Primary care Contents

3Building the new team

Primary care workforce

Workforce planning

126.Summarising the current position, the King’s Fund cited evidence from the Centre for Workforce Intelligence which concluded that:

there is likely to be a significant undersupply of GPs by 2020 unless immediate actions are taken to redress the imbalance between supply and demand and to increase training numbers for longer-term sustainability.180

127.The Government outlined its broad ambition to increase the workforce in written evidence to us. It referred to 5,000 additional doctors working in general practice:

the Government has committed to increasing the primary and community care workforce by at least 10,000, including an estimated 5,000 more doctors working in general practice by 2020.181

Professor Ian Cumming explained that 5,000 additional doctors in general practice is not the same as 5,000 additional GPs:

The 5,000 figure is broken down into 4,000 additional GPs that HEE have a responsibility for producing and work on getting people to come back to GP practice, or work on persuading people not to leave. [ … ] We will have 1,000 through return to practice and better retention, and 4,000 through new trainees that HEE are putting in the system. The reason it is worded as “doctors in general practice” and not “GPs” is because we count GP registrars in the figure. These are people who are training to be GPs but they are in practices delivering care alongside the GPs, not when they are in the hospital period. So they are in both sides of the equation.182

128.The Government’s evidence showed that 87.6% of GP training places were filled in 2014.183 Professor Cumming told us that whilst the number of training places created is the number “that we think we need for the future” if the fill rate was “above 90%, personally I would be delighted.”184

129.Ben Dyson, Director of the NHS Group, Department of Health, observed, however, that if the 3,250 training places are successfully filled by 2020 then the mechanisms designed to encourage retention of the existing workforce and help those who have left return to practice would not need to be as productive as Professor Cumming had estimated:

we would have an extra 4,400 or so doctors working in general practice. It is the balance between that and the 5,000 that would need to be made up through improvements in both retention of the existing workforce and encouraging doctors who may have taken career breaks or may have gone overseas to come back into general practice.

130.The programme to bring doctors who have moved abroad back into English general practice is the induction and refresher scheme introduced in April 2015. Rosamond Roughton said that NHS England had identified a number of practical steps to improve the scheme which they would implement in early 2016, but even by July 2015 the scheme had shown that it was an improvement on previous arrangements.185 The BMA warned that more funding will be required to fund further places and provide an adequate bursary for participants.186 Ms Roughton said that to date no formal analysis had been undertaken of the financial support available in the first nine months of the scheme but it is something NHS England “will need to review”.187

131.Ensuring there are 5,000 additional doctors in primary care by 2020 is dependent in part on attracting people to return to the profession. The induction and refresher scheme is a vital component of the efforts to do so. It should be subject to annual review to ensure that it is facilitating the return of qualified professionals as quickly as possible.

New starters and early leavers

132.Whilst Ben Dyson’s analysis provided some degree of encouragement as to the number of new doctors the system could produce it is clear that achieving even a 90% fill rate would be ambitious, especially as the initial rate for 2015 applications was 82%.188 The Centre for Workforce Intelligence [CFWI] sounded a strong note of caution:

efforts to boost the number of GP trainees is proving difficult. The number of accepted offers to GP training posts in 2014 (2,608) was below its 2011 peak, and the first 2015 recruitment round left 616 GP trainee posts in England unfilled, requiring a second autumn round.189

133.The Government’s assumptions about future GP numbers rely not only on very high fill rates for training places but also on the number of GPs leaving the profession remaining stable. Ben Dyson noted that in 2013–14 the difference between the number of GPs joining and leaving started to narrow190 and the King’s Fund warned that “the number of GPs over-50 who intend to ‘quit direct patient care in the next five years’ rose from 42 per cent in 2010 to 54 per cent in 2012 (Hann et al 2013)”.191 The Health Foundation’s survey of 1,001 UK GPs reported that overall “29% of GPs in the UK want to leave the profession within five years.”192

134.The British Medical Association reported that one finding of their GP Workforce Survey of 2015 was that “9% of GPs are hoping to move abroad in the next five years. This includes 19% of current GP trainees.”193 In addition the Recruitment and Employment Confederation’s (REC) evidence said that amongst trainees:

1 in 10 hope to leave the UK to work overseas; this figure rises to 21 per cent amongst GP trainees (the number of GPs applying for certificates that enable them to leave the UK to work abroad has already increased by almost 50% [between] 2008 and 2014).194

The Londonwide LMCs highlighted the problem of foreign employers targeting British doctors and said that “a number of overseas healthcare providers actively target young British GPs as part of their recruitment strategy.”195

135.In light of the projected number of doctors leaving the profession it is almost certain that the fill rate for training places will not be sufficient to achieve the net increase in the number of doctors projected by the Government.

