GP Academics. Visible? Viable? Invaluable. The Battle of Britain called General Practice..

NHSreality agrees with Dr Lewis. There are not enough pilots, and the enemy is growing stronger.. A disaster is pending, and a miracle is unlikely.. A direct result of prolonged rationing of medical school places.. Only the GP makes the cost-effective diagnosis in primary care … and, by the way, his insurance cover is becoming prohibitive.

From John Campbell, chair, heads of departments of general practice and primary care, and others, in the BMJ (BMJ 2015;351:h4164)

Visible? Viable? Invaluable

The report of Higher Education England’s commission on the primary care workforce is timely and welcome.1 The UK has led the way in delivering high quality, effective, accessible, and equitable healthcare at modest cost.2 Getting the right workforce to deliver the strongest possible NHS primary care focus3 is critically important in times of financial constraint, healthcare innovation, and the changing population demographic characterised by complex care needs and multimorbidity. But in parallel, attention must be given to the importance of recruiting, retaining, and developing the primary care academic workforce—an agenda that was beyond the remit of the commission.

The UK’s 205 senior academic GPs comprise just 6.5% of all clinical academics, and a tiny fraction of the 64 923 GPs currently registered with the General Medical Council (32 628 established GP full time equivalents). The overall increase in GP academic capacity from 153 full time equivalents in 2000 to 205 in 2014 has been almost exclusively the result of an increase in the numbers of GP professors from 33 to 78; the static number of GP lecturer posts (40) over 15 years reflects reduced opportunity for career progression at this level (Medical Schools Council, personal communication).

The recent trend to move academics who mainly teach into central undergraduate teaching units4 has also fragmented university primary care departments (a consequence of the leadership of primary care academics in professionalising training and teaching roles) and reduced the already modest critical mass. Although the move towards centralisation of teaching may have some apparent advantages in terms of institutional management, it carries substantial risks. It may reduce academic capacity and separate undergraduate teaching in primary care from research in the discipline. Given that exposure to charismatic role models and observation of academic opportunities during rotations5 6 are important drivers of the career choices of medical students, such dislocation may reduce the number who consider general practice as a career.

Academic GPs make an essential contribution to the NHS through education, research, clinical practice, and service development, usually while continuing to provide direct patient care. It is academic GPs who lead the general practice and community based undergraduate teaching of all future doctors, including those considering general practice as a career. Around 15% of the clinical curriculum in UK medical schools is general practice based.4 However, since the only generalist discipline left in the NHS is general practice, it is essential that all future doctors have sufficient quantity and quality of exposure to primary care to ensure that they learn about undifferentiated symptoms, value longitudinal patient care, and understand modern NHS systems.

Academic GPs are increasingly involved in curriculum development, quality assurance, assessment, admissions, welfare, and senior educational leadership. Furthermore as local education and training boards and deaneries restructure, university departments are key players in the emerging models for integrated delivery of community based undergraduate, postgraduate, and non-medical clinical education.

Academic GPs are also research leaders, developing and overseeing high quality studies and building the evidence base around the organisation and delivery of clinical primary care. This discipline contributes disproportionately to major NHS research initiatives, supporting the work of the National Institute for Health Research, including leading the NIHR School of Primary Care Research. It contributes to leadership in primary care research education and training, research design and delivery, and to supporting the development of national research strategy.

International comparisons show UK primary care researchers outperform other countries in terms of the number of publications.7 Primary care research addresses NHS priority areas, including, for example, antibiotic stewardship in primary care,8 9 the management of patients with atrial fibrillation,10 diabetes,11 12 multimorbidity,13 14 serious illness,15 and risks arising from lifestyle.16 The organisation of care17 and informing new approaches to managing patients18 19 20 are examples of core themes in current primary care organisational research. UK based primary care research often has direct societal impact, influencing government policy and international clinical guidelines.21 22 23 This research is directly relevant to GPs—the research findings help guide their clinical practice, with reliable evidence derived from their own setting. Hosting research can provide GPs with a more varied role and wider colleague interaction, can generate extra capacity in practice if the research is adequately funded, and can stimulate future doctors and energise training GPs.

Although the challenges facing the NHS with respect to the general practice workforce are substantial, we believe in the need to secure a strong, critical mass of leaders in primary care research and education. Offering academic career development and training in conjunction with clinical service delivery is an important means of enhancing recruitment to, and retention of GPs.24 Much has been achieved in supporting the clinical academic training of academic GPs in the past 10 years through initiatives such as the national academic foundation programmes and a range of academic clinical fellowships. However, capacity within these programmes remains small, and opportunities for long term academic career development are limited. Overall, the capacity of clinical academic general practice needs to increase, and this requires the establishment of new mid-career GP lecturer or senior lecturer posts. It is vital that such efforts are further developed to ensure the continued visibility, core viability, and continued value of this discipline to the NHS.

and reply from Dr Sam Lewis and others. UK academic general practice and primary care. (BMJ 2015;351:h4164)

So very few ..

