Standalone GP posts for doctors not on the speciality register – a proposal
Dr Sara Bodey – GP in N Wales (Bradley’s Practice, Buckley, Flintshire)
January 2017
My background
I am a GP in Flintshire in North Wales (and have been for 12 years), NWLMC Vice Chair, and a GP speciality trainer. I am also an educational supervisor for F2 doctors having experience in General Practice and an undergraduate tutor for the University of Liverpool.
The Workforce Problem
We don’t currently have enough GPs regardless of what model of provision primary care is going to follow. And in the next few years many doctors in their 50s are likely to retire (many factors are pushing GPs to retire sooner than they otherwise would, which is another discussion). We are not currently recruiting enough new GPs to replace those leaving or even to fill the gaps already present, as can be seen by the number of practices having to hand back contracts because they cannot recruit.
Where do GPs come from?
Currently there are 4 main ways we can recruit GPs into Wales:
· The standard route is for young doctors to complete a 3-year formal GP training programme and then enter the workforce. A GP training programme consists of three 6 month posts in hospital specialities (for example medicine for the elderly, paediatrics, psychiatry) and then 2 posts in GP training practices, one of 6 months and one of 12 months. During their training, they must pass a written knowledge based exam (the AKT) and in the final year a practical exam that looks for high level consulting skills and decision making (the CSA), they are also continuously assessed by their supervisors and trainers during day to day work. To enter onto a GP speciality training programme doctors must have completed their foundation programme (the first 2 years after graduating, in which they work in a sequence of 4 month posts in different specialities). Some doctors will do other jobs prior to deciding to join a GP speciality training programme – they may be able to count some of their additional experience towards their GP training but currently only 6 months.
· Recruiting GPs who have already completed UK GP training into Wales from elsewhere in the UK – such doctors can start work straight away
· Recruiting doctors trained in primary care in other countries – these doctors have to go through an assessment process and then do a period of supervised practice before they can work as GPs (the Induction and refresher programme)
· Encourage GPs who are UK trained but who have taken a career break (for whatever reason) to come back into the workforce (currently these doctors would have to go through the induction and refresher process too unless they have been out of the workforce for less than 2 years)
My focus in this discussion will be on the first group with the intention of improving both the numbers and the quality of applicants to GP speciality training by making it possible for young doctors to experience general practice before they must decide which speciality they want to apply for after their foundation programme.
The current situation – a lack of opportunity to try general practice before committing
At present, the only doctors allowed to work in general practice are either those who have completed GP speciality training and are therefore on the GP register, or those on a recognised GP speciality training scheme. The number of places on GP speciality training schemes in Wales is limited to around 130 across the country and hasn’t changed since I have been a trainer (it is notable that all other countries in the UK have significantly increased the numbers of GP training posts available). We struggle to fill even this number of places, although last year showed some improvement. My local scheme, Wrexham, nominally has 8 places, and was full last year but the year before only had 2 doctors appointed and the year before that 5. This is in an area that is a real risk in terms of viability of GP service provision at present because of recruitment.
Since the mid-2000s it has also been possible for doctors in the second year of their foundation programme (so called F2 doctors) to undertake supervised posts in general practice. However, the number of these posts available is limited and it is still the case that most young doctors in Wales do not have the opportunity to experience general practice except as a student before they must choose which speciality training programme to apply for. It is not really surprising that a lot will consider specialities that they have experienced during foundation rather than ones they haven’t. Increasing F2 GP experience seems sensible but is restricted by understandable concerns about what would happen to hospital rotas if these doctors were in GP rather than hospital placements.
I train F2 doctors in my practice, and have realised from talking to them that many of them don’t know what they want to do after the foundation element of their training is completed, and in fact many opt to not go straight on to speciality training of any sort. This is not just because they are uncertain about which option to choose, it is also because they are often exhausted by the continual assessments they have had to do through medical school and then foundation training.
This year, nearly 50% of F2 doctors did not enter Speciality training after completing their two-year Foundation program. Some went abroad and proportion of them won’t come back to the UK. Others chose to locum in different specialities to test the water before deciding to formally commit to a training programme. At present because of the regulations around the performers list (of which more later), they cannot locum in General Practice, but these restrictions don’t apply to hospital specialities which they can test out at this point, further reinforcing the pressures to choose a hospital speciality rather than GP.
So, barriers to gaining experience in General Practice exist both during and after Foundation training, and for most, the only way to try it is to commit blindly to the training program; something which we know they do not wish to do. This reinforces an application to GP training as often either being a best guess, or at worst a last option, whereas we want it to be a willing choice from young doctors who really understand what they are signing up to – then they should be more likely to stay for the long haul.
My solution – make it possible for doctors to do standalone posts in General Practice, under supervision, once they have completed their foundation programme
The key here is that it is the young doctors themselves who want this to be possible. They want the option of choosing a post in general practice along the lines of the locum hospital experience they are currently getting after foundation. In fact, this whole concept came from a discussion with a young doctor who had been one of my medical students. A survey I sent out last year to foundation doctors in Wales showed that over 40 doctors (80%) of those who responded would have been interested in doing these posts and contributing to the GP workforce in August 2016 – the link is here: https://www.surveymonkey.com/results/SM-V27ZT38W/
I had a lot of emails from doctors who responded to the survey asking me if it was really going to happen and expressing their enthusiasm for the idea.
