Moving the point of GMC registration
Moving GMC registration to the point of graduation may have profound and far reaching effects
Should doctors become fully registered with the General Medical Council (GMC) as soon as they graduate from medical school? That’s one of the more controversial proposals in the Shape of Training review, published in December 2013, with remarkably little fanfare. The report, by David Greenaway, vice-chancellor of the University of Nottingham, looked into the state of postgraduate medical education in the United Kingdom and made recommendations on how it should be adapted to suit the changing health needs of the UK population.
Currently, medical students in their final year of study provisionally register with the GMC. They then go on to work as foundation year 1 (FY1) doctors with supervision and training. Providing they fulfil the raft of FY1 competences, their medical school will recommend them to the GMC for full registration at the end of that year. From foundation year 2 (FY2) onwards, they may work as fully fledged doctors.
This is a slightly odd arrangement. Although medical schools retain responsibility for their former medical students, they lack the ability to properly supervise their alumni in training once they are on the wards around the country. It is this discrepancy the Shape of Training review has sought to tackle. If registration were to be moved forward, full responsibility for junior doctors would lie solely with local education and training boards in England and postgraduate deaneries in the other home nations.
On the surface, this recommendation seems to make sense, offering a clean break between medical school and the next phase of a doctor’s training. However, while this is convenient for medical schools and the deaneries, it will have an impact on graduates’ careers, the future role of medical schools, and, perhaps most importantly, on patient safety.
Impact on graduate careers
To practise medicine in the UK you must be registered with the GMC. To obtain full registration graduates must enrol on the UK foundation programme to demonstrate and develop their clinical and professional competences. This is the only way you can progress your medical career in the UK. However, the foundation programme has been oversubscribed each year since 2011. In 2014 the foundation programme was initially oversubscribed by 293 applicants. Although all applicants have now been placed, any shortage of training posts means that graduates are unable to progress their careers until they get a place on the programme.
A concern with this new proposal is that cutting the link between medical school and the foundation programme would remove the responsibility for providing graduates with a clear route to progress their training. Health Education England is the organisation responsible for postgraduate medical education and the body tasked with implementing the Shape of Training review’s recommendation. Health Education England is keen to point out the benefits of moving full GMC registration, suggesting that newly graduated FY1 doctors with full registration will be able to provide more services than their preregistration counterparts Theoretically, graduates who are unable to get a place could work as doctors or in related clinical posts in a locum capacity before they reapply to the foundation programme. However, it is unclear which additional services Health Education England envisages FY1 doctors providing. The BMA insists that fully registered FY1s would still require the same level of supervision and guidance as preregistration doctors.
Some graduates might leave medicine before they’ve properly entered the profession or emigrate to a country with available training posts, such as the United States or Australia. This would be a considerable waste of talent for the NHS and a huge expense to taxpayers, who foot the bill of £175 000 (€220 500, $285 600) to train each medical student. A further concern is that once medical students graduate they will be subject to European Economic Area employment competition laws, meaning that UK graduates would have to compete for foundation programme training posts with candidates from the European Union. Full registration may give graduates more choice about where they work, but they could face more competition for jobs.
How will this affect patient safety?
Currently, the GMC expects a fully registered doctor to meet the standards of an FY2 doctor. So should the GMC standards for full registration be lowered, or will FY1 doctors be expected to have already gained all the necessary experience and competences in medical school? Health Education England has yet to clarify, although Shape of Training states: “Patients and the service are likely to expect graduates who have full registration to meet the same competence level as the current threshold. This change will inevitably have a knock-on effect on undergraduate medical education, which will have to ensure graduates meet more advanced outcomes.”
Niall Dickson, chief executive of the GMC, has stated that the GMC has no objection in principle to moving the point of registration but he has said that the focus of such a move must be patient safety, not the ebbs and flows of workforce planning. Further, as the GMC uses the standards expected for full registration as the benchmark in the Professional and Linguistic Assessments Board (PLAB) exam for overseas medical graduates wishing to practise in the UK, lowering the standards necessary for full registration would require a lowering in the standards expected in the PLAB assessment. This is at odds with recent suggestions that the difficulty of the PLAB exam should be increased.
A more likely alternative is that medical students will have to acquire the equivalent of FY1 competences while still in medical school, as suggested in the report. This would require a restructuring of medical school curriculums across the UK. With curriculums already packed it is difficult to see how medical schools will adapt.
Moving the point of registration may endanger current postgraduate courses. Four year courses can provide the 5500 hours of training required by EU law only by including within their course the first year of foundation training. Full registration could not be achieved without extending postgraduate degrees by another year, adding further cost to studying medicine.