136.Alistair Burt told us that the additional GP numbers “will not just maintain the current status quo but will respond to the changes that are taking place”.196 We believe that at best the Government’s proposals might allow primary care to absorb the pressure posed by additional demand. It will not be sufficient to allow routine seven day services in addition to existing extended hours services that practices already provide.

137.Whilst British trained doctors have long spent periods of time gaining work experience abroad, there will be a worsening workforce shortfall if they do not return from overseas. The Government should publish an analysis of the trends in doctors leaving the profession. This analysis should encompass their age, experience, specialism, the length of time for which doctors work abroad, the reasons for leaving the profession, and rates of return.

138.Approximately £500,000 is invested in educating and training an individual to the point that they qualify as a GP.197 Patients cannot afford for the UK to lose this highly skilled workforce.

139. In our view this scale of investment by the NHS creates an obligation to public service in the UK. We are also aware, however, that as a consequence of university fees and living costs, medical undergraduates will accumulate significant debt during a five to six year year medical degree.

Selection of undergraduates

140.Professor Ian Cumming and Professor Steve Field both observed in evidence that to meet our long-term needs half of all medical school graduates will have to become GPs.198 It is the opinion of the NHS Alliance, however, that the existing training arrangements:

produce doctors who largely want to become specialists. They require a radical overhaul in order to restore the popularity of general practice and encourage more doctors to enter the profession.199

The problem of the way in which medical schools prepare students for their careers was highlighted by Professor Field:

At medical school, we still have students who come to my own practice who have been told by specialists that general practice is an inferior career. While most medical school time is dominated by placements in hospitals, you are going to bring out hospital consultants at the end.200

141.Alistair Burt addressed this concern in the evidence he presented to us. He argued that undergraduate selection for medical degrees may have to evolve to reflect the skills required of a GP:

Medical schools may also have to look at their own intakes and who they are taking in. [ … ] You do not need the scientific qualifications you need to be a Nobel prize-winning scientist to qualify as a doctor and be in general practice. You need a very strong level of science, but you need the human feel as well. Looking at that background and enthusing people who want to work through the generations with people is a part of the encouragement as well.201

Professor Field made a similar point:

We need to select people to medical school with a real commitment to working with people in the community in general practice. We need to look at how we select schoolchildren.202

142.A former Chair and President of the RCGP, Sir Dennis Pereira Gray OBE, told us in a written submission that the approach of medical schools represents a fundamental problem and noted that some do not teach general practice as an independent discipline:

Medical schools give three reasons for not teaching general practice as a subject. These are: problem-based learning, an “integrated curriculum … we don’t teach disciplines,” or the need to focus on students learning clinical skills. None of these three arguments stand up to analysis.203

143.This view formed part of Sir Dennis’ wider argument that medical schools actively discriminate against general practice as a discipline. Sir Dennis reasoned that evidence of this ranges from medical schools failing to reference general practice in prospectuses to allocating only a small proportion of their teaching budgets to general practice.204 In addition he said:

If a medical school does not teach general practice as a subject, has no GP curriculum and provides no GP reading list, it is gives a powerful non-verbal signal that general practice is not important and that there is nothing written from or about general practice which future doctors need to read! The current generation of medical students are the most able academically ever, usually being selected on very high A level grades. They are thirsty for theory and principles and want to know the hows and whys of medical practice. If in five years they are not taught any theory or the principles of general practice, naturally they will tend to turn away from it or enter it only for other reasons.205

144.Medical schools should recognise that they have a responsibility to patients to educate and prepare half of all graduates for careers in general practice. Much greater emphasis should be placed on the teaching and promotion of general practice as a career which is as professionally and intellectually rewarding as any other specialism. Those medical schools that do not adequately teach primary care as a subject or fall behind in the number of graduates choosing GP training should be held to account by the General Medical Council.

