Health CommitteeWritten evidence from Royal College of General Practitioners (ETWP 102)

Introduction

1. The Royal College of General Practitioners is the largest membership organisation in the United Kingdom solely for GPs. Founded in 1952, it has over 44,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline. We are an independent professional body with enormous expertise in patient–centred generalist clinical care.

2. The College has a direct role in devising and delivering a high-quality GP postgraduate curriculum, and supporting the continuing training and development of GPs throughout their careers.

3. Whilst due to space constraints this submission does not cover all issues raised in the terms of reference, the College would be more than happy to provide additional written or oral evidence to the Committee.

Executive Summary

4. There are huge challenges ahead for all those working in the NHS—and for the primary care workforce in particular—as the Government’s reforms are implemented in England. As the new system emerges it must adequately support and involve medical generalism, ensuring that GPs and other members of the primary care workforce have the training they need to deliver improved outcomes for patients.

5. The College identifies four key elements that are needed to ensure the primary care workforce can adapt to meet the challenges ahead. These are; the development and use of effective generalist care to support patients who have multiple problems without undue fragmentation and duplication of care provision; extending GP training, boosting the number of GPs and establishing a national framework for education, training and workforce planning that involves GPs in making decisions, taking a long-term approach.

A Vision for the Future of Healthcare Education, Training and Workforce Planning

6. The College believes strongly that a clear vision is needed—shared by patients, professionals and policy makers alike—for the future of postgraduate education, training and workforce planning, in primary care and the health service as a whole.

7. Evidence strongly suggests that good primary care—led by a well-trained medical generalist workforce—has a very positive impact on outcomes throughout the health service, reducing emergency and elective admissions and referrals, and providing preventative care in a community setting.1 Medical generalism and primary care as a whole is associated with high patient satisfaction, low medication use and care related costs. The importance of medical generalism to the health service as a whole has been explored in depth by the Independent Commission on Generalism.2 It is critical to the future of the NHS that we get generalist—and wider primary care—medical education, training and workforce planning right.

8. The College believes that this vision should include the following broad goals:

Delivering safe care and better health outcomes to patients by ensuring the mix of skills, workforce numbers and level of training within the system are all geared to support the best possible people delivering the best possible care.

A primary care workforce equipped with a level of high-quality training that reflects the increasingly complex challenges facing GPs and the NHS as a whole.

A well-tested, stable national framework for education and training that enables primary care clinicians to lead decision making at a local or regional level—tailoring provision to local circumstances—whilst also providing adequate levels of national oversight.

Consistent standards in postgraduate medical education and training, with quality assured across the UK, the number of training placements monitored and coordinated centrally, and health inequalities are tackled effectively.

A system which provides the incentives at all levels for decision makers to take a long-term approach.

Delivering this VisionThe Challenges

9. It is important that we do not underestimate the challenges to delivering this vision, particularly at a time of huge change for the NHS as a whole. There is compelling evidence to show that action is needed to ensure that the GP workforce is able to adapt to meet the needs of the future.

10. In the context of an ageing population and the increasing movement of particular treatments and care into primary care, GPs have a growing and increasingly demanding role. Alongside their role as providers of care, GPs in England are now also being asked to take on commissioning responsibilities, which is a major addition to the GP curriculum.

11. The College urges the Committee to consider three important areas in which we believe action is needed to ensure the primary care workforce of the future can deliver the above vision: (1) extending GP training; (2) boosting the number of GPs; and (3) ensuring that in the new landscape of the NHS, education, training and workforce development is “fit for purpose”, with decisions about primary care medical postgraduate training being led by GPs.

Extending GP Training

12. General practice has the shortest postgraduate training of any speciality—amongst the shortest in the EU. There is now a long list of high profile evidence which supports the need for extending GP training, including The Tooke report, The Commission on Generalism, Birmingham University’s Evaluation of the GP Curriculum and the APPG on Dementia. The NHS Future Forum also stated in November 2011 that it will be publishing a report recommending that GP training be extended before the end of the year.

