Radstock, United Kingdom
Half of all doctors in the United Kingdom are general practitioners. Why is it such a popular career choice for young British doctors, and how does the GP training system work in the UK?
How does primary care work in the United Kingdom?
The United Kingdom’s (UK) healthcare system is called the NHS: the National Health Service. Most of its services are free for British people. The money to pay for the NHS comes from general taxation: it cost UK taxpayers £122 billion (CHF162 billion) in 2017, about £2950 (CHF3510) per person , which was 8.7% of the gross domestic product (GDP).That compares with about CHF6566 per person in Switzerland in 2017, where it was 12.2% of the GDP.
About 1.6 million people work for the NHS, making it the world’s fifth largest employer. All British citizens register with a general practitioner (GP), who gives cradle-to-grave care, and there are 80 GPs per 100,000 inhabitants . This compares with 110 GPs per 100,000 Swiss residents. British GPs are directly or indirectly responsible for all of their patients’ medical care: most patient care is given in the patient’s GP practice, and specialist care is purchased and monitored by GPs through the NHS’s ‘internal market’ system.
Most specialists work only in hospitals. There is a strict ‘gate-keeper’ system: except in an emergency, specialists are only allowed to see patients if they have been referred by a GP. In most cases, as soon as the medical problem has been assessed and treatment planned, the specialists hand patients back to their GPs for on-going care.
How does the GP system work?
Almost all GPs work in group practices with other GPs. Most are self-employed, usually in their own premises, but almost all their work is paid for by the NHS through a complex funding system.
British patients expect their GPs to manage most of their problems, whether physical, psychological or social, and even in an emergency many patients will contact their GP rather than going to an emergency department. GPs run highly structured care of most chronic medical problems, investigating, starting and continuing treatment for most of their patients with hypertension, diabetes, ischaemic heart disease, asthma, chronic lung disease and depression. Relatively few patients with these chronic diseases see specialists.
What attracts young doctors to become GPs?
Since the 1980s, there has been a large increase in the importance and status of GPs within the medical profession. This is because:
– medical students spend more time in GP practices, so are aware of the key importance of the GP role;
– 60% of all newly qualified doctors have to spend at least four months working in GP practices as part of their postgraduate medical education;
– all doctors who want to work as a GP have to complete a three-year GP-focused training programme;
– they then have to pass a tough examination before they can work independently;
– there is a focus on consistent quality of care from all GPs, with an expectation that they will practice evidence-based medicine and follow the National Institute for Health and Care Excellence (NICE) guidelines;
– GPs control both the primary and secondary care budgets within the NHS;
– GPs have the same income as specialists.
All this means that all medical students, and over half of young doctors, have experience of what life as a GP is really like, and see general practice as a high-status career.
The UK’s GP training system
After graduation, all UK doctors need to complete two years (the ‘foundation’ years) of general training posts. This time is spent in a mixture of specialities, for instance general practice, internal medicine, surgery, paediatrics, psychiatry and emergency medicine.
Doctors who want to work as GPs then have to apply for a three-year GP training programme. This application is a competitive process which involves three examinations:
– a multiple-choice test (MCQ) that assesses judgement and decision-making in a workplace context;
– an MCQ that tests clinical knowledge and the ability to apply it in practice;
– a face-to-face examination with simulated consultations.
Doctors who do not pass this assessment (up to 20%) are not allowed to join a GP training programme, and therefore will not be able to work as family doctors. They can either reapply a year later or apply to train in one of the other specialities.
Once in a GP training programme, doctors spend 18 months in selected hospital training posts in a variety of specialities, and 18 months in accredited GP ‘training practices’. All these hospital posts and training practices have regular visits from GP educators to assess their educational quality. GPs educators design these training programmes and run weekly half-day release courses with workshops and group work, which trainees must attend. Each trainee also has a GP as a supervisor who, throughout the three-year course, teaches and supports them, and monitors their progress.
In all GP training posts there is a system of weekly continuous assessment (‘workplace based assessment’, WBPA), which looks for the skills needed for general practice. This is part of an exit examination, the Membership of the Royal College of General Practitioners (the ‘MRCGP exam’) .