145.Medical school entry requirements should look beyond pure scientific qualifications and actively to seek out candidates who not only possess academic ability, but can also demonstrate a commitment to providing care within their own community.

General practice as a rewarding career

146.Despite the pressure facing primary care, and GPs in particular, we heard that general practice remains a rewarding career. Professor Ian Cumming, illustrating how to persuade young doctors into general practice, gave the example of a hospital trainee who “had seen more pathology in a day in general practice than he had seen in a week in his hospital environment.”206 Even when discussing the challenges facing the profession, Dr Chaand Nagpaul argued that is external factors which can make a career in general practice less attractive to medical graduates, not the discipline itself.207

147.Outlining the merits of the profession, Professor Steve Field said:

I think general practice is the best job in the world. It is an amazing role where patient satisfaction is very high, the public esteem is high and you can get involved in education, research or medical politics. At the moment we are not selling that job and working systematically from school onwards to make it a better place for the youngsters to come in.

This theme was also acknowledged by Professor Cumming, who said:

Without in any way downplaying the pressures primary care is under, we need leaders of primary care to talk about what a fulfilling and rewarding profession it is. Yes, there are pressures at the moment, but we need to turn the corner. We will turn the corner by getting more people choosing to work in primary care.208

148.General practice places huge responsibilities onto the shoulders of GPs, but can deliver a unique sense of professional satisfaction. Senior GPs naturally have an obligation to provide young doctors with a realistic appraisal of the challenges that they will face when providing care at the heart of local communities, but they should also acknowledge the part they can play in attracting young graduates into the profession. GP leaders have a keen responsibility to promote the rewarding aspects of a career in general practice and to illustrate why they have dedicated their working lives to the profession.

Tackling local shortages

149.The CfWI outlined the challenge of filling training places in areas which prove unattractive to graduates and how increasing supply does not necessarily meet demand:

Simply increasing the supply of GPs will not necessarily lead to a more equal distribution, as several studies have found. Reducing geographical inequity in access to GP services requires targeted area-level policies, including increasing GP training opportunities in those areas with the poorest coverage.209

150.Health Education England has introduced a broad range of initiatives to make general practice a more attractive proposition to medical graduates and also to make shortage areas more attractive.210 The ten point plan agreed by Health Education England, NHS England, the Royal College of General Practitioners and the British Medical Association in 2015 to improve the recruitment and retention of GPs included a recommendation to implement an additional year of post CCT (Certificates of Completion of Training) training (training after final qualification). The ten point plan said:

HEE will work with partners to resource an additional year of post CCT training to candidates seeking to work in geographies where it is hard to recruit trainees. The aim is to encourage new GP training applicants to those areas.211

Professor Ian Cumming explained how this incentive is expected to work:

They qualify as a GP, they get their certificate of completion of training, and then we say, “If you go to this part of the country, we will give you an extra year of training. In that year you will work as a GP for part of the time, but you will also train in mental health, paediatrics or emergency medicine, something that is needed in the local area, but also something that is a particular interest of yours. We are training you up, and at the end of that we expect you to stay in that area and practise as a GP but also practise in your specialist skill area.”212

151.Professor Cumming outlined the extent of the shortages of trainees in some parts of the country. He highlighted the fact that expanding training places in London had produced unintended consequences:

because as we have created more training jobs we have continued to have 100% fill rate for GP training in London and the south-east. Effectively, we have filled all the training jobs in London and the south-east and drawn predominantly from the north and the east, with bits of the west midlands and the east midlands thrown in. In the north and the east numbers have gone down, in London the numbers have gone up, but we have maintained the same level overall.213

Consequently, shortages of trainees translate into shortages of qualified GPs:

In some parts of the country, you would find that one in four training posts is not filled. [ … ] If you have one in four training posts not being filled, it is fair to say that there will be a 25% shortage of GPs coming to take posts in that area.214

152.The extent of the problem was emphasised by UCL medical school. They said that in some areas up to 40% of training places have remained unfilled.215 Healthwatch Coventry reported that:

There is also evidence that local GP training places not being filled within the Deanery of Health Education West Midlands. There are 350 vacancies, which is 47% of places. This raises concerns about how appealing trainee Drs find the option of training as a GP and how trainees are recruited to local training.216

