INTRODUCTION
In 1985 Julian Tudor Hart observed:
‘… our medical schools teach and our students learn better than ever before’,1
yet he also noted that there was a ‘… crisis of structure’.
In response to that crisis he went on to make a case for ‘turning the world upside down’, arguing for a reversal in undergraduate medical education to see the preponderance of teaching time spent in the community rather than in hospital. The change he advocated did not occur; however, the discipline of academic general practice was recognised as playing a key role in the medical school curriculum and the education of medical students.
Fast forward over 30 years.
A CRISIS OF STRUCTURE
Although general practice has become embedded in the medical school curriculum, most teaching continues to remain hospital centred and hospital focused. The ‘crisis of structure’ observed in 1985 is arguably being felt more sharply now, not only in terms of recruitment and retention, but also rippling through increasing workload, complexity, and uncertainty. The pressures on general practice arising from the reduction in full-time partnerships, an increasing number of early retirements, and the ongoing absolute reduction in whole-time equivalent working have been recognised for some time.2 Yet the educational response to this persisting workforce strain has remained superficial, save for increasing the number of students entering medical school.
Strategies generally seek to improve attitudes towards general practice through increased and more frequent exposure, and initiatives to ‘champion’ the specialty. Yet the current waxing unpopularity of general practice as a career has rendered even the increase in medical school student numbers ineffective as a workforce strategy. It is often quoted that some 50% or more of medical students need to go into a career in general practice to maintain the workforce, but recent evidence shows as few as 7% of students from some medical schools select general practice and no more than 30% from others — averaging a mere 17%.3
In 1985 Tudor Hart argued:
‘… it is clearly intolerable that as a nation we should continue at huge expense to train all doctors to be nascent specialists, and then retrain about half of them to be community generalists.’1
EXTENDING THE MODEL
The rhetoric of research and ‘thought’ pieces to date has been about levelling up and ‘extending’ primary care experience in the undergraduate years. Yet the expected outcome of more graduates choosing general practice has not been realised. We therefore propose extending the traditional model of undergraduate training. Indeed, the need for changing focus in medical curricula has long been recognised,4 and points to fundamental issues with the way undergraduate education is structured and delivered.
PRACTICE-BASED EDUCATION
We propose that an additional pathway into medicine be developed at postgraduate level, which locates learning within a primary care environment. A postgraduate course entry point opens up an underused level of learning. Graduate entry programmes have paved the way and demonstrate a workable shortened pathway of studies, although the content of the curriculum is still typically modelled on undergraduate programmes. The proposed curriculum would be informed by the current GPST curriculum for its focus, learning, and approach to assessment, but with certain aspects substituted to meet the GMC requirements of Promoting Excellence.5 This might mean that curricular topics linked to specific general practice management would be exchanged for other more generic professional skills linked to becoming a doctor. The majority of learning would take place in primary care within the existing training practice network and model the well-established supervision structures already in place. Specialty attachments would still exist, but with the principle of returning to the primary care base for continuity and a sense of belonging. Small-group learning facilitated by experienced educators would ground the approach to learning, built around real cases encountered by the students, thus the patient and the skills needed for an effective consultation would be at the heart of learning. The final exit assessment would be framed by current practice in graduate entry programmes and the proposed single national medical licensing assessment (MLA). Graduates of this course would move into the foundation programme alongside their peers.
- © British Journal of General Practice 2018