INTRODUCTION
The general practice workforce is in crisis, with large numbers of GPs reaching retirement age, choosing to take time off or to work part-time across a range of jobs (portfolio work). Extra GPs are needed to manage the increasing demand from an ageing population, with more services moving into primary care and greater commissioning and public health responsibilities. GPs wishing to return to practice after a career break and those trained outside the UK represent an important resource, but it is essential to provide good induction and refreshment opportunities to promote patient safety and to protect doctors by ensuring they are properly fit for independent NHS general practice.
Across the UK a range of approaches have been developed over the past 10 years to support GPs wishing to return or start practice in the NHS. In England, GPs have been able to take part in the GP Induction and Refresher (I&R) scheme.1 Although voluntary, following the case of Daniel Ubani2 in 2010, it became standard practice for all primary care trusts across England to request a learning needs assessment via their local GP I&R scheme as a condition of inclusion on to the Performers List, a responsibility taken over by NHS England in 2013.
The scheme involved completing a two-part entry assessment, comprising a multiple choice exam and a simulated patient surgery, followed by a supervised placement of variable length in general practice, and completion of a workplace-based assessment ‘log-book’ and the Royal College of General Practitioners’ Applied Knowledge Test exam to exit the scheme.
The process varied considerably across the country with some areas providing full funding and educational support and others none. Concerns were raised that the current systems acted as barriers to getting these GPs into the workforce.3 The 10-point plan to build the workforce for general practice called for a fresh look at the scheme, building on the successes to date but also addressing many of the concerns.4 In light of this. the pan-London Professional Support Unit has reviewed the feedback from GPs who had been on the scheme in London between 2009 and 2014.
THE EVIDENCE FOR AN INDUCTION AND REFRESHER SCHEME
Returning to medicine or beginning work in a new country can be daunting and it is important that doctors feel safe and confident. Furthermore, at a time when there is demand for greater accountability, we need validated and robust ways to allow GPs to demonstrate up-to-date skills, knowledge, and fitness to practise. Supporting doctors who want to return to practice or move countries has to be essential for both quality and safety yet surprisingly little has been published about the most effective ways of doing this.
In the UK, focus groups exploring the needs of GPs who had graduated overseas highlighted the desire for an effective individualised learning needs analysis at the beginning of training, and ongoing support to integrate into the NHS.5 Challenges faced by doctors who have not been practising in the NHS include knowledge and skills deficits;6 the application of their knowledge and skills to new contexts, where diverse cultural and population health issues add complexity;7 and lack of confidence and low self-esteem.8 An evaluation published on the implementation of the scheme in one region suggested broad support but concerns over funding and practical requirements. Importantly, GPs did report improvements in their clinical skills and knowledge, understanding of NHS policy, and perceived self-confidence.9 Overall, although the GP I&R scheme is generally promoted as worthwhile, little has been published about what participants themselves think of it.
EVALUATION 2009 TO 2014
We evaluated feedback from GPs who had completed the London I&R scheme from 2009 to 2014, using an analysis of both exit feedback forms and telephone interviews with an independent researcher. In this period, 56 GPs completed the London scheme, out of whom 34 (61%) had completed an evaluation form at exit. Thirty-five GPs, for whom current contact details were held, were invited for telephone interview and 23 (66%) agreed. Of these, half were UK-trained returners, one-third European Union (EU)-trained GPs, one in 10 GPs had had performance concerns, and one in 20 had trained outside the EU.
Overall the feedback indicated the scheme was a positive experience and, in both interviews and feedback forms, the majority of GPs said that the scheme had helped improve their skills, knowledge, and confidence to practice. UK returners repeatedly said they would have struggled to return to practice if the scheme was not available or that they would have delayed returning for longer, and even those who said that they had initially been sceptical about the scheme said they could now see its value.
In both interviews and feedback forms, the components of the scheme that GPs reported as being most useful were having an opportunity to work under supervision in a practice, be allowed to adapt and learn at their own pace, and to feel part of a practice team. Another well regarded aspect of the scheme was the opportunity to take part in regular facilitated peer support sessions particularly for those who needed support with practical issues or felt less confident and more isolated.
The main suggestions for improvement related to the purpose of the scheme and the process, which was felt to be potentially daunting or frustrating. Some GPs believed that the scheme was inappropriately attempting to ‘train’ GPs and to assess competency rather than to provide an induction to NHS systems. Some felt that the scheme should focus on orientating doctors to computer systems, referral pathways, and aspects of NHS culture, rather than assessing whether GPs were competent to practice. Many felt that their wider expertise was not adequately valued, even though the skills they developed were useful in clinical practice. Examples included working in medicine internationally, working in the UK in another medical field, or working in the home raising a family. UK-trained GPs who had held senior positions internationally or in other fields and those trained outside the EU were most likely to report these views.
A number of GPs said that it was difficult to find out how to access the scheme. They were not told at registration with the GMC that it existed or that they needed to join the Performer’s List. This generated animosity on arrival in the UK as many were expecting to start work in general practice straight away.
Lastly, a major issue related to the financial support available. Across England this varied enormously from nothing to a full trainee level salary. In London, GPs taking part in the Scheme were paid £50 a session. The majority of GPs interviewed mentioned that it was difficult to survive on this stipend or ‘educational grant’. There were also concerns that the financial issues could be a barrier for some groups of GPs, including systematically excluding females.
DISCUSSION
This evaluation showed induction and refreshment to be useful and valued, and emphasises the need for a supportive, educational experience tailored to a GP’s individual needs. However, the process was felt to be unnecessarily bureaucratic and did not always recognise the experience of applicants. The lack of meaningful reimbursement was also a barrier, although a cost–benefit analysis of London data suggests adequate reimbursement would not be costly, particularly when compared to the £400 000 it costs to train a new GP.10
We have a workforce crisis. Female GP trainees outnumber males, and females are more likely to have a career break. Both men and women want flexibility and are choosing to work in portfolio careers, balancing other responsibilities with clinical care. This is a trend that is likely to continue making it essential that return to practice schemes are not a barrier to maintaining our GP workforce, but attract not only UK-trained GPs back into practice but also GPs who have trained abroad.
The new scheme, launched in March 2015, aims to deliver a funded, more streamlined process throughout England.11 The updated and funded assessments will allow differentiation between GPs who require little more than support through e-learning modules and early appraisal, to those who require longer supervised funded placements, ensuring the approach is tailored to the individual doctor’s learning needs. Delivering a working I&R scheme will go a long way in boosting our ailing workforce with experienced GPs. Getting it right will be essential to ensure we maintain high quality primary care that both patients and practitioners can feel confident in.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2015
