Trends in attractiveness of general practice as a career: surveys of views of UK-trained doctors

Background It is current UK policy to expand the numbers of newly qualified doctors entering training to become GPs, to meet increased demand. Aim To report on trends in young doctors’ views on the attractiveness of general practice as a career, compared with hospital practice. Design and setting Questionnaire surveys in the UK. Method Surveys of doctors, 3 years after graduation, conducted in successive year-of-qualification cohorts between 1999 and 2015. Results The overall response rate from contactable doctors was 55%. In response to the statement ‘General practice is more attractive than hospital practice for doctors at present’, 59% of doctors agreed in the 1999 survey, 77% in 2005, and only 36% in 2015. One-third of doctors agreed that their exposure to general practice had been insufficient for them to assess it as a career option, but this improved over time: agreement fell from 39% in 1999 to 28% in 2015. As a factor influencing specialty choice, enthusiasm for, and commitment to, the specialty was rated as very important by 65% of intending GPs in 2015, up from 49% in 1999; the corresponding figures for intending hospital doctors were 91% in 2015, up from 61% in 1999. Conclusion Over the 16 years covered by this study, the attractiveness of general practice has fallen relative to hospital practice. This may not necessarily reflect a decline in attractiveness of general practice in absolute terms; rather, it may reflect a greater increase, over time, in the appeal of hospital practice.


Aim
To report on trends in young doctors' views on the attractiveness of general practice as a career, compared with hospital practice.

Design and setting
Questionnaire surveys in the UK.

Method
Surveys of doctors, 3 years after graduation, conducted in successive year-of-qualification cohorts between 1999 and 2015.

Results
The overall response rate from contactable doctors was 55%. In response to the statement 'General practice is more attractive than hospital practice for doctors at present', 59% of doctors agreed in the 1999 survey, 77% in 2005, and only 36% in 2015. One-third of doctors agreed that their exposure to general practice had been insufficient for them to assess it as a career option, but this improved over time: agreement fell from 39% in 1999 to 28% in 2015. As a factor influencing specialty choice, enthusiasm for, and commitment to, the specialty was rated as very important by 65% of intending GPs in 2015, up from 49% in 1999; the corresponding figures for intending hospital doctors were 91% in 2015, up from 61% in 1999. state their level of agreement with the following statement: 'General practice is more attractive than hospital practice for doctors at present.' Responses were collected on a 5-point scale covering 'strongly agree', 'agree', 'neither agree nor disagree', 'disagree', and 'strongly disagree', with a 'no opinion' option.
To enable the use of χ 2 analysis by avoiding small cell counts, and to simplify the tabulation of data, this scale was reduced to a 3-point scale (with 'strongly agree' and 'agree' combined, and 'strongly disagree' combined with 'disagree'). Two further statements were presented using the same 5-point scale of agreement: 'My exposure to general practice has been insufficient for me to assess it as a career option' (not presented to the graduates of 2008); and 'Generally speaking, GP training in the UK is of a higher quality than training in the hospital specialties' (only the 2012 graduates).
Doctors were asked to specify their choice of specialty for their eventual career. Doctors could nominate up to three choices and could indicate an order of priority and whether any of their choices were tied; that is, of equal priority. The present study focuses on first (untied) choices. Responders were grouped for analysis into four groups according to their first choice of career specialty: general practice, the hospital medical specialties, surgical specialties (including obstetrics and gynaecology), and other hospital-based specialties combined (paediatrics, emergency medicine, anaesthetics, radiology, clinical oncology, pathology, and psychiatry).
Each doctor rated the influence of each of 12 factors on their career choice (Box 1). The doctors were asked to indicate whether each factor had influenced their choice of specialty 'not at all', 'a little', or 'a great deal'.
Variation in agreement or disagreement about the attractiveness of general practice careers was examined by qualification cohort, sex, and specialty chosen. The data were analysed by univariate crosstabulation. To test statistical significance χ 2 statistics were used (reporting Yates's continuity correction where appropriate).

Response rates
Surveys were sent to 20 527 UK doctors. Responses to the statement 'General practice is more attractive than hospital practice for doctors at present' Overall, most doctors (60%) agreed or strongly agreed with the statement, 17% neither agreed nor disagreed, and 23% disagreed or strongly disagreed. There was a huge fall over time, however, in levels of agreement that general practice was more attractive than hospital practice, from 77% in 2005 to 36% in 2015 (Table 1), a pattern observed in both males and females.
Doctors whose specialty choice was general practice were much more likely to agree with the statement (80%) than doctors who chose a hospital specialty (51%), but in both specialty choice groups there was a substantial decline in agreement between 2005 and 2015 (

How this fits in
The percentages of new doctors entering general practice training are much lower than the 50% required by the UK healthcare system. There are also retention problems with the GP workforce. This study considered the views of doctors, 3 years after qualification, on whether or not they chose a career in general practice. It was found that the attractiveness of a career in general practice relative to hospital practice has declined substantially in recent years.