What happens next?
Health Education England’s plans to move the point of GMC registration rest on one important assumption: that the point of GMC registration can be moved. Currently, registration follows an acceptable period of training as dictated by the Medical Act 1983. [.] Nobody in the UK possesses the legal powers to change it. The proposal requires government legislation, which is most unlikely until after the general election in 2015. In addition, Dickson says that the system would require a five year delay to allow a new cohort of medical students to pass through the system. It seems that nothing is likely to happen very fast.
Who’s driving the change?
It is not clear who or what is driving the proposed change. In his foreword to the Shape of Training review, Professor Greenaway says the move was needed to ensure doctors in training would meet the changing needs of the population, in particular a need for more generalists and fewer specialists. It’s hard to see how changing the point of GMC registration affects this. In the review itself, the rationale given is to simplify the supervision of foundation doctors, so that responsibility for their training lies clearly with their postgraduate institution. In a rapid response published on thebmj.com Benjamin Dean, an orthopaedic registrar, says that the “true motives of the Shape of Training review are not yet known.” He has asked to see documentation of meetings between the chairman of the review, Professor Greenaway, and government ministers or civil servants. Dean calls the review “highly flawed” and says the public deserves to see “all the information that may shed light on the true motivations behind such a review.” The report has also been widely opposed by medical authorities on a number of grounds. At its recent annual representatives meeting, the BMA voted to oppose moving GMC registration to the point of graduation. It is clear that moving the point of GMC registration has the potential to have profound and far reaching effects on both undergraduate and postgraduate medical education. Regardless of the reasoning behind it, this is a subject that medical students at all levels should continue to follow with an especially watchful eye.
Box 1: Timeline
- 2005—Two year foundation programme is introduced as part of the Modernising Medical Careers programme
- December 2013—Shape of Training review is published. Among other things, it recommends moving the point of GMC registration to graduation from medical school
- February 2014—Departments of health for the UK nations agree to collaborate on how to move forward with the review’s recommendations. Responsibility for implementation lies with Health Education England
- 2014—Health Education England is due to unveil its plans for implementing the move of full GMC registration to the point of graduation
- January 2015—UK Foundation Programme Office is likely to confirm the number of applicants by which the foundation programme is oversubscribed
- 2020—Earliest date at which plans to move the point of full registration could be implemented, according to Niall Dickson, GMC chief executive
Box 2: Who is involved?
- Health Education England—Since the Health and Social Care Act 2012, this body has been in charge of postgraduate education of doctors and nurses in the UK. They are responsible for implementing the recommendations of the Shape of Training review
- General Medical Council—Regulatory body of doctors in the UK. No one can work as a doctor in the UK without registering with the GMC. Currently, they do not have the power to change the point of registration; neither does any other body
- Academy of Medical Royal Colleges
- NHS Scotland
- NHS Wales
- Northern Ireland Department of Health
- Medical School Council
- Conference of Postgraduate Medical Deans of the UK
Davies R. Plans to move GMC registration to end of medical school to be announced. Student BMJ 2014;22:g3549
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- Shape of Training review: Securing the future of excellent patient care. December 2013. www.shapeoftraining.co.uk/static/documents/content/Shape_of_training_FINAL_Report.pdf_53977887.pdf.
- Foundation Programme. Oversubscription numbers confirmed for FP2014. www.foundationprogramme.nhs.uk/news/story/oversubscription-numbers-confirmed-for-fp-2014.
- Rimmer A. Competition for foundation places will rise if GMC registration moves to point of graduation, BMA warns. BMJ Careers 2014; http://careers.bmj.com/careers/advice/view-article.html?id=20016603.
- Dickson N. Moving the point of doctors’ registration. BMJ 2014;348:g2863.
- Moberly T. Examination bar for overseas doctors must rise, researchers say. BMJ 2014;348:g2858.
- General Medical Council. Tomorrow’s doctors. http://www.gmc-uk.org/static/documents/content/Tomorrow_s_Doctors_0414.pdf.82-3.
- Medical Act 1983. www.gmc-uk.org/about/legislation/medical_act.asp#2.
- Dean B. Rapid response. Moving the point of doctors’ registration. BMJ 2014;348:g2863.
- Lintern S. Medical graduates should be denied full medical licence, says BMA. Heal Service J 2014. www.hsj.co.uk/news/medical-graduates-should-be-denied-full-medical-licence-says-bma/5072411.article#.U67Pq_ldXwo.
Cite this as: Student BMJ 2014;22:g4815