As well as WBPA, the MRCGP examination has:
– An MCQ that assesses the knowledge needed for independent general practice in the United Kingdom. About 80% of the questions are about clinical medicine, 10% are on evidence-based clinical practice and 10% are about organisational issues. The questions focus on problem-solving rather than just remembering facts. Only about three-quarters of candidates pass the MCQ the first time they take it.
– A ‘simulated surgery’, in which doctors are given a consulting room and have 13 consultations, each lasting ten minutes. GP observers assess doctors’ ability to integrate and apply clinical, professional, communication and practical skills. This examination has a first-time pass rate of 80%.
After passing the MRCGP examination, young doctors can work independently as GPs. Most will join a practice, either as a partner or as an assistant GP, but some work for organisations that provide emergency GP care outside normal working hours. Others do ‘locum’ work, temporarily taking the place of GPs who are on holiday or unwell.
This system has been developed over many years and has many advantages:
– medical students have a positive experience of general practice and its central role in the UK’s health system;
– young doctors can only join a GP training rotation if they have shown that they have the right knowledge, skills and attitudes to let them work towards becoming GPs;
– the three-year training programme is carefully structured to support GP trainees and give them the relevant skills;
– the programme can be adapted for the many GP trainees who want to work part-time for family reasons;
– the NHS pays GP trainees’ salaries, so there is no cost to the GP trainers and their training practices;
– the MRCGP examination is designed to make sure that only doctors who have developed the right skills and expertise can start to work as GPs;
– this ensures that their patients are cared for competently and safely;
– experienced GPs have the option of becoming GP trainers, which helps them to develop their careers and their practices;
– the GP training system is the same across the UK, so there is a consistent approach whichever part of the country GP trainees want to work in.
However, there are also criticisms:
– although GP trainees do not have to pay for their training, they do have to pay £1811 (CHF2165) to take the MRCGP examinations; they have to pay the fees again if they fail;
– black, Asian, and minority ethnic doctors tend to be less successful in their MRCGP examinations. For those who graduated outside Europe, this may be because of different backgrounds and experience, but there have been concerns that the examination system is biased against them;
– during their 18 months in a GP training practice, young doctors are protected from the heavy workload that they will have when they work independently, and some find the transition stressful and difficult;
– GP trainees get experience in a variety of specialities, but sometimes only four months of this is spent in internal medicine;
– the GP training system is complex and bureaucratic in parts, which makes it expensive for the NHS to run;
– the system is rigid: if an experienced doctor from a different speciality wants to become a GP, they are not considered to have the GP-specific skills that are needed for primary care, so they still have to apply for and complete a three-year GP training programme.
The UK has a model of healthcare that gives GPs high status and puts general practice at the centre of patient care. Medical students find this attractive, resulting in high levels of applications for GP training programmes. These programmes include hospital placements that are matched to the needs of learners and the requirements of the GP training curriculum. There is continuity in the GP training programmes: trainees are regularly released from their hospital and practice posts for GP-led programmes of seminars and courses, and they each have a nominated GP as an educational supervisor throughout the three-year course. Although the system is costly, complex and relatively inflexible, it means that patients across the UK can be sure that their new GPs have the right skills and experience to give them good quality care.
UK-BA3 4SJ Radstock
1 Papanicolas I, Mossialos I, Gundersen A, Woskie L, Jha AK. Performance of UK National Health Service compared with other high income countries: observational study. BMJ 2019;367. doi:http://dx.doi.org/10.1136/bmj.l6326
2 National Institute for Health and Care Excellence, NICE. Published guidance and advice. NICE. 2020. Available from: https://www.nice.org.uk/guidance/published?type=apg,csg,cg,cov,mpg,ph,sg,sc (accessed 3 Sep 2020).
3 The General Practice (GP) National Recruitment Office. The GP Training Programme. GP Recruitment. 2020. Available from: https://gprecruitment.hee.nhs.uk/recruitment/training (accessed 3 Sep 2020).
4 Royal College of General Practitioners. MRCGP exam overview. 2020. Available from: https://www.rcgp.org.uk/training-exams/mrcgp-exam-overview.aspx (accessed 3 Sep 2020).
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