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Opinion

The GP workforce crisis: putting the right doctors in the right place at the right time

Authors: Mark Purvis 

Publication date:  03 Jan 2013


Primary care is critical to the future of the NHS, but the service continues to train the wrong type of doctors in the wrong place, says Mark Purvis

The NHS is facing unprecedented challenges, and the pace of change is increasing, driven by the demographics of our population; the possibilities offered by technology to deliver more care closer to patients’ homes; and the need to transform the NHS to better meet patient needs in a challenging financial climate.

Access to high quality primary care has long been recognised as a prerequisite for high quality, cost effective healthcare systems.[1] Primary care is the key to transforming the NHS from a reactive “disease” service that is too heavily focused on treating ill health and dealing with acute need to a genuine “health” service that tackles the determinants of ill health and addresses health inequalities.[2]

Primary care is critical to the NHS, yet the number of full time equivalent general practitioners (GPs) in England per 100 000 population fell from 58.8 in 2009 to 56.8 in 2010. A drop of two full time equivalent GPs per 100 000 population means that a practice with a moderate list size of 10 000 patients will have a day less a week of GP input—and that’s before the GP undertakes additional marginal or non-core work such as involvement in a clinical commissioning group.

On the other hand, the number of hospital consultants in the NHS increased from around 4100 in 2004 to more than 11 000 in 2010.[3] The Centre for Workforce Intelligence predicts that the NHS will have 60% more consultants than at present by 2020 if it continues to recruit and train hospital doctors at the current rate, providing the NHS with more fully trained hospital doctors than are needed to meet demand at a cost that the NHS is unlikely to be able to afford.[4] [5]

The prescription is clear. We need better trained GPs, as described in the Royal College of General Practitioners’ educational case for enhanced GP training,[6] and we need to tackle the current imbalance between the supply of hospital doctors and the supply of GPs. The challenge, then, is to overcome the three main barriers to delivering this transformation: capacity, funding, and applicants.

Firstly, primary care training capacity and infrastructure must be increased. In 2008 the government sought to increase the number of general practice specialty trainee year 1 (ST1) places in England from 2500 a year to 3300 a year, yet as of 2011 the junior doctor workforce was nearly 1000 GP trainees short of this goal.[7] We need to invest in the primary care training infrastructure, especially in our most deprived communities. Competence is context dependent and we will fail another generation of the NHS workforce if yet again we seek to train a future primary care workforce in a different context from that in which they will begin their independent practice.

Secondly, training in primary care, more than any other part of the NHS, needs a long term view with respect to funding. Although it is far more cost effective to train a foundation doctor to become a GP than to train one to become a consultant, in one financial year the average cost of a year in GP training exceeds the cost of a year in core specialty training.

We need to take an allocative approach to the funding of training that is not driven by short term annual budget cycles. We need to think in terms of the funding that we commit, the total postgraduate training costs, and the return on the investment of public money. Every year that funding shifts are delayed is a year wasted. We need more urgency—it is not good enough to continue to place a tariff for primary care education and training on the “too difficult” pile.

Finally we need high quality applicants who are keen and motivated to work in general practice. The shortfall in doctors wanting a career in general practice is not accounted for by doctors considering general practice and then rejecting it, rather “they do not consider general practice at all.”[8] If the UK is to be self sufficient in medical graduates then we must require our medical schools to produce an output where 50% of graduates wish to work in primary care. Medical schools that fail to deliver such an output are failing to meet the needs of the UK taxpayer, and commissioners of undergraduate medical education should act accordingly.

One of the many benefits of investing in primary care training is that it will raise standards in our most deprived communities. We know that it is possible to deliver good care where there is not good training, but it is rare to see good training that is not underpinned by good patient care. Placing our most talented enthusiastic young doctors in areas of high need with a mandate and educational support to make a difference and reduce health inequality has the potential to catalyse the change that our patients deserve.

When general practice is not working well, it is secondary care and tertiary care that break. If the NHS is to have a bright future we need to be candid about current GP workforce supply and we need to show courage to grasp the opportunity for change. We should be ambitious for better primary care that is the foundation of the NHS.

Competing interests: MP is director of general practice education at Yorkshire and the Humber strategic health authority.

References

  1. Starfield B. Is primary care essential? Lancet  1994;344:1129-33.
  2. King’s Fund. Transforming the delivery of health and social care: the case for fundamental change. 2012. www.kingsfund.org.uk/publications/transforming-delivery-health-and-social-care.
  3. Federation of the Royal Colleges of Physicians of the UK. Census of consultant physicians and medical registrars in the UK, 2010: data and commentary. Royal College of Physicians, 2011. www.rcplondon.ac.uk/sites/default/files/census-2010.pdf.
  4. Torjesen I. NHS is set to train 60% more consultants than needed by 2020. BMJ Careers  , 10 Feb 2012. http://careers.bmj.com/careers/advice/view-article.html?id=20006582.
  5. Health and Education National Strategic Exchange (HENSE). Review of medical and dental school intakes in England. Dec 2012. www.dh.gov.uk/health/2012/12/medical-school-intakes/.
  6. Royal College of General Practitioners. Preparing the future GP: the case for enhanced GP training. 2012. www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/Case_for_enhanced_GP_training.ashx.
  7. Jaques H. GP trainees news story. Medical workforce is short of nearly 1000 GP trainees. BMJ Careers  , 15 Dec 2012. http://careers.bmj.com/careers/advice/view-article.html?id=20010122.
  8. Lambert T, Goldacre R, Smith F, Goldacre MJ. Reasons why doctors choose or reject careers in general practice. BJGP  2012;62:851-8.

Mark Purvis director of postgraduate general practice education Yorkshire and the Humber Deanery, UK

 mark.purvis@yorksandhumber.nhs.uk

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