Financial incentives

153.Professor Roland acknowledged that ‘golden handshakes’ (i.e. financial incentives) had been used in the past as a mechanism to attract young doctors into general practice. He told us that there was a “£5,000 incentive to work in deprived areas sometime around 1996 or 1997”.217 During our visit to Sheffield a number of GPs told us that they felt that this had been a useful tool in increasing GP numbers.218

154.We note that a limited scheme is already in operation whereby a bursary of £20,000 will be made to trainees who agree to work in one of 119 locations that have historically struggled to attract trainees.219 The success of this scheme should be kept under review to build an evidence base for the use of financial incentives in workforce planning. We recommend that the Government should assess the merits of supporting student loan repayments for newly qualified GPs and nurses working in primary care especially in areas with acute recruitment challenges, over a concurrent period of obligated service to the NHS.

155.In light of the current workforce crisis we recommend that in response to this report the Government should provide a comprehensive assessment of the full range of incentives that are available to attract young primary care professionals into general practice and to encourage returners and retention in areas where the need is greatest.

Nursing

156.The challenges for primary care nursing are similar to those faced by GPs. Just as primary care competes with other parts of the NHS for young doctors to choose general practice as a career, the same applies in nursing. Unless these challenges are met, the development of multi-disciplinary teams will founder amid a shortage of nurses vital to the provision of patient centred care. The Nuffield Trust’s evidence noted that:

Like general practice, primary care nursing also struggles to attract trainees and faces the impact of large numbers of retiring nurses over the next decade. For this reason, the Primary Care Workforce Commission has rightly highlighted the need for measures equivalent to the Ten Point Plan agreed for GPs to improve recruitment and retention in primary care nursing.220

157.The Royal College of Nursing’s written evidence argued that the age profile of practice nurses, and national drivers behind nurse recruitment, had adversely affected primary care. The RCN said:

Many sections of the non-acute sector workforce have experienced significant under investment over the last four years: it is an unfortunate consequence of the system’s response to the Francis Report that necessary investment in acute, elderly and general medicine sectors has been at the expense of community based nursing. [ … ]

A further challenge is the demographic of the existing workforce: available estimates of the age profile of the total nursing workforce show a progressively ageing primary care nursing workforce. The nursing workforce as a whole is ageing, in 2013 46 per cent of the workforce was aged over 45, compared with 37 percent in 2005. The average age is even higher in the community than in acute settings and there is expected to be an increase in the numbers of senior nurses retiring within the next five years, which will lead to worrying shortages in some areas.221

158.Commenting on the nursing workforce challenge facing primary care, Professor Ian Cumming told us that in the long term supply and demand should balance out:

We have a huge shortfall at the minute—somewhere in the region of 15,000 to 20,000 fewer nurses than we actually need—but that is because the NHS, as a result of Mid Staffordshire and the focus on quality, has increased the establishment for nurses by about 25,000, and we train 20,000 nurses a year, give or take. [ … ] By 2019 or 2020, we should be back in equilibrium in terms of supply and demand.222

159.Candace Imison of the Nuffield Trust, however, questioned the wisdom of working towards a specific target designed to alleviate nurse shortages:

We have underpinned our nursing workforce—traditionally—from international sources, and as things change internationally people who have come here may well go back again. That argues for an active policy to oversupply nurses, not to try to land the jumbo jet on a pin, which is traditionally what we have tried to do in workforce planning and inevitably come unstuck.223

Professor Chris Ham of the King’s Fund remarked that if “there is equilibrium in demand and supply, it will be the first time in the history of the NHS.”224

Attracting nurses to primary care

160.The RCN believes that reform to pay mechanisms could be significant in retaining nurses in primary care, preventing a drain into the acute sector and ensuring there is a sufficient workforce to support new teams. They observed that:

Recruitment and retention for primary care nurses must also be seen in the context of individual local health economies. It is important to note that unlike acute or other community nurses there is no agreed pay scale for nurses working in general practice. This has led to a gap in terms and conditions between nurses working in general practice and those working in the wider NHS.

