Following the centenary of the First World War, military metaphors spring to mind: Lose the battle but win the war? Dig in for the long haul? Regrettably, we have not yet been victorious in securing 4-year training for doctors entering general practice. Yet in 2013 we had victory in our sights; the Royal College of General Practitioners’ (RCGP) educational case had been approved,1 the four home nations were debating costings, the Academy of Royal Medical Colleges had declared its support, and taskforces were planning the transition.2 Now, we find ourselves in the midst of a recruitment crisis, unable to fill the vacancies in our 3-year training schemes, and supporting a struggling GP workforce in all four countries.3 What has happened to our ambition for enhanced training? This editorial provides an update on the progress made, the barriers faced, and the options available.
A RECAP
The original rationale for a longer period of GP training centres around the finite capacity of the existing 3-year (whole time equivalent; WTE) period, which was implemented nearly 40 years ago and is no longer sufficient to cover the full breadth and depth of the modern generalist medical curriculum. Considered groundbreaking in the 1980s, this duration of training now only meets the European Union’s minimum requirement and has not grown with the expanding role of the NHS GP.
There is ample evidence from the popular First5 programme and published surveys that newly qualified GPs feel under-prepared and see value in consolidating their recently-formed competences,4 embedding them through additional educational experience and greater challenge. Beyond this, numerous evidenced reports and evaluations have identified the need for additional GP training in managing the ageing population, mental health problems, and sick children.5 There is also demand for the leadership, quality improvement, and basic financial management skills required to underpin the GP’s role in organisational and service development (including commissioning in England). Independent sources have demonstrated minimal scope to squeeze more training and assessment activities into the UK’s existing 3-year programme.6,7 Summarising all this evidence, the RCGP presented a case for change to the relevant bodies in the four nations and won support to proceed with plans for a new, integrated 4-year training programme.
SO WHY HASN’T THE FUNDING BEEN APPROVED?
Although the challenge of managing a transitory drop in GP training output has been a concern, a major derailer has been the Greenaway report on The Shape of Medical Training.8 Ironically, despite calling for a minimum 4-year core training period across specialties and reinforcing the RCGP’s case, the report has triggered a far wider reconsideration of the need to bolster generalism across the breadth of medical training. In this context, together with the localisation agenda9 and reorganisation of the NHS, there has been a clear message that improvements to GP training can only go forward in the context of wider service and training changes. However, nearly 18 months on, the bulk of the Greenaway recommendations are yet to be implemented, and the extent to which this uncertainty will continue to hamper improvements to GP training remains unclear.
In an attempt to ‘keep the home fires burning’, the RCGP has made considerable efforts to engage in constructive conversations with a range of stakeholders, including the other medical Royal Colleges, the funding bodies in the four nations and our COGPED, Conference Of Postgraduate Medical Deans (COPMeD), British Medical Association (BMA) and Associates in Training (AiT) partners. As well as supporting the development of shared training pilots in areas of service need, such as the innovative GP and paediatric ‘learning together’ programme10, we have progressed development work on the quality improvement and the basic financial management and leadership skills that GPs need to manage multiprofessional healthcare organisations. We are now exploring the option of piloting a new educational post for newly qualified GPs following MRCGP, to demonstrate the feasibility and added value of additional training and to allow Local Education and Training Boards (LETBs), Clinical Commissioning Groups (CCGs) and GP Federations to make an attractive career offer to newly qualified GPs that will help them address workforce and retention difficulties in under-doctored areas.
WHAT LESSONS CAN THE RCGP TAKE AWAY FROM ITS CAMPAIGN SO FAR?
We have certainly learned that policy initiatives in one part of the service can delay activities in another; that unless the whole system values a proposed change, advocacy from several parts of the sector may not be enough; and that any investment is seen as a major barrier in a time of austerity, especially if the training component is perceived to be relatively expensive for the system as a whole (for example, investing in GP trainees compared to an increase in nursing students).
The fundamental case for extending and enhancing GP training remains as valid as ever. The role of the GP has grown massively and our patients deserve GPs who are confident to manage medical risk, lead multidisciplinary teams and provide high quality service to very complex patients. It is also time to reassure medical students and trainees that if they chose a career in general practice, they will be adequately equipped and supported to become lifelong learners and reflective practitioners, with the skills to lead their teams through the NHS battleground!
To achieve this, we need a training programme that provides enough protected training time for professional development while meeting the needs of the wider health system. We need to take up any options presented to us that will extend the supported period of training we can offer our young doctors, evaluate these options, and, if they are effective, fight for their wider implementation.
CAN YOU HELP?
If you are already taking part in an extended training pilot or can influence the commissioning of training opportunities through your local education or health board, please email one of the authors so we can hear about your experience. If you are a trainee, try to persuade your practice, local federation, CCG or other health organisation to offer you a year’s salaried contract with a built in educational package, based around local population needs and the competences set out for the 4-year curriculum.
Once we have demonstrated the benefits that enhanced general practice skills will bring to our local populations and health services, we will finally win national support, securing victory for our cause.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2015