I have taken this concept to LMC conference in 2016 where it was passed and therefore is accepted as policy for GPC Wales. It has also been presented at RCGP Wales who had concerns about some aspects around the legislation, but it is going back for a second discussion sometime this year. In addition, I have discussed it at national (UK) LMC conference and it is being seriously considered by national BMA.
Such posts could be for as little as 4 months or as much as a year. They would need a governance structure and appropriate supervision in place but the young doctors often don’t want to have them as formal training posts because they have been completing education assessments for many years and want the opportunity to try the speciality without being tied to electronic portfolios of experience and frequent assessments.
There are two other types of doctors who would also benefit from time in General Practice who are not currently able to access it: those who are already committed to a speciality program in a hospital but who are having second thoughts (often this is because they have been pushed into choosing too soon) and would like to try General Practice, and those who are in GP training already but who need more time to pass their exit CSA exam.
This latter group are often overseas trained doctors who struggle to reach the high-level consulting standards required to pass the CSA within the 3-year time limit because they are having to adjust to different cultural and linguistic norms without which it is impossible to perform at the level required. Currently these doctors are offered the opportunity for a final sitting of the exam once the training programme is completed but they cannot stay in general practice (because they are not on the specialist register or on a recognised training programme). Thus, they usually return to hospital practice and sit the exam whilst working in a hospital speciality which means they have less opportunity to fine tune their consulting skills, thus making the exam even harder to pass. If they fail to pass the CSA these doctors are lost to the GP workforce for ever – they are not allowed to reapply.
In short, there are many potential GPs of the future already in Wales who are currently unable to access experience of this speciality at different points in their career. Additionally, a substantial proportion of new graduates are being lost from the health service in Wales completely because of the lack of options available to them at the post-foundation point of their training. Making it possible for these doctors to choose to do standalone posts in GP would potentially increase both the number and I would suggest quality of those applying for GP speciality training. It would also immediately increase the pool of doctors available to work in GP practices.
Potential Benefits
· Increasing the numbers of doctors choosing GP as a career
· Increasing the number of doctors who apply for GP training really knowing what GP involves and therefore staying in the workforce after training is complete
· Offering flexibility after foundation training rather than demanding commitment
· An immediate workforce boost to general practice: ‘bums on seats’. In my experience of training F2 doctors is that they can develop into a very useful part of the team and make a significant positive contribution to the practice workload.
· Giving doctors struggling to pass the CSA exam within the time constraints of current GP training the opportunity to stay in a GP work environment whilst they continue to attempt to pass and complete GP training
Potential Pitfalls considered
· Current legislation. The performers list legislation and GMC rules mean this sort of post is currently not allowed. Those doctors allowed to deliver primary medical services must have either completed formal GP training or be on a recognised training programme to do so. It is not immediately clear to me from reading the legislation how F2 posts in GP are actually allowed, particularly in Wales where they aren’t mentioned at all! It may be possible to overcome this by recognising these posts as part of a formal programme – although it needs to be noted that the young doctors DON’T want to have to count this sort of experience towards formal training. If not then there is going to need to be legislative change, which will take more time and need to be discussed both at WG and GMC and potentially at a UK government level. However, I do believe that this can, and indeed must, be done.
· Indemnity. Conversations with the main MDOs suggest they would be willing to offer indemnity cover to such posts at a reasonable rate
· Appraisal/revalidation issues. These should be resolvable – the LHB locally already assigns an RO and facilitates appraisal and revalidation for doctors doing locum posts in the hospital at various career stages.
· Safety and supervision issues. There are well defined supervision and job plans available for F2 doctors in General Practice which could be duplicated for these doctors
· Finance. Who will pay for these posts? If the supervision requirements are not overly onerous then it is likely that employing practices may well be willing to fund these posts at least in part – certainly those I have spoken to in North Wales who are currently finding it so difficult to recruit other doctors or indeed nurses have expressed a willingness to do so. There is a case for the LHB or indeed WG being prepared to contribute to the cost of employing the young doctors too, particularly given the positive effects such placements will hopefully have on area wide recruitment. This may be direct to supervising practices as a way of recognising the supervision requirement, or it may be by the provision of some centralised access to training throughout the placement, and training to supervising practices or both. If the post is to be educationally recognised there would be a need for the additional input of the supervising practice to be recompensed via the deanery or WG, and any eportfolio requirements to be resourced – but I do not expect many of the young doctors to want this option.
· Interest from practices. Any concern about using non-GPs can be allayed by experience and adequate support. The scheme should be trialled in current training (ST or F2) practices before being rolled out to non-training practices to identify any problems.
· Avoidance of abuse of the role. There is a risk that this may be viewed by less scrupulous employers, whether GPs, LHB or private providers outside of Wales, as a way of cheaply staffing surgeries. This can be swiftly avoided by the provision of clear reporting pathways for the doctors, and clear requirements for supervision.
I ask Welsh Government to support this concept and work with the GMC and the Performers List to find a solution to the current restrictions on developing such a role in as short a time frame as possible.