Primary care staff do not have the same access to the annual incremental rise under Agenda for Change (AfC) available to staff in acute care and independent practitioners’ pay remains at the discretion of the employing GPs. The RCN advocates the adoption of AfC terms and conditions for all nurses employed within primary care.225

161.Developing this view, Janet Davies, Chief Executive of the RCN, explained that what is most important is providing consistency for nurses across employers in primary care:

The problem is consistency. There are some surgeries that are fantastic employers—there is lots of opportunity for continuing education and nurses are encouraged to develop their skills—and then there are others where the terms and conditions are poor, they do not get paid very well and they do not have those opportunities.226

Primary care nurses: conclusion

162.We recognise that nurses in primary care face uncertain and varied career development and locally agreed terms & conditions all determined by their employer. This acts as a deterrent to those who may wish to pursue a career in primary care.

163.We recommend that Health Education England, NHS England and the Royal College of Nursing develop a plan for primary care nursing akin to the 10 point plan agreed for general practice. This should include proposals to attract trainees, reform undergraduate training and ongoing professional development, establish recommended pay and conditions, and outline examples of different types of careers that can be accomplished in primary care. As well as focusing on retention of the existing workforce, greater attention should be paid to incentivising qualified nurses to return to primary care after taking career breaks or working abroad.

Training and education

164.Exposure to primary care at undergraduate level is a pre-requisite of attracting sufficient numbers and quality across all professions. This includes GPs, nurses, pharmacists and physiotherapists—the core of the multi-disciplinary team in primary care. Janet Davies said that providing exposure to primary care during nurse training should be a central element to attracting nurses into the profession. She described the nursing degree as being

almost like a graduate apprenticeship, so nurses are trained partly in university and 50% of the time is in clinical practice. In that 50% of time we need to ensure that nurses are all exposed to what they are likely to be doing in the future, not just focusing on hospital, which I know is not the case. There has been until recently very little exposure to primary care, working in general practice at that level.227

165.The significance of this was underlined by Professor Cumming, who said that:

We know from several pieces of work that have been undertaken that there is a correlation between how much time people spend in a particular area and how likely they are to choose that as a future career.228

166.We recommend that the Nursing and Midwifery Council urgently review nurse training curriculums with a view to increasing the exposure to primary care for healthcare professionals in training. The same principle should apply across the wider primary care team including physiotherapists and pharmacists. The education and training programme for physician associates should also be tailored in this fashion given their potential contribution to primary care and the developing nature of the profession.

SIFT payments

167.Concern has been expressed that a failure to adequately renegotiate Service Increment for Teaching (SIFT) payments is, in some cases, making it impossible for general practice to offer placements to undergraduates.

168.SIFT payments offset the costs of offering undergraduate medical (and dental) students clinical placements. The Society for Academic Primary Care (SAPC) expressed concern that renegotiation of these payments has become an obstacle to offering placements in general practice to medical students. They said there is an “urgent need to expedite the review of national funding arrangements (SIFT funding) to increase capacity for undergraduate placements in primary care.”

169.The evidence submitted by University College London Medical School illustrated an even more worrying picture. They noted that:

a published survey of all UK medical schools has found that on average medical students spend only 13% of their time based in GP surgeries and that this time has declined since 2002 (Harding et all BJGP June 2015).229

170.In discussing the various factors which have contributed to the decline in undergraduate exposure to general practice UCL Medical School said:

SIFT (Service Increment for Teaching) payment available to reimburse practices providing undergraduate placements has been static for more than 10 years and no longer reflects the cost of re-providing service lost when they are teaching students. [ … ]

The Department of Health working group set up to review GP SIFT arrangements with a view to costing primary care education and replacing SIFT with a new Primary Care Education Tariff has not met since November 2013. Uncertainties around the new Tariff arrangement have blighted medical schools’ ability to deliver current levels of GP based teaching let alone expand this provision in line with future workforce needs.230

171.The RCGP has called for “greater exposure to general practice by increasing the funding available to medical schools for GP teaching and research staff through the medical undergraduate placement tariff.”231 Professor Cumming addressed this matter in oral evidence, noting that Health Education England had commissioned a piece of work on training GPs, which he expected to address the issue of remuneration for training undergraduates.232

SIFT payments: conclusion

172.It is unacceptable that a failure to provide sufficient funding should make it more difficult for medical students to gain experience of primary care. Financial constraints which limit undergraduate exposure to primary care represent a false economy which will only generate costs elsewhere. We were, however, encouraged that Alistair Burt said that the Government is “working to develop a national payment mechanism for primary care with payments that better reflect the costs of the placements”.233 We recommend that the Government accelerate their work to create a payment mechanism which reflects the true cost to GP practices of teaching medical students. The objective of this work should be to ensure that reimbursement of the costs of training is not a barrier to undergraduates being able to access training in general practice. With this in mind, new proposals to replace the existing SIFT arrangements should be in place by the beginning of the 2016–17 academic year.

