INTRODUCTION
There are many reasons why doctors may not wish to commit fully to a lifetime’s work in the NHS. However, the early loss of GPs is contributing to the impending GP workforce crisis. The Retainer and Induction & Refresher (I&R) schemes help to keep or reintroduce GPs in the workforce, but at a time of intense budgetary restrictions there is pressure to review the limited funding that supports them. This article analyses how cost-effective they are.
The Department of Health (DoH) has set a target that one-half of all UK medical graduates entering postgraduate specialty training should go into GP training.1 However, according to the Centre for Workforce Intelligence (CfWI),2 we are 550 short of the target, therefore undertraining GPs by approximately 18% per year. It is possible to increase the number of UK GPs by:
increasing the number of students in UK medical schools and then GP training;
raising the number of medical graduates who go through GP training;
attracting more EU-trained GPs and providing them with an induction to prepare them for UK general practice;
bringing more GPs back to practice after a career break; and
retaining more GPs who, principally because of domestic commitments, can only undertake a small amount of paid professional work.
The first two options have significant time and cost implications. It costs £488 730 for a student to complete undergraduate medical school and then GP training,3 while the cost of a GP training programme for a medical graduate is £196 500 (£11 600 per subsequent working year using peak joiner and median retirement ages calculated from NHS Information Centre data4). This article makes an economic appraisal of current use of the other three options outlined above.
JOINING AND LEAVING PRACTICE
The peak age for doctors joining the GP Medical Performers’ List (MPL) over the 10 years from 2001–2010 was 32 years.4Figure 1 shows an analysis of the data for the ages of males and females leaving general practice.
Ages of males and females leaving general practice 2001–2010.
Both lines are bimodal, but the sex difference is striking: of the 11 633 doctors that left general practice in 2001–2010, the peak age for females leaving the MPL was 35 years, while for males it was 57 years. Sixty per cent of the female leavers were below the age of 45 years, compared to 28% of males. The NHS Information Centre data show no subsequent ‘bulge’ in the figures for joiners, suggesting that few doctors rejoin at later stages in their careers.
THE INDUCTION & REFRESHER SCHEME
The I&R scheme (formerly the Returner scheme) aims to reintroduce GPs to practice following career breaks and provides an entry for EU doctors. It allows doctors a maximum of 6 months full-time equivalent supervised work in an approved general practice as part of a competency-based programme.
A Committee of General Practice Education Directors (COGPED) position paper5 recommends that, if a doctor has had ≥2 years of absence from NHS general practice, the likelihood of waning skills means that further assessment and, if required, retraining will be needed before starting back in practice. Under the 2004 Performers’ List regulations,6 those with responsibility for local licensing must ensure that a doctor returning to the workforce has retained the competences expected of a GP. This was reiterated by the House of Commons Health Committee report7 following the inquiry into the Daniel Ubani case.
Doctors who have been through the I&R scheme have been shown to deliver additional elements to primary care, such as teaching and training responsibilities, and involvement with local management and clinical commissioning groups (J Morison, personal communication, 2012).
THE RETAINER SCHEME
The aim of the Retainer scheme is to preserve the skills of doctors who, for varying reasons but principally domestic, wish to avoid complete career breaks by reducing their clinical commitment and workload while working in a supportive environment. Help and advice from a named deanery-approved supervisor must be available and the scheme should provide a wide experience of general medical services.8 While it is possible that some of these doctors would remain in the workforce without the Retainer scheme, for others absence from the workplace would result in their skills waning: the Retainer scheme is designed to allow doctors to keep up-to-date and further develop their careers.
Our own research (Young et al, unpublished data, 2013) shows that the Retainer scheme is highly valued by its members. As well as being used while raising families, it is used by carers and those that suffer from illness or disability. Retained doctors report that the scheme provides a framework that is tailored to their needs and enables them to feel valued.
THE COSTS OF THE SCHEMES
We have used London Deanery data (P Trafford, unpublished data, 2013) to calculate the I&R scheme cost per expected subsequent year of work, by dividing their scheme costs by the number of years that I&R doctors are subsequently expected to remain in practice. This results in a figure of £1240 for UK-trained GPs and £1160 for EU-trained doctors. This analysis includes payment of a salary equivalent to a GP specialist trainee (GP ST3).
For Retainers, the cost to the Severn Deanery is £4430 per expected subsequent year of work.
In comparison, the cost of a full GP training scheme is £11 600 per expected subsequent year of work (£19 650 for females, £7860 for males).
DISCUSSION
We were surprised at the high proportion of GPs, particularly females, leaving general practice at a young age. We need to consider how best to support workforce retention in this group.
The Royal College of General Practitioners recommends that doctors complete a minimum of 200 clinical half-day sessions over the 5-year revalidation cycle.9 Those who have been working abroad or on other career breaks may find this challenging without the I&R and Retainer schemes.
Estimating costs per expected subsequent year of work depends on a prediction of how long each I&R or Retainer doctor will remain in the workforce. Our analysis assumes that the typical leaving ages derived from the NHS Information Centre data will apply to these groups.
Data published by the CfWI10 suggest that overall participation rates (the average proportion of full-time equivalent working) were 0.94 for male and 0.83 for female GPs in 2008–2011. We found that, while 24% of Retained doctors subsequently became GP Principals and 47% continued as salaried doctors, few returned to full-time work, most having a participation rate between 0.4 and 0.6, similar to that of the post-I&R doctors that we surveyed.8
CONCLUSION
We are under-training GPs by 550 per year, and GP training costs £11 600 per subsequent working year. In addition, there is a time lag of at least 4 years between an increase in recruitment to GP training and the resulting fully-trained GPs.
Therefore, it appears that the average cost of £4430 per subsequent working year for doctors going through the Retainer scheme is, in spite of all the caveats to the calculation of that figure, good value for money. If Retainer doctors are lost to the workforce where it is not in use, the arguments in this article suggest that the Retainer scheme is cost-effective. This is still the case even if a proportion of Retainer doctors would have continued work without the scheme: if only one in four Retainers is truly retained by the scheme, the cost per subsequent year worked is still less than that of a female doctor going through GP training.
The arguments for supporting the I&R scheme are even stronger, with the cost for UK-trained GPs approximating to £1240 per subsequent working year. This includes the cost of a salary during the Refresher months. Attracting doctors to the scheme by making it fully financed and salaried makes sound economic sense.
Notes
Provenance
Freely submitted; externally peer reviewed.
- © British Journal of General Practice 2014
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