the solution.
The RCGP recently said 5,000 GPs needed to be trained a year to deal with workforce shortages. How achievable would it be to train more?
We’ve been working on increasing GP numbers for years. I’m not really fixated on a number – I want there to be more, but I don’t know if it will be 5,000 or more than that. We are working with ideas to reform GP training, to expand it.
Is it enough to just train larger numbers of GPs, or should there be greater efforts to retain those already in the profession?
It’s got to be a whole-system solution. My team and I have ensured that trainees see this as the career to go for, but there’s so much more to be done.
First, the GP trainees we’re recruiting need to be welcomed. They need to be encouraged to stay in general practice at the end of their training.
Second, the established GP workforce needs sorting. There needs to be a lot more done in all avenues. Work intensity is a key thing. When I started as a GP, one in three consultations involved a patient with more than one problem, and it was complex. But gradually more and more of my work is being passed on to other healthcare professionals.
Pensions, as well, must be sorted out. I’ve got friends I trained with who have already retired. When you get your pension quote, or you get your tax bill, that’s the point when you think, why do I carry on doing this?
So, just putting more trainees in is not the only answer.
I wanted flexibility – I just didn’t have the sense to believe it was on offer
Do you think portfolio careers encourage people to work in general practice?
Many doctors want portfolio careers, and rather than seeing the loss of full-time GPs as a threat, we should see the opportunity.
We really value frontline GPs doing frontline general practice, and what general practice needs is the expert generalist. If we do other things in portfolio careers, we’re still GPs. What’s more likely to happen is that it makes the career sustainable.
We’re working on one of the themes set out in the People Plan [the NHS workforce strategy], called ‘Making the NHS the best place to work’. General practice has got to benefit from that. It’s about making our working conditions better. I want GPs and their staff to feel cared for and valued, and I’m not sure that’s universal yet.
How do you respond to concerns that trainees do not see themselves becoming partners, or working in full-time frontline care?
The first thing to consider is the number of them who say their career intention is to be a GP. Some actually want to be partners from the start. Some may have relationships that mean they’re not necessarily able to stay in one area at first. I also think people are wisely saying, ‘I’ll do what fits my choice’.
When I look at what millennials want, it’s not that different from what I wanted. What’s changed is opportunity. I wanted flexibility, I just didn’t have the sense to believe it was on offer, or the courage to accept it would be okay. I was thinking of my mortgage, supporting my kids. I look down the list of what millennials want and think, ‘Good on you, I agree’.
I get that they want different things, but what I don’t want is them labelled as though they are offering something less than other generations did. They’re not – they’re just as committed.
Don’t sit your exams too early. Don’t sit them until you’re ready
HEE is working on a five-year GP training pilot in east London. Will it be expanded elsewhere?
Our plan is to have 13 or 14 pilots. Ideally, I’d like one in every deanery area. I’m having discussions on those at the moment. I’ve said before, why do we train people for 18 months in hospital? Often they’re not even learning much about general practice; they’re providing a service in the hospital, but that’s the way it’s currently funded.
Looking at that pilot in Tower Hamlets, there are going to be seven people starting next year in FY2. They’re going to do a year of FY2 in the community. They’ll do three years of GP training, and then the fellowships automatically at the end of it.
What has been the effect of HEE changing the rules for trainees who fail their MRCGP exams?
We got the rules changed so that if people fail the exams they can have up to a year’s extension to their training programme – it used to be only six months. That’s been one of our biggest changes in helping people, because we had the shortest training programme, with the shortest opportunity for extension. We’re saying to people, ‘don’t sit your exams too early. Don’t sit them until you’re ready’.
People take the AKT at the start of ST2. They take the CSA as soon as they can in ST3, often before they’re ready. If they fail, it’s costly and distressing. The exam is run at no profit by the college, but it’s expensive due to the costs of examiners and actors.
I don’t want people to keep resitting it, so I’m trying to encourage them to delay until their trainer thinks they have a good chance. If that means they don’t take it before they’re ready, that’s better.
We’ve piloted this – we’ve said in the targeted training programme [introduced by HEE to give trainees who fail one of their exams another attempt] that people shouldn’t sit it until they have got the agreement of their trainer; if they fail it they should have the agreement of both their trainer and their training programme director before a resit.
What plans are there to train extra healthcare professional staff joining primary care networks?
HEE has now had its one-year spending review, and in that we were allocated a 3.4% funding increase. This gives us a real opportunity to plan for the integration of other healthcare staff into PCNs.
For example, we’re working with ambulance trust chief executives who are worried about who is going to be on the ambulances if they lose their paramedics to general practice.
We’ve put forward a programme based on rotating paramedics, where people might spend some time on a vehicle, some time in an emergency department and some time in general practice.
Do you expect to include the digital GP model and new tech in GP trainee curriculums?
It most certainly needs to be a part of the future curriculum, although if you go back to the RCGP curriculum and look at the bit about being a GP and about the consultation, none of that says it has to be in a consulting room.
Rather than focusing on any particular provider, what I would say is, this is a disruptive innovation. My worry would be that if people go straight into online consulting, they may not have the full grounding in being a GP. I would hope we would include it more and more – through it being one of the modalities we offer patients. But we also have to ensure this is a model that supports everybody; one thing I want to be careful of is that this doesn’t exacerbate the inverse care law [whereby those most in need of care have least access to it].
Have any lessons been learned from the 2015 GP recruitment drive that featured a GP ticking a consent form for a patient skydive?
There was a huge backlash from established GPs – [but] it was really popular among the people we were trying to recruit. Every single advertisement or video we now use is tested against all age groups. That particular advert was tested to make sure it would appeal to the people we needed to recruit – but what we didn’t do was test it to see if it would upset anybody else.
• 1990 Graduated with MBBS from the University of London
• 2019-present Deputy medical director for primary and integrated care, Health Education England
• 2019-present Board member, Maggie’s Cancer Centre, Northampton
• 2018-present Trustee, RCGP
• 2016-present Board trustee, Astrea Academy Trust
• 2014-present Ethics chair, RCGP
• 1995-present GP, King Edward Road Surgery, Northampton