Who would be a GP?
What needs to change to increase the number of medical students choosing general practice?
General practice is the front line of medicine in the United Kingdom, where 90% of patient contacts take place. Demand is increasing, with more and more patients using out of hours services and mounting pressures on emergency departments. In recent months, in the lead up to the UK general election in May 2015, several of the major political parties have made pledges to increase funding for primary care services. In September 2014 prime minister David Cameron pledged seven day access to GP services across England by 2020. This was followed by a commitment to invest a further £1.2bn (€1.6bn; $1.8bn) on GP facilities and services, spread over four years. Ed Miliband, leader of the Labour party, promised that if elected his party would increase GP numbers by 8000.
As medical students, we are often told that half of us should expect to become general practitioners. In 2013, Health Education England was set the target to ensure that 50% of medical students become GPs.
But despite these promises to increase recruitment into general practice, practices consistently struggle to recruit enough trained doctors, and at present too few medical students are choosing general practice training. This calls into question whether the promise to provide seven day access is realistic in the current climate and whether it will only add to the challenge in persuading medical students that general practice is an attractive career choice.
Why are medical students less keen on general practice, and what can be done about it? For a sustainable future for the service, changed perceptions must start at medical school.
General practice is not a popular option among graduates applying for specialty training. In 2013, it had the third lowest competition ratio of all the training programmes. Only 20-30% of UK medical graduates applying for specialist training picked general practice as their first choice, with many choosing it as a back-up option. In 2013, 4100 doctors (60%) entered hospital specialty training, compared with 2800 (40%) entering GP training. In 2014, applications to GP training were so low that an unprecedented third round of applications was opened. In some areas, the fill rate for GP trainee jobs was as low as 62%; even after this third round, one in eight posts nationally was vacant.
The recruitment crisis hits some areas harder than others. In Wales, many posts are left unfilled, and few foundation year 2 posts include an attachment in general practice.
Practices at risk
Many GP practices struggle to recruit doctors. Maureen Baker, chair of the Royal College of General Practitioners, warned that 600 practices across the UK are at risk because more than 90% of the doctors working there are aged 60 or over and expected to retire soon. A survey of more than 2500 GPs in Oxfordshire found that 61% found it difficult to recruit partners for their practice, and more than half had trouble recruiting salaried and locum GPs.
Of the GPs surveyed, 80% said at least one doctor in their practice was experiencing burnout. Also, 97% of respondents said their workload was ever increasing and unsustainable. In addition to retirement, younger doctors emigrating or leaving general practice may further reduce the numbers. Of the Oxfordshire GPs surveyed, 11.6% said they intended to emigrate in the next five years.
But it’s not all negative. Simon Gregory, a GP in Northampton and primary care lead for Health Education England, remains enthusiastic after 20 years in general practice. “I do still think it’s the best job in medicine,” he said. He expressed concern that some of the negative messages around general practice “have made it sound like a bad job.”
And Essex GP Sunita Dhanjal, now a partner at the practice where she did her GP training, agreed. She switched to general practice after starting to train as a surgeon and enjoys the family friendly lifestyle. “I have two children, I’m married, I have a good income—that in itself is such an advantage compared with friends still training in hospital,” she said. “I know I’ll be home at 7.30 pm and can plan things for the weekend. I love my job and I love my patients.”
Few medical students start medical school intent on becoming GPs, but many become interested during their clinical years. Historically, general practice has often been seen as a “lifestyle option,” as it is more accommodating to part time work than many hospital specialties. This can allow people to pursue other interests and juggle work with family life. However, the move to ensure surgeries are open seven days a week, from 8 am to 8 pm, could threaten the perception that it’s a more flexible career.
George Chater, a medical student at the University of Cambridge, weighed into the debate on how to make general practice appear a more attractive career prospect to medical students. In a letter published on thebmj.com, he and two colleagues wrote: “From our perspective, the attractiveness of the job is the most important factor when choosing a career.” They went on: “In the past, general practice was highly attractive, with sociable working hours and strong doctor-patient relationships. We think this has changed over the years.” He told Student BMJ “no one was asking us” about the problem and added that, of his peers, “nowhere near” the 50% required were planning a career in general practice.
Jamie Goodhart, a medical student from the University of Warwick, does not consider working less hard to be the main attraction of general practice. “GPs have always worked hard as far as I can tell,” he said.
Gregory agreed that workload had increased but said this has happened across the NHS, not just in the primary care sector. Regarding the prospect of seven day access, he pointed out that general practices made their own arrangements and had a degree of flexibility over how and when their doctors worked.
“Working across the week does not mean working seven days a week. You’re not going to be forced to work every weekend. It’s vital that [general practice is] an enjoyable and sustainable career.” Dhanjal added that she had “never worked a weekend since [completing training].”
What of the perception that continuity of care is a thing of the past? “The patient leads this continuity—we know that young, fit, well people aren’t bothered [about it], but older people with long term conditions are,” said Gregory. He described as “fantastic” the feeling of seeing patients he’d treated as children now bringing in children of their own.
Dhanjal agreed. “There is continuity. You have responsibility for your own patients. You see people, refer them, see the outcome, they come back and you get a lot of feedback. In hospital, often you see someone and diagnose them, then never see them again.”
She pointed out that many GPs develop clinical specialties within their field, allowing them more flexibility in their clinical work. She chose to become a GP with a special interest in minor surgery and dermatology, building on her initial surgical training.
