In 1998 the World Health Organization (WHO), after consultations with academic institutions for general practice and UEMO (the umbrella organisation for all European unions of GPs), published a document entitled: Framework for Professional and Administrative Development of General Practice/Family Medicine in Europe.1 The document describes the core characteristics of general practice and the structural conditions that must be met if politicians, as recommended, should support a strong primary care sector with general practice as the cornerstone. The most important part of the document is the recommendation of a specific educational curriculum in primary care at all educational levels.
In 2000, an editorial in the BMJ followed this by questioning whether it is time for a new definition of general practice.2 The new association of all academic colleges and societies for general practice in Europe took on the task: Wonca Europe, which was founded in 1995 after the political reunification of Europe.
In 2002, this academic society published The European Definition of General Practice/Family Medicine.3 The purpose was to make the definition the cornerstone in the development of an agenda for research, teaching, and quality development in the three Wonca Europe networks and in the member countries.
In 2005, the European Academy of Teachers in General Practice (EURACT) drew up an educational agenda describing how the core competences should be addressed in the curriculum in all countries.4 The EURACT educational agenda is intended for teachers, learners, curriculum planners, healthcare planners, and the whole medical profession. It focuses on GP specialty training, but is also intended as a guide for student training and continuing professional development for GPs.
Through the curriculum statement Being a General Practitioner,5 the Royal College of General Practitioners (RCGP) has fulfiled the national part of the task assigned by Wonca Europe, and has filled the gap in the development from WHO-vision and idea through the European definition and EURACT educational agenda, to a national curriculum for GP specialty training.
Although acknowledging its European roots, the RCGP document also rests on the national rules on education laid down by administrative and academic bodies within the UK NHS, such as the General Medical Council's Good Medical Practice which provides guidance for GPs working within the NHS.6
The curriculum statement defines the mandatory learning outcomes and describes the skills required to practice as a GP in the NHS. On the RCGP website (www.rcgp-curriculum.org.uk/) additional detailed descriptions of each component of the very comprehensive curriculum can be found. Furthermore, the website gives detailed information to trainers and trainees on educational methods and resources. It also provides information on the comprehensive appraisal and assessment that is part of the new training scheme leading to certification as a GP and membership of the RCGP.
The RCGP describes the specialty within six domains of core competences:
As general practice is a person-centred scientific discipline, three types of features are considered essential:
Contextual: using the context of the person, the family, the community, and their culture.
Attitudinal: based on the doctor's professional capabilities, values, and ethics.
Scientific: adopting a critical and research-based approach to practice, and maintaining this through continuing learning and quality improvement.
These main headings are all elaborated in great detail in the RCGP curriculum statement.5 For example, ‘Primary care management’ is dealt with in six sub-headings, the first being: ‘To manage primary contact with patients, dealing with unselected problems’. This sub-heading has four associated abilities including: ‘An organisational approach to the management of chronic conditions’. Browsing the Curriculum Map on the RCGP site, this path ultimately leads to a learning resource: an NHS-website dealing with long-term conditions.
Someone might ask whether core aspects of clinical medicine are forgotten with these headings. But if you navigate further into the depths of the curriculum, you will find it all, including areas like ‘ENT and facial problems’ and ‘Care of acutely ill people’.
The curriculum statement and the other material on the RCGP website are remarkably clear, comprehensive, and detailed and ought to provide a solid framework for future GP training in the UK. The level of ambition is high, as it should be, but a natural question from abroad could be: is a training period of 3 years enough?
Besides being an inspiring national ‘bible’ of education, the curriculum statement from the Royal College also sends a very important message to colleges in other European countries. It shows how they, by systematic work, can set up a national, well-described, transparent educational programme for nationwide teaching. Furthermore, such a national paper from each EU member country would show other EU countries what to expect from a GP educated within the framework of a given national programme. In a European Union with uniform minimum standards for the length of training to become a GP and free movement of doctors across countries, physicians, politicians, and the population in general in any EU country have the right to know the standards for medical education in any other EU country. This is the only way to ensure the quality of education of the medical workforce in countries with freedom of movement of workers.
The adoption of a common EU standard for the minimum duration of vocational education was a step forward, but some academic bodies find a mandatory minimum length of 3 years too short. This may well be true, but in any case it is time to promote transparent quality standards of education. Real inter-European problems will arise if the quality and content of European education programmes are unsubstantiated or too diverse: a Scandinavian or Polish doctor working in the UK should have the same level of education in terms of knowledge, skills, and attitude as a locally-trained doctor. Therefore, we urge other countries to take similar initiatives based on the European definition of GPs.
It is not all roses, though. The RCGP and other colleges and teachers in family medicine in Europe should consider if it is time to look ahead and ask if all problems have been solved. In this connection we may return to the WHO document which brilliantly describes how general practice is part of a comprehensive healthcare system, and that all GPs in Europe must realise that they are part of this system.1
The responsible cooperation of general practice with other professions and decision makers in a comprehensive healthcare system is very important if we shall still be able to create and maintain political will to support national public health insurance systems — whether funded through taxes or by contributions to insurance schemes. Such national health systems based on a strong frontline primary care with GPs as key stakeholders, are the best way to create equal access to high-quality health care for all citizens in a country.7
Therefore, it may be time to combine our good, but somewhat narcissistic, educational agenda with an agenda for teaching young doctors how a comprehensive healthcare system functions, and what other parts of the healthcare system may expect from us and our participation in teamwork to make it a well-functioning national health service.
Perhaps it is also time to teach young doctors the need for collaboration with politicians, administrative bodies, and society in general. Many of the crises in European healthcare systems are due to lack of understanding between stakeholders and lack of respect for all the competing rationales behind the decision-making processes where both politicians' and health professionals' views are important.
After all, a bright future for a well-managed healthcare system with free and equal access and high job satisfaction among GPs depends not only on trust between GPs and their patients, but also on trust between politicians as purchasers and GPs as providers in the healthcare system. All these aspects are, to some extent, covered in the curriculum statement, but there may still be room for improvement in years to come.
For GP trainees and trainers in the UK the RCGP curriculum statement gives a very comprehensive and detailed framework for future GP training. From an international perspective, the RCGP deserves praise for the achievement represented by the curriculum statement, and we hope that many countries will follow the example.
- © British Journal of General Practice, 2007.
