INTRODUCTION
In 2008 the Tooke report stated that the length of training in general practice is ‘currently inadequate to meet the demands of shifts in care to the primary sector’ and that it ‘should be extended to 5 years’.1 This report identified significant differences between GP training in the UK and other developed European countries and also with other specialities within the UK. The Royal College of General Practitioners (RCGP) recently published their vision for general practice in 2022.2 This document states that:
‘GPs will need enhanced and extended training, in order to develop the knowledge, skills and expertise to be fit for purpose in the NHS and to meet the health needs and expectations of patients and the wider population’.
The RCGP has also considered an ST5 year specifically, commenting on the opportunity to broaden trainees’ experiences of general practice into the community and to give them opportunities to specialise according to their own interests.3 This article offers an alternative to an ST5 year, proposing a fifth year of training to be undertaken after obtaining Certificate of Completion of Training (CCT). This is based on the current system for teachers in England. The Newly Qualified Teacher (NQT) induction programme introduces teachers to the profession in a ‘light touch’ mentored and regulated year following completion of their vocational training.
THE NQT YEAR IN TEACHING
After achieving Qualified Teacher Status (QTS), NQTs must satisfactorily complete an induction year. NQTs apply for teaching posts, competing against experienced teachers for positions within the teaching job market. Once appointed, the head teacher notifies the local authority that the NQT has a suitable post. The induction year can be completed part time and can be completed in more than one consecutive post. However, NQTs must spend at least one school term in each post to ‘demonstrate their ability to meet the relevant standards consistently over a sustained period in their practice’.4 Although NQTs are encouraged to start their induction as soon as possible after gaining QTS there is no time limit for starting or completing their induction year. If an NQT chooses to work as a supply teacher, they may only do this for up to 5 years before they must complete an induction year.
Schools offering posts to NQTs have a statutory responsibility to make certain provisions. These include reducing teaching ‘contact’ time to 90%, assigning an induction mentor and providing an induction programme to help smooth the trainee’s transition into teaching. This induction programme will continue throughout the year and should include relevant training, opportunities for useful experiences, observations, and feedback. The NQT is assessed against the core professional standards three times throughout the year. The head teacher will keep the local authority informed of the NQT’s progress before making a pass/fail recommendation. The Teaching Agency will then be told the final outcome.
While most NQTs will pass their induction year, the importance placed on the induction year in the teaching profession is demonstrated by the consequences of failure: the teacher can never take up a post in a state school. They retain their QTS but cannot be lawfully employed in the state sector as a teacher, they must be dismissed from post in 10 days and their names are kept on a register with the Teaching Agency. There is an appeals process for failed NQTs.
THE NEWLY QUALIFIED GP (NQGP): A FIFTH YEAR OF TRAINING?
A fifth year of training would provide an opportunity to develop independent practitioners with an even broader and deeper knowledge of the profession. This article introduces a model for a fifth year of GP training that is fundamentally the same as the NQT year. There are many details to be filled in (Figure 1) but the core idea is that trainees would receive their CCT at the end of their ST4 year. They apply for jobs as an NQGP who would require a mentor (not a supervisor) to support them and scheduled teaching throughout their first year of practising. During this year NQGPs would demonstrate that they are able to develop as part of the general practice community in their local area, within a practice that they will be working in long term. Once NQGPs have completed their induction year satisfactorily, they are then able to continue working in their practice as fully qualified GPs.
An NQGP year, topics for debate.
This structure of continued training would overcome many of the challenges that would face an ST5 year of training (Box 1) and there could also be additional benefits of this scheme:
It would encourage all recruiting practices to engage with the training process.
It would further embed the concept of career-long learning; new GPs would formally begin their careers combining work and learning within a supportive framework.
It is generally recognised that GPs need more support in their first few years of practicing and the introduction of First5® by the RCGP5 aims to help meet this need. As well as being the final stage of training, an NQGP induction year could be seen as a formalised part of this support.