13. The College is calling for an initial increase in the length of GP training from three to four (and eventually five) years. General Practice has always evolved and adapted to meet the challenges and expectations of a modern health service. Now, the need for extended training is greater than ever. In addition, there is a need to enhance postgraduate GP training to ensure that trainees gain sufficient exposure in the areas of child and mental health.

14. The role of the GP is evolving, encompassing not only GPs’ ongoing commitment to delivering care to patients on the front line but also newer roles as a “navigator” of the wider care system and now also “commissioner” of care. To perform these responsibilities successfully the GPs of the future will need a growing range of skills, for example in care planning, service redesign and leadership.

15. We believe an additional year would allow the already “squeezed” curriculum to be delivered in more depth, equipping GPs to work in all environments, including working in under-doctored and high-deprivation areas.

16. Next year the College will be submitting a business case for the extension of GP training to Medical Education England.

Increasing the Number of GPs

17. Changes in the gender and age profile of the GP workforce, to job roles and in patterns of working are all driving up the number of GPs needed. If the number of GPs is not increased, the positive outcomes we aspire to cannot be achieved, and there is a risk of a negative impact on access to primary care.

18. Since 2000, according to the NHS Information Centre, the full time equivalent GP workforce in England has grown by 18% (dropped slightly between 2009 and 2010). In comparison, the number of hospital consultants grew by 61% over the same period.3 Attracting newly qualified doctors into GP training is proving challenging, with 2011 figures showing that only 20% of recent medical graduates indicating general practice as first choice of medical career.4 The Centre for Workforce Intelligence has recommended a 17% increase in recruitment into GP speciality training, phased over the coming four years.5

19. At the same time, demand for GP services has been growing. Figures from the Centre for Workforce Intelligence show that between 1995 and 2008 there was an increase of slightly over 40% in the number of consultations per patient, reflecting the fact that GPs are increasingly seeing patients with long-term care needs, requiring an increased level of case management.6

20. The College urges the Committee to consider the issue of GP numbers in relation to this Inquiry. Working with the medical profession and informed by the work of the Centre for Workforce Intelligence, Medical Education England—and Health Education England when it comes into being next year—should make it a priority to consider potential solutions to this problem and how investment in the workforce needed for the future will be funded. Two potential solutions include:

Attracting more postgraduate doctors into GP training by developing the status of generalism as a career choice. Extending GP training as outlined above in line with other medical specialties would be one step to achieving this. In addition, promoting the importance of generalism during the medical undergraduate years and increasing exposure to primary and community care should be part of this process.

Encouraging more doctors who have left general practice (for example to start a family) to return, with appropriate training and professional development support.

Measures to tackle the shortage of GPs in under-doctored areas should also form an important part of the overall solution.

The New NHS Landscape

21. In its March 2011 response to the Government’s consultation on Liberating the NHS: Developing the Healthcare Workforce,7 the College expressed serious concern that the proposed system would fall significantly short of delivering a fair, effective and efficient approach to education, training and workforce planning. The College continues to be concerned that the proposals lack an evidence base to support such large-scale uprooting of the existing system, which is seen to broadly work well.

(a) Health Education England (HEE) and Local Education and Training Boards (LETBs)

22. The College remains concerned that the proposed new system of LETBs overseen nationally by HEE may fail to deliver the high quality postgraduate medical education and workforce planning needed to achieve the best outcomes for patients. The College is particularly concerned about the impact on primary care training.

23. In the College’s view a key challenge for HEE will be to ensure that there is comprehensive national oversight of standard setting, monitoring of training numbers and quality assurance across the system. The College has supported proposed amendments to the Health and Social Care Bill to strengthen the role of HEE and the NHS Commissioning Board to provide national oversight on the number of training places. The College notes that the Government has committed to revisiting this area of the legislation at Report stage in the House of Lords.

24. The College remains concerned that LETBs are not the right vehicle to drive forward education and training in the coming years. If LETBs do go ahead, however, it is important that the relationship between HEE, LETBs and deaneries is properly defined with clear lines of responsibility. There is a real risk that a weak relationship between HEE and LETBs will result in an uncoordinated system lacking the right incentives for decision makers to take a long-term approach.