Not only do you have an ongoing relationship with individual patients, Gregory said, but also with colleagues. “You work in close knit teams, so you get to know them very well and it’s fun to work with them,” he said. ‘We should be celebrating all this.”
What can be done?
The high proportion of medical school tutors or deans who are hospital based consultants is thought to play a part in the low uptake of general practice among students. Of the 33 medical schools represented by the Medical Schools Council, only two are led by GPs. Promotional material for medical schools also tends to focus on seemingly glamorous hospital medicine and research, at the expense of primary care. Not all foundation courses include a community or general practice placement, which can also influence people’s career choice. Tackling general practice representation at medical schools is a good start.
However, in a Rapid Response published on thebmj.com, Azeem Majeed, a professor of primary care at Imperial College London, said that medical schools are the wrong target for the blame. He points the finger at the government, in particular the Department of Health and NHS England. “Newly qualified doctors are not applying for general practice training schemes and established general practitioners are retiring early because the working conditions of general practitioners have deteriorated substantially in recent years,” he said. He attributes an increase in the volume and complexity of the workload required by GPs and large budget cuts as major reasons for this decline. In a recent BMA survey of 1019 members, almost three quarters of GPs (72.8%) said their workload was unmanageable or unsustainable, compared with just 40.2% of hospital based doctors.
What else can be done? Last year’s General Practice Taskforce recommended “a professionally led marketing strategy . . . to promote general practice as an attractive and positive career choice.” The extremely low proportion of Cambridge graduates going into general practice led the Cambridge GP tutors to produce a music video entitled “I’m a GP” to promote the variety and other benefits of general practice (link to video: http://vimeo.com/87969915 ).
Gregory said Health Education England was establishing a committee, expected to report in the summer, which would review different models of general practice and training and look at best practice. “It’s a real opportunity to look at how we develop a sustainable general practice in future,” he said.
Unless general practice is made more attractive to students and junior doctors and moves are made to stem the numbers of GPs leaving, maintaining the current service is likely to be challenging. The target of 50% of new graduates going into general practice seems unlikely to be met without further effort, in spite of an increased number of training posts.
It is encouraging that Health Education England is undertaking a review of general practice and that the government has committed to increased funding for the sector. Yet it seems that the traditional appeal of flexible working and varied workload are no longer a strong enough draw. Further exposure to general practice during medical school and the foundation years is a good start, but unless that exposure shows general practice to be a rewarding career, students will continue to vote with their feet.Alice Buchan, fifth year medical student
1University of Oxford
Correspondence to: email@example.com
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- Wintour P. GP access seven days a week by 2020 “guaranteed” under Tories—Cameron. Guardian 2014, 30 September. www.theguardian.com/society/2014/sep/30/gp-access-seven-days-week-2020-tory-cameron.
- Pym H. NHS Funding: how do the sums add up? BBC News 2014, 30 November. www.bbc.co.uk/news/30271649.
- BBC News. Ed Miliband promises £2.5bn funding boost “to save NHS.” 23 September 2014. www.bbc.co.uk/news/uk-politics-29310512.
- Department of Health. Delivering high quality, effective, compassionate care: Developing the right people with the right skills and the right values. A mandate from the Government to Health Education England: April 2013 to March 2015. May 2013.
- GP Taskforce. Securing the future GP workforce delivering the mandate on GP expansion. 2014. http://hee.nhs.uk/wp-content/uploads/sites/321/2014/07/GP-Taskforce-report.pdf.
- Rimmer A. GP recruitment opens for unprecedented third round after low fill rates. BMJ Careers 2014; 9 July. http://careers.bmj.com/careers/advice/view-article.html?id=20018342.
- Rimmer A. One in eight GP training posts vacant, despite unprecedented third round of recruitment. BMJ Careers 2014;24 October. http://careers.bmj.com/careers/advice/view-article.html?id=20019782.
- Rimmer A. Wales is “ill prepared” for crisis in GP recruitment, BMA warns. BMJ Careers 2014; 9 October. http://t.co/3bTWMJzGAa.
- Hann M, McDonald J, Checkland K, Coleman A, Gravelle H, Sibbald B, et al. Seventh national GP worklife survey. August 2013. www.population-health.manchester.ac.uk/healtheconomics/research/FinalReportofthe7thNationalGPWorklifeSurvey.pdf.
- Campbell D. Up to 600 GP surgeries could close over course of next year as doctors retire. Guardian 2014, 1 October. http://gu.com/p/4248c.
- McHugh A, Dawson L, Moncrieff G, McDonald B, Parton S, Gillies H. Are you in despair for your future in general practice? July 2014. https://pracmanhealth.files.wordpress.com/2014/08/are-you-in-despair-for-your-future-in-general-practice-final-report1.pdf.
- Chater G. Why we don’t want to be GPs: the student perspective. BMJ 2014;349:g6971.
- Goodhart J. Re: Fire the Medical Schools Council if you want more GPs. BMJ Rapid Response; 30 November 2014.. www.bmj.com/content/349/bmj.g6245/rr/791266.
- Wakeford R. Fire the Medical Schools Council if you want more GPs. BMJ 2014;349:g6245.
- Majeed A. It is the NHS—not medical schools—that is responsible for the crisis in GP recruitment. BMJ 2014;349:g6245.
- British Medical Association. BMA quarterly tracker survey. http://offlinehbpl.hbpl.co.uk/NewsAttachments/PGH/BMA_quarterly_report.pdf.
Cite this as: Student BMJ 2015;23:h317