Factors influencing specialty choice
The percentages were compared in each survey of those who stated that each of 12 factors had affected their career choice 'a great deal' (Figure 1 and Appendix 2), with specific interest in absolute levels of influence, differences between aspiring GPs and aspiring hospital doctors, and trends over time. Enthusiasm for, and commitment to, the specialty ranked highly both for GPs and hospital specialties, with higher scores for the latter than the former. This was scored as influencing choice a great deal by 67% of GPs in 2015 (up from 49% in 1999 to 63% in 2005, but with no appreciable change since then). By contrast, enthusiasm for their chosen hospital specialty was rated very highly by 91% of hospital doctors (up from 61% in 1999, 70% in 2005, 87% in 2011). Another factor that hospital doctors rated much more highly than GPs was 'experience of jobs so far': in 2015 this was 'a great deal' of importance for 38% of GPs and 62% of hospital doctors.
'Wanting a career that suits my domestic circumstances' became much more important to choosers of general practice in the recent cohorts ('a great deal' of importance for 83% in 2015, up from 47% in 1999). It also increased in importance for choosers of hospital specialties, but by a lesser amount (27% in 2015, up from 17% in 1999). 'Wanting a job with acceptable hours and working conditions' retained a huge level of importance to choosers of general practice (84% in 1999, 84% in 2015), but was less important and declined somewhat among doctors who chose hospital practice (40% in 1999, 32% in 2015). 'Availability of career posts', which barely registered as a consideration in 1999 when it was first asked about, was important to over 42% of 2015 responders who chose general practice and to 24% of responders who chose hospital specialties. 'Future financial prospects' were more important to GPs (16% in 2015) than hospital doctors (8% in 2015). Other changes across the cohorts were similar for those who chose general practice and those who chose hospital practice; differences in 2015 between GPs and hospital doctors were small ( Figure 1 and Appendix 2).

Sufficiency of exposure to general practice
In 1999, 2005, and 2015, doctors were presented with the statement 'My exposure to general practice has been insufficient for me to assess it as a career option.' Over all 3 survey years combined, 34% agreed or strongly agreed with the statement, 12% neither agreed nor disagreed, and 55% disagreed or strongly disagreed. The percentage who agreed fell from 39% in   (Table 2). Of those who did not seek a career in general practice, the percentage who agreed fell from 49% in 1999 to 32% in 2015, In other words, trends over time show that doctors felt better informed in recent than in earlier years about careers in general practice. This pattern was found among both males and females (see Table 2 and footnotes for test results, and Appendix 3 for details of all five response categories).

Quality of GP training compared with hospital training (2012 graduates in 2015)
In 2015 the graduates of 2012 were presented with the statement 'Generally speaking, GP training in the UK is of a higher quality than training in the hospital specialties.' In all, 32% of the responders answered 'no opinion', 23% agreed or strongly agreed, 19% neither agreed nor disagreed, and 26% disagreed or strongly disagreed (Table 3). There was no significant difference in agreement between males and females. Doctors who chose general practice were more likely to agree with the statement (36%) than doctors who chose hospital practice (17%).