25. The College is concerned that the new system may be dominated by secondary care providers such as Foundation Trusts, further exacerbating problems regarding GP workforce supply described above. Whilst GP-employed staff only account for 10% of the NHS workforce (according to the NHS Information Centre), the College believes that as a minimum GP provider representation on LETBs should be in excess of 10% because:

There are many more GP provider organisations and GP provision is heterogeneous, so general practice is a more complex sector to represent.

GP provision covers 90% of patient contacts and primary care has a disproportionate effect on the whole system.

Within the postgraduate medical workforce, GP CCT holders are almost as numerous as secondary care CCT holders.

26. In addition, the College feels that stakeholder involvement in LETBs could be improved by the creation of reference groups which would inform their work. A primary care reference group, for example, would enable other significant players from the primary care workforce to input their views.

27. The College remains concerned that introducing significant new market forces into healthcare education and training will produce a similar effect to the “inverse care law”, with training quality varying from area to area, potentially impacting on patient outcomes and, ultimately, exacerbating health inequalities.

(b) The future of postgraduate deaneries

28. Postgraduate deaneries must play a central role in the new system given the importance of their function and the expertise they provide. Postgraduate deaneries must have sufficient autonomy to continue to deliver clinical postgraduate training without unnecessary interference.

29. As well as GP representation within LETBs, postgraduate deans should also sit on the Board of any such organisations.

30. In addition, postgraduate deans should also be closely involved in the work of HEE so that their knowledge of local and regional training needs feeds into the national view taken by this body.

(c) Funding the new system

31. The College feels that more clarity is needed as a matter of urgency on how the proposed levy funding model would work in practice. Such a system could have significant unintended consequences for small providers, including GP practices, who have previously not been required to pay for training. Such payments could cause an exodus of senior staff, destabilising the system as a whole.

(d) Transition to the new system

32. The College is concerned that whilst LETBs are expected to be established by April next year, HEE will not come into being until October. Without national oversight LETBs could begin to develop in an uncoordinated way, leading to instability.

33. The College is supportive of the work of the Centre for Workforce Intelligence (CfWI). As we enter a period of transition and uncertainty, the information gathered by the Centre should be used to ensure that decisions about education, training and workforce development are based on detailed evidence.

34. The Centre should inform the work of HEE, the NHS Commissioning Board, LETBs, providers and others under the new system. The Centre needs to be provided with adequate resources, appropriate powers (eg obliging healthcare providers to provide information on their current and anticipated workforce needs) and relationships with Clinical Commissioning Groups and Health and Wellbeing Boards.

The Future of Training Curricula

35. The Royal Colleges should retain lead responsibility for developing curricula for postgraduate medical training. The RCGP is continuously working towards a living, dynamic GP curriculum which reflects patients’ changing expectations; the needs of the service; current evidence of best practice; the needs of the training community; and changes in society. Our vision for the future is that curricula should increasingly be influenced by, and influencing, those who deliver and receive training, and other stakeholders in the process, including patients. The College would like to see more funding for evaluation of curricula based on participator research.

December 2011

1 Starfield B, Is Primary Care Essential? 1994 The Lancet Vol 344 (8930) pp 1129–1133.

2 Guiding Patients Through Complexity: Modern Medical Generalism, Commission on Generalism (2011),
http://www.rcgp.org.uk/policy/commissn_on_generalsm.aspx

3 NHS Information Centre: http://www.ic.nhs.uk/statistics-and-data-collections/workforce accessed 19/10/2011

4 Lambert T and Goldacre M. Trends in doctors’ early career choices for general practice in the UK: longitudinal questionnaire surveys. BJGP. 2011; 61: 397-403.

5 Shape of the Medical Workforce: Informing Medical Specialty Training Numbers, Centre for Workforce Intelligence (2011).

6 Medical Specialty Workforce Factsheet, August 2011, Centre for Workforce Intelligence.

7 RCGP response to Liberating the NHS: Developing the Healthcare Workforce:
http://www.rcgp.org.uk/pdf/%20Developing%20the%20Healthcare%20Workforce%20%282%29.pdf

Prepared 22nd May 2012