Workforce and federations

173.Chapter 2 described the way in which federations and networks of practices will be central to developing new models of care. Professor Roland made a strong case to illustrate how collaborative working can make advancing the workforce a more realistic prospect for groups of practices. He said that new structures provide the headroom for general practice to find ways to change their models of care and professional teams as it “is very difficult to innovate when you are constantly trying to catch up.”234 Professor Roland gave an example of how bigger structures can improve the workforce, telling us that the PCWC envisaged:

networks and federations playing a key role. For example, in terms of the new roles, such as physician associates, how are we going to train them and how are we going to deal with governance issues and liability? Those are the sorts of things that an individual practice will find really hard.235

174.Similarly, Professor Roland emphasised the support that federations will have to offer in crucial areas such as developing leadership roles for nurses in primary care:

We could see a very good case, for example, for a federation having a lead nurse who would take some responsibility for the training and support of nurses in the practices in that federation.236

175.Co-commissioning of general practice services by clinical commissioning groups presents an opportunity to tailor services to patient needs by making best use of local knowledge and experience. Allied with NHS England local area teams, Clinical Commissioning Groups should use their co-commissioning powers to oversee and guide the development of federations so that patient care is central to their ambitions. We recommend that a principal element of this oversight should be a requirement for federations to develop multi-disciplinary teams focused on enhancing access to primary care and improving the quality and range of services available.

176.In order to accelerate the development of nursing roles in primary care we recommend that federations appoint a lead nurse to design and implement career pathways and continuing professional development for nurses. Health Education England should assist in setting standards and supporting federations and networks to meet them.

Regulation

177.Over the course of this inquiry we sought to assess the merits of extending the role of physician associates within general practice and in Chapter 2 we commented on their potential to contribute to new models of care. Whilst the majority of witnesses have been largely positive regarding the clinical role they can play, the lack of professional regulation of this profession is a significant barrier to their further deployment.

178.This point is of significance given the substantial expansion of the physician associate workforce that is planned and the fact that the PCWC endorsed the principle of physician associates forming part of the multi-disciplinary general practice team.

179.The Nuffield Trust identified the restrictions on physician associates as an impediment to expanding this workforce:

New roles such as physicians’ associates are hampered by their inability to prescribe medicines. They need to be formally regulated in order to enable this and we would urge the committee to support this change.237

180.Professor Roland discussed the ways in which physician associates should work in the context of them being an un-registered profession for whom the employing GPs would be vicariously liable. Professor Roland said the view of the Primary Care Workforce Commission

would be that in due course they should have a limited prescribing list, yes, because that would significantly extend what they can do with minimal risk to patients. I think it is a limitation. In the same way we have pretty slowly seen prescribing pharmacists, prescribing nurses, obviously, and now prescribing physiotherapists.238

He noted, however, that many of the major challenges related to the expansion of the physician associate workforce have not yet been addressed, adding:

There is a question, for example, as to whether they should be seeing children and pregnant women, so there are physician associates who quite significantly limit their practice at the moment to, for example, acutely ill adults.239

Acknowledging the risk carried by GPs, Prof Roland said the GP

is in a position of personally, potentially, taking responsibility. The issues of liability are important and for that reason, regulation of the profession would be desirable.240

181.Dr Chaand Nagpaul of the BMA outlined and emphasised the concerns relating to regulation and also raised the issue of physician associates’ qualifications:

There are some very real and understandable concerns about the role of physician associates in terms of their qualifications, the indemnity and the regulation. Rather than starting with some target of 1,000 physician associates and looking at it in terms of physician associates, why not look at the skill mix that can support general practice? [ … ] Being simplistic and saying it is about 1,000 physician associates is probably not the way to interpret it.241

182.The Medical Protection Society’s written evidence implied that ascribing additional responsibilities to physician associates could increase the indemnity costs faced by practices:

The level of risk attached to any one individual will obviously depend on their role and degree of autonomy, regulatory requirements, level of delegated authority and most especially the extent of autonomous decision making.242