Never in the field of general practice..(at an ever increasing workload and diminishing pay rate)has so much been owed ….(NHS priorities, early cancer diagnosis, antibiotic stewardship, QoF atrial fibrillation, diabetes, multimorbidity, serious illness, and prevention and risk-management of lifestyle. Add on student attachments, academic fellowships, VTS training and clinical research, whilst delivering high quality, effective, accessible, and equitable healthcare, subject to locally appointed panels of patients to meet local needs )by so many..(John Campbell, F D Richard Hobbs, Bill Irish, Sandra Nicholson, Mike Pringle, Joanne Reeve, Joe Rosenthal, Denis Pereira-Gray, Rebecca Fisher, JK Anand, Susanne Stevens)to so few..(GP vocational training in Wales needs 100 new GPs a year to fill vacancies. Only half have been taken up. The 50 per cent uptake is replicated in north of England, the north Midlands, East Anglia and the West Country. The Oxford region for the first time is having problems.) Meantime one-third of working GPs are due to retire, and have to pay medical insurance of £9000 p.a. to work on..

Re: UK academic general practice and primary care: response to Dr Sam Lewis

Yes, we need all those doctors in general practice. We have been training doctors in ever increasing numbers, buckets full of them. But the buckets go on leaking faster than you can fill them.

The answer is certainly not filling up a jumbo jet, parachute the recruits over, Liverpool, Machynleth, Bethnal Green……, give them a crash course in the NHS culture, the social anthropology of the Clinical Commissioning Group patch, let them say hello to the administrator of a group practice and then Go, Go, Go.

The answer is retention, retention, retention.

Cast your mind back. Once GPs would take a 24 hour retirement, then return to at least part-time work. Now? They retire and bid good-bye.

The sensible thing is to firstly recruit as medical students (after the first MB), students who actually like caring for patients, rather than ticking computer boxes. Then, for general practice, follow Susanne Stevens’ suggestion – put a local person on the selection panel. This will help ensure that the appointee can relate to the local population, have some sympathy for the local mores.

27 August 2015 JK Anand Retired doctor

 ” We need pilots .. “

I fear the authors and the respondents all miss the essential point in this latter-day Battle of Britain called general practice.

To paraphrase Larrie Olivier, playing Air Vice-Marshall Dowding:

“Gentlemen, you’re .. missing the essential truth. We’re short of [10000 doctors], those that we have are tired, strained and all overdue for relief. We’re fighting for survival, losing. We don’t need [an academic] wing, or a [community] wing. We need [doctors]…and a miracle…Good night, gentlemen

Re: UK academic general practice and primary care

Campbell et al highlight the attention that must be paid to the recruitment, retainment and development of the primary care academic workforce. In particular they call for an increase in capacity within clinical academic general practice and furthermore the establishment of new mid-career GP lecturer posts.

It is a viewpoint with which we strongly agree and is also supported and added to by our recent work (unpublished) examining the future aspirations and backgrounds of current academic clinical fellows (ACFs) in primary care.

As is acknowledged in their editorial, ACF posts have done much to progress the formal, structured, combined clinical academic training pathway for early years clinical academics (1). Most commonly funded by the National Institute for Health Research (NIHR), they allow dedicated and protected periods of academic training embedded within clinical training, at the end of which Certificate of Completion of Training (CCT) is achieved.

There is little published work on the future of this cohort of trainees and exploring the views and experiences of this group who are likely to make up the ‘future’ of academic primary care is key to the recruitment and retention of the academic general practice workforce.

In 2014, at the National Primary Care ACF Conference, hosted in Oxford, we undertook a questionnaire study distributed to all delegates to explore these issues in more detail. Fifty responses were received (83% response rate of potentially eligible participants at the conference), of which 15 (30%) were from males and 34 (68%) from females (1 declined to answer).

It is reassuring that our survey found that 70% of respondents wished to continue along a clinical academic path after CCT, although it is of note that concerns were consistently raised about the feasibility of this: these included the financial implications of a career in academic medicine and the ability to successfully obtain funding to undertake research. Furthermore, although the majority of ACFs intend to continue clinical work following completion of their ACF (88%), it is interesting that just 30% aspire to be a GP partner.

Our study also examined prior backgrounds of those undertaking ACF posts and, whilst there are 33 medical schools in the UK, over a quarter of our survey cohort had attended either Oxford or Cambridge for their primary medical degree: this is despite the fact that graduates from these two Universities made up only 2.4% of those entering GP training in 2012-14 (2). Other key findings were the majority (84%) of GP ACFs who have some research experience prior to commencing the programme, and the proportion of those entering ACFs from an Academic Foundation Programme (28%).

Our work highlights the clear majority of ACFs who wish to continue to undertake academic work after CCT. However, concerns raised about combining clinical and academic careers need to be taken seriously: these were consistent and therefore continued work towards the removal of these barriers is essential.

We also identify the need to widen recruitment to ACF posts. This includes the promotion of these posts to those graduating from universities other than Oxford and Cambridge and the need to encourage applications from those who may not have undertaken an a prior clinical academic research post.

These findings lend support to the development of new mid-career GP lecturer posts but also suggest that in order to be successful these need to incorporate flexibility to take into account the desire to continue clinical work, as well as less than full time working. To ensure the success of these initiatives we would advocate the involvement of more junior academics in their design and delivery and suggest more formalised processes for monitoring the value and outcomes of current posts.

Whilst recognising the methodological limitations of this small study, we hope that perspectives from more junior ranks of academic primary care can help to lend support to a common aim; the furthering and safeguarding of an academic discipline which has so much to contribute to the health of this nation and beyond.

Yours,

Dr Rebecca Fisher
Dr Helen Ashdown
Dr Rachel Brettell
Dr David McCartney
Nuffield Department of Primary Care Health Sciences, University of Oxford.

 

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This entry was posted in A Personal View, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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