Box 1. Meeting the challenges of extended training
| Challenge for extended GP training | Meeting the challenge with an NQGP year |
|---|---|
| • The RCGP wants continued challenge for trainees by both broadening their experience into the community and allowing them to specialise3 | • Within their own practice there should be greater opportunities to take on leadership roles and manage change to meet the updated RCGP curriculum |
| • Finding placement for trainees • Finding additional trainers | • No requirement for additional training placements |
| • Finding the additional funding required | • Salaries would be met by recruiting practices (with the NQGP filling the post of partner of salaried doctor) rather than coming directly from the NHS budget |
| •Dealing with the break in workforce supply | • No delay for trainees in obtaining their CCT |
| • Avoiding the length of training becoming a deterrent for new applicants | • Minimises the impact on recruitment by not affecting the salary progression |
However, it would be very important to minimise the burden on individual practices to avoid prejudice against NQGPs when recruiting.
There are a number of mechanisms currently in place within general practice that could be adapted or extended to support an NQGP induction year. Clearly, there would be potential to link up with the current vocational training schemes or directly with local deaneries. It could also be possible to use the current appraisal system or the new RCGP revalidation ePortfolio and there could be links with clinical commissioning groups (CCGs) or local First5 groups. These are all opportunities to make the implementation of a fifth year of training more straightforward and less costly.
DISCUSSION
The NQGP year
The initial discussion would have to involve the fundamental format of the NQGP year. This would include decisions on the length of contracts that would count, whether locum jobs would count, and which primary care settings would be suitable for an induction year. Consideration would also need to be given to potential time limits imposed on completion of induction.
Training and support for NQGPs
An induction mentor would be there to provide a formal contact point for NQGPs who need the opportunity to discuss their transition to their working environment and their continued learning. The role of the induction mentor would need clarification, with recommendations or directives for amount and content of formal contact time that does not overburden practices.
The provision of training sessions would also be a requirement, but may represent a large workload for individual practices. So to whom should this burden fall? CCGs could pool resources or VTS/deaneries could provide scheduled teaching. If organised by the VTS or deanery this fifth year of training could be tied to the ST1–4 years and smoothly integrated from previous training. However, releasing control of NQGP teaching to CCGs would potentially allow it to be adapted to meet local priorities. This latter option would perhaps tie the fifth year more closely to their future careers rather than past training.
The expectations of the induction teaching would also need discussion. Perhaps the content would be best determined locally to meet local needs or, alternatively, a nationalised curriculum could be used. The challenge would be finding a balance between regulation and allowing individuals to develop areas of special expertise and undertake specific projects in their local community.
The NQGP mentor
The identity of the induction mentor would need to be decided: they could be an experienced GP, a current trainer, or perhaps a current appraiser. There could be, or perhaps should be, training for induction mentors: would this be compulsory or voluntary? Would it be a one-off accreditation or a regular requirement to maintain up-to-date good practice? It may not be necessary for the induction mentor to be a member the practice employing the NQGP, perhaps CCGs could provide a pool of NQGP induction mentors similar to appraisers.
Regulation and completion
It is most likely that NQGPs would have to provide evidence to pass their induction year. Here is an opportunity to utilise current systems: the RCGP revalidation ePortfolio may be used to log evidence of continued professional learning and the appraisal system could, potentially, be utilised to ‘sign off’ NQGPs once evidence has been presented. The nature and quantity of the evidence would need discussion, it would be important to recognise the difference in focus of the NQGP year compared to previous ST years. While some evidence would likely be the same, the NQGP year would need focus on specialist interests and wider practice/community-based projects in order to meet the RCGP vision of the fifth year of training.
Trainees need to receive their CCT before practising unsupervised, so this must be awarded at the end of the ST4 year. Therefore it may be necessary to have a mechanism to revoke CCT if an NQGP fails their induction year, involving the GMC. There would also be an opportunity for the RCGP to recognise excellence at the start of a GP’s career.
CONCLUSION
The current financial constraints on the NHS and the time pressures on implementation of the new health bill make the introduction of an ST5 year as recommended in the Tooke report seem an impossibility. Here is an alternative fifth year of training that mirrors the induction year currently in place in teaching. It offers a potentially low-cost option that could, in the main, utilise systems already in place. This format of training could help embed a culture of ‘learning on the job’ as well as providing a structured support system at a key transition point for trainee GPs.
The success of this format for a fifth year of training would depend on a careful balance between standardisation and freedom for individualised progression. It would also require the engagement of all practices with the training process. However, as long as the burden on practices is kept to a minimum, the benefits of an enthusiastic, NQGP should easily outweigh the requirements placed on practices.
Notes
Provenance
Freely submitted; not externally peer reviewed.
- © British Journal of General Practice 2013
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