183.The General Medical Council has indicated that it would be supportive of measures to regulate physician associates, although they stopped short of committing themselves to assuming this function:

The GMC has received a number of approaches about taking on the regulation of physician associates. We support the proposal that they should be subject to statutory regulation and we have made clear that should the four UK governments ask the GMC to take on this role, we would at least consider doing so.243

Physician associates: conclusion

184.Without expansion of the workforce, the role of the physician associate cannot naturally evolve to meet the demands of working in general practice as part of multi-disciplinary teams. The Government should heed the warnings of general practice and indemnity providers that 1,000 additional physician associates will not be recruited into primary care unless there is a regulatory structure to underpin their clinical work. The vicarious liability faced by employers as a consequence of employing clinicians who work without professional regulation is a clear disincentive to recruitment.

185.We welcome the fact that the Royal College of Physicians now hosts a faculty which will operate the re-certifying process for physician associates, but this is not an adequate substitute for professional regulation.244 Regulatory change is required for the statutory regulation of physician associates to be made possible.245 Within 12 months we expect the Government to have drafted proposals that will achieve the objective of professionally regulating physician associates. It is unacceptable to encourage new graduates to train as physician associates without giving the public or these new members of the primary care workforce the assurance that they will be a regulated professional group.

GP leadership

186.GP leaders have a key role to play in helping to mobilise professional support for implementing the recommendations of the Primary Care Workforce Commission, for example by emphasising the benefits not only for patients but for professional colleagues. We heard in evidence that working collaboratively is often associated with delivering excellent care and provides a positive environment in which to work.246 Innovative examples of new models of care have already begun to develop and these range from a nurse led practice in west London to practices making active use of self-referral to physiotherapists in Suffolk. We would welcome the RCGP and BMA taking a greater role in helping to promote and drive forward multidisciplinary working and new models of care.


180 The King’s Fund (PRI 191) para 18

181 Department of Health, NHS England and Health Education England (PRI 200) para 77

182 Q78

183 Department of Health, NHS England and Health Education England (PRI 200) para 84

184 Q84

185 Q408

186 BMA (PRI 49) para 33

187 Q409

188 Department of Health, NHS England and Health Education England (PRI 200) para 83

189 Centre for Workforce Intelligence (PRI 183) section 3

190 Q391, Mr Dyson

191 Ibid

193 British Medical Association (PRI 49) para 31

194 The Recruitment and Employment Confederation (PRI 179) para 4

195 Londonwide LMCs (PRI 172) para 23

196 Q392

197 Q64

198 Q84 & Q344

199 NHS Alliance (PRI 90) para 3.2

200 Q343

201 Q402

202 Q343

203 Sir Denis Pereira Gray OBE (PRI 238) page 7

204 Ibid, p 5

205 Ibid, p 5

206 Q84

207 Q342

208 Q84

209 Centre for Workforce Intelligence (PRI 183) p 2–3

210 Department of Health, NHS England and Health Education England (PRI 200) paras 86–89

211 RCGP, BMA, NHS England & Health Education England, Building the Workforce – the New Deal for General Practice (January 2015), recommendation 2

212 Q61

213 Q78

214 Q90

215 UCL Medical School (PRI 223) p 1

216 Healthwatch Coventry (PRI 71) para 1.31

217 Q66

218 Note of Committee visit to Halifax & Sheffield

219 GP National Recruitment Office ‘Targeted Enhanced Recruitment Scheme in England’ accessed 11 March 2016

220 The Nuffield Trust (PRI 175) para 6.2

221 Royal College of Nursing (PRI 63), paras 8.3 – 8.4

222 Q89

223 Q16

224 Ibid

225 Royal College of Nursing (PRI 63) paras 9.2 – 9.3

226 Q104

227 Q124

228 Q50

229 UCL Medical School (PRI 223) p 1

231 RCGP (PRI 174) para 16

232 Q85

233 Q417

234 Q13

235 Q2

236 Q30

237 The Nuffield Trust (PRI 175) para 6.5

238 Q42

239 Q43

240 Q43

241 Q347

242 The Medical Protection Society (PRI 235) para 55

243 General Medical Council (PRI 217) para 19

245 Prof Veronica Wilkie (PRI 236)

246 Qq 272 343




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20 April 2016