Strengths and limitations
The 100% response rate combined with the specific, detailed questions about GP teaching in the questionnaire suggest that this study gives the most accurate representation of GP teaching to date. It is also the first UK-wide description of funding made available by all medical schools of practice-based GP teaching.
As curricula are continually evolving, this study provides a snapshot only. This work focuses on the quantity of GP teaching; it cannot provide data on the quality of teaching, nor on other types of community-based teaching that may be increasing. Staffing calculations assume alignment between funding sources and allocated activities; however, staff may undertake roles supporting both GP teaching and other teaching. Measuring the amount of all GP teaching in the entire curriculum has made the reliability of comparisons to historical data limited because of previous methods being unclear or different from those used in this study.20
The percentage of curriculum spent in general practice does not assume that the remainder of the curriculum is dedicated to hospital-based specialties. The significance of GP representation would be enhanced by comparative data on other specialties, as well as data on teaching in other primary care or community settings that may be expanding.
Finally, the authors acknowledge that this discussion focuses entirely on UK medical schools. The international picture is unfortunately even more variable and challenging, for example, in Brekke et al’s 2013 study25 of 400 medical schools in 39 European countries, many schools had only very brief exposure to general practice, and 13.5% had none at all.
Comparison with existing literature
The proportion of undergraduate curricula dedicated to GP teaching appears to be falling, contrasting with the perception of most participants that the GP teaching in their curricula has increased over the last 5 years. A number of factors may explain this apparent discrepancy.
Differences in the methods of calculating GP teaching historically may obscure the trend: previous surveys asked individual medical schools to calculate the percentage of GP teaching themselves,20,26 whereas this survey produced more standardised and granular results by calculating the percentage from detailed data requested from medical schools.
Alternatively, GP teaching may truly be falling, with widely discussed proposals for expansion not materialising in reality. Recruitment difficulties, reported here and in the literature,27 alongside inadequate remuneration for teaching, are likely to be contributors.
The perceptions held by leads of undergraduate GP teaching that teaching is either increasing or static contradict the survey’s quantitative findings. This may be a result of increasing student numbers necessitating increasing delivery of GP teaching from a medical school perspective, but without translating to an increase in GP teaching experienced by individual students. Other possible explanations are that the increased focus on GP teaching gives the impression of a greater volume of teaching, or of an impending increase in teaching in new curricula, which has not been captured in this survey.
It is clear that GP teaching is not expanding as recommended by academics, the Royal College of General Practitioners (RCGP), the GMC, the NHS Chief Executive, and the Scottish Government.3,4,20,23,28,29 This threatens the future medical workforce, given the importance of students gaining sufficient experience in general practice to understand primary health care, gain medical generalist skills, and to consider a career in general practice.11,12 The lack of expansion of GP teaching also undermines building a medical workforce for sustainable primary health care.30
Funding levels and mechanisms for GP teaching differ across the UK: in England and Wales there is no national tariff and funding has not been updated since 1995,21,22 whereas in 2019 the funding in Scotland was increased.23 The data in this study demonstrate funding for in-practice GP teaching varies significantly across UK medical schools. The average funding for in-practice GP teaching of 55.60 GBP/student/session translates to an annual sum of 20 572 GBP based on 37 weeks per year and 10 sessions per week. In contrast, the 2019 national tariff for secondary care placements in England is 33 286 GBP per year,21 and a recent costing exercise has found the actual cost of undergraduate teaching to GP practices in England to be 111 GBP per teaching session, equivalent to 40 700 GBP per year.22 A similar costing exercise in Scotland found the cost of teaching to be 85 GBP per teaching session, equivalent to 31 450 GBP per year.23 A lack of funding to support investment in practices is also concerning given the evidence that space is a barrier to hosting medical students.29,34
In 2016, the UK House of Commons Health Select Committee called for new funding arrangements that reflect the true cost of teaching undergraduates to be expedited to be in place by 2016–2017.35 Despite these recommendations, no changes have been made to date. Underfunding of undergraduate GP teaching has also been highlighted by the RCGP; the disparity of funding between primary and secondary care teaching is emphasised by the cited statistic that GPs receive around 40% less than their hospital counterparts for undergraduate teaching.36
Implications for research and practice
In summary, the authors would recommend that a minimum quantity of GP teaching is mandated across all regions of the UK, an adequate primary care tariff is agreed, and a similar survey is repeated on a 5-yearly basis in the UK and replicated internationally. The authors’ recommendations are outlined in Box 1.
| Study finding | Background | Recommendations |
|---|
| The amount of GP teaching in undergraduate medical curricula has not increased over the past 20 years | The Scottish Government has mandated 25% of the curriculum is delivered in the primary care setting and allocated funding in support23 | The authors recommend a similar central mandate to make more GP teaching in undergraduate curricula a reality for all UK medical schools |
| Funding for undergraduate teaching in general practice falls well below estimated costs to practices | Funding that reflects the actual cost of teaching medical students is urgently needed to maintain current teaching levels and additional funding (for example, investment in surgeries that lack space to teach) is needed to increase the quantity and quality of GP teaching | The authors recommend an adequate primary care tariff, which reflects the cost of teaching and simplifies current payment mechanisms |
| Recruitment of teaching practices is a challenge for most medical schools | Near peer teaching is recognised to be mutually beneficial for GP trainees and students alike, and recent literature provides practical suggestions to help promote these developments31–33 | The authors recommend an introduction of formal mechanisms to encourage GP teachers from underused areas such as GP trainees, early-career GPs, and locums27 |
| Less transparent and granular methods have been used historically to measure GP teaching in the UK | Few similar surveys have been undertaken internationally | The authors recommend that this survey is repeated on a 5-year basis to review progress in the UK and is replicated elsewhere to make international comparisons |
This research has shown current levels of GP teaching are static or falling. Significant variation exists across the UK in the amount of GP teaching and its support, both financial and human. Continuing underinvestment relative to the actual costs of teaching students seems to be the main factor threatening the sustainability of GP teaching and preventing its expansion. Without sufficient funding, medical schools are unlikely to influence GP recruitment issues positively or be able to promote generalism for all future doctors.
Based on these findings, and building on recent work in Scotland, a UK-wide review of general practice in medical curricula and its associated funding is urgently required to facilitate high-quality undergraduate GP teaching and promotion of the expert medical generalist role.