DISCUSSION Summary
The attractiveness of a career in general practice relative to hospital practice, at least for these groups of doctors, has declined substantially in recent years. In response to the statement that general practice is a more attractive career than hospital practice, 59% of doctors agreed in the 1999 survey, 77% in 2005, and only 36% in 2015. The study statements were phrased in relative terms: aiming to find out how doctors regarded the appeal of general practice compared with the appeal of hospital practice. Over the 16 years covered by this study, the attractiveness of general practice has fallen relative to that of hospital practice. This may not necessarily reflect a decline in attractiveness of general practice in absolute terms; rather, it may reflect a larger increase, over time, in the appeal of hospital practice. Of factors specified by a higher percentage of aspiring hospital doctors than aspiring GPs in these surveys, enthusiasm for the specialty and good experiences of it (which may, of course, often be closely related) stand out. It would be deeply undesirable, of course, to try to reduce these in any way, in respect of the hospital specialties, in attempts to recruit more GPs. Further, it does not necessarily follow that finding a career attractive means that responders want to (or feel able to) pursue it. These findings instead should be seen in the context that, for many years, the percentage of UK-qualified doctors who seek a career in general practice has been far smaller than that needed to meet requirements for primary health care. A specialty that fits the doctors' domestic circumstances well has been much more important for aspiring GPs than hospital specialists ever since these surveys began. This has become even more important to choosers of general practice in recent cohorts; GPs' ability to manage their hours and working conditions retained their importance. Any policies to reduce GPs' ability to manage their work, or that adversely affect their work-life balance, may well have detrimental effects on recruitment. Overall, one-third of doctors thought that their exposure to general practice had been insufficient for them to assess it as a career option, but fewer doctors rated their exposure as insufficient in the latest survey (2015) compared with 1999. Male doctors were more inclined than females to rate their exposure as insufficient. More doctors who had chosen careers in hospital practice rated their exposure to general practice as insufficient than doctors who had chosen general practice. It is important to ensure that all doctors feel that they have had enough exposure to general practice to be able to assess it as a career option.

Strengths and limitations
These results are from an ongoing, longitudinal, national study that provides a view of doctors' opinions about the attractiveness of general practice as a career. It has been possible to track how views have changed between 1999 and 2015. Generally, there have been good response rates to the surveys and the numbers of responders are large. As with all surveys, however, non-responder bias is a possibility, and it is acknowledged that the lower response rates in the more recent surveys may be an additional source of bias, although there is no evidence to suggest that responders are different from non-responders in characteristics relevant to this study. For example, 42.8% of nonresponders from the 2012 cohort were male, compared with 39.7% of responders (P = 0.03).

Comparison with existing literature
The present study details a decrease in the ratings of the attractiveness of general practice between 2005 and 2015. Research in the UK over the 10-year period from 2000 onwards found that career preferences for general practice among successive cohorts remained static over the years, with only one-fifth of cohorts naming it as an unequivocal first choice of career. 3 Research in Switzerland has also found that general practice is not attractive as a career to medical students. 11 It was found that 34% of doctors reported inadequate exposure to general practice. In a recent study, a similar percentage of Scottish Foundation doctors (37%) reported receiving career advice on general practice (compared with 50% reporting receiving career advice on hospital specialty   training). 12 This Scottish study also found that the most influential factors when considering a career in general practice were: undergraduate GP placement, discussion with peers and specialty trainees, and foundation GP placement. Therefore, the very factors that may persuade doctors to follow a career in general practice are the same factors to which doctors report receiving inadequate exposure.

Implications for research
Further work is needed to establish whether the observed decrease in the relative attractiveness of general practice translates into a decreased preference for general practice as a career among more recent graduates. The attractiveness of general practice to current medical graduates is undoubtedly affected by their beliefs about GPs' work-life balance, and their exposure to general practice in their training. GP choosers highly value hours and working conditions. This is clearly a key area in which to motivate doctors to choose general practice. It is noted that, in the most recent survey in 2015, the availability of career posts as a factor in motivating career choices became more important both among doctors choosing general practice and doctors choosing hospital practice. Improving the attractiveness of general practice is paramount to persuading the current generation of doctors to choose general practice in the large numbers required to meet government targets, especially when the most important determinants of general practice are enthusiasm and compatibility with family life. 13,14 Studies from the same cohorts have been published previously on why some doctors initially choose, but then do not pursue, careers in different specialties. 13,15 Comparatively few doctors actually considered general practice seriously and then rejected it. Of those who do want a career in general practice, most follow it through. The level of agreement between specialty choice expressed at year 1 after qualification and career specialty destination 10 years later is higher for general practice than for any other specialty. 16 This suggests that doctors who do choose general practice enjoy working in it. 17 The shortfall in doctors seeking a career in general practice is not accounted for by doctors considering it and rejecting it. Too few consider it at all.
The factors that influence specialty choice are a complex mix including the doctor's interests, passion for the specialty, fascination with the job content, likely job satisfaction, aptitudes, likely ability to be successful in a chosen specialty, opportunities, compatibility with domestic and social life, material and intellectual rewards, and personal aspirations about how best to contribute to the service of patients. In a straightforward, brief, factual survey of career intentions, some of these are difficult to capture. In-depth studies are needed of motivators and interests to investigate what more might be done to achieve a better match between percentages of doctors wanting a career in general practice and percentages needed.

Funding
This is an independent report commissioned and funded by the Policy Research Programme in the Department of Health (project number 016/0118). The views expressed are not necessarily those of the funding bodies.