Overseas GP recruitment to bolster the UK GP workforce – how can we maintain registration standards and patient safety?

In the context of our department’s GP workforce research and in light of reports today that GP numbers are showing a sustained drop, Emily Fletcher introduces the ‘GMAP’ project which aims to support the UK’s ambitions to recruit GPs from overseas.

Key points:

  • Across the UK, the number of GPs relative to the size of the population show a sustained drop. GPs are leaving or decreasing their hours in large numbers. Our own survey of GPs indicated that even in South West England, 37% were likely to quit patient care within five years. Some of our work highlights the many reasons for this.
  • The Nuffield Trust reports today that the fall in GPs per person reflects “insufficient numbers previously being trained and going on to join the NHS; more practitioners leaving for early retirement; and failure to recruit enough from abroad”.
  • On the subject of recruiting from abroad, ‘GMAP’ is a research project commissioned by NHS England and the Royal College of General Practitioners in late 2017 to compare the training and experience of overseas GPs to support the UK’s international recruitment ambitions.

International referencing and mapping of UK GP training curricula (GMAP)

Addressing a knowledge and information gap identified by NHS England, and working in collaboration with the Royal College of General Practitioners (RCGP), the GMAP project aimed to develop and pilot a method for mapping GP training and other relevant healthcare system contextual data from an overseas country to the UK, to inform future consideration of streamlined processes for overseas doctors joining the UK GP register.

Professor John Campbell leads the research team, with expert medical education input from Professor Adrian Freeman, international expertise from Dr Emma Pitchforth, project management and data collection overseen by Emily Fletcher and data collection support by Dr Leon Poltawski and Dr Jeffrey Lambert.

Background Over the last six years, the UK has experienced a worsening GP shortage in relation to recruitment and retention. Amongst a number of responses, the UK government and NHS England have sought to develop opportunities for doctors who are suitably qualified as GPs overseas to be attracted to work in the UK. In this context, for doctors outside of the European Economic Area (EEA), there is a need to ensure that their training and experience is appropriate to support them working in UK primary care.

Between the RCGP and the General Medical Council, the ‘Certificate of Eligibility for GP Registration’ (CEGPR) process examines whether doctors have equivalent experience to UK-trained GPs. However, CEGPR is cumbersome, and NHS England commissioned GMAP to develop a method for determining whether a streamlined process for assessing doctors from certain countries was possible.

Method Developing the method involved a number of stages. Our final approach to comparing training and experience of GPs who have trained outside of the UK involved mapping five specific domains: (i) the healthcare context, (ii) the GP training pathway, (iii) the GP curriculum, (iv) Assessment processes, and (v) ongoing continuing professional development and revalidation.

Pilot We published a paper in the BJGP Open in April which outlines the development of the method and its application to a pilot case study site: Australia. We concluded that implementing this systematic method for mapping GP training between countries may support the UK’s ambitions to recruit more GPs and alleviate current GP workforce pressures.

Application Since developing the method, we have gone on to apply the mapping to more countries (South Africa, Canada, and the United States of America) to further support NHS England’s overseas recruitment programme. We are also currently applying the mapping process to GP training in New Zealand.

Mapping these additional countries will inform further considerations of the CEGPR process by the RCGP and GMC as to whether streamlining can be introduced for GPs/family physicians from these countries wishing to enter UK general practice.

My reflections

Whilst GMAP is very different to other research undertaken by our department, it has been hugely interesting and challenging to undertake, and with the added bonus of being of immediate use to NHS England, the RCGP and the GMC. Sadly (for me) no field trips have been required (!) but in writing up the findings for each country I have been fortunate to speak to contacts in each setting who have been generous in giving their time to help refine our interpretations.

Overseas recruitment is hardly the wholesale answer to the UK GP workforce crisis. However, it is important to draw the various strings of our GP workforce research together, and overseas recruitment is one of the many approaches to alleviating the pressure.

Emily Fletcher

Research Fellow

e.fletcher@exeter.ac.uk, @emilyfletcher1

References

  1. Palmer B. Is the number of GPs falling across the UK? Nuffield Trust; 2019. URL: https://www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling-across-the-uk
  2. Baird B, Charles A, Honeyman M, Maguire D, Das P. Understanding pressures in general practice: King’s Fund; 2016.
  3. Fletcher E, Abel GA, Anderson R, Richards SH, Salisbury C, Dean SG, et al. Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners. BMJ Open 2017;7:e015853. http://dx.doi.org/10.1136/bmjopen-2017-015853
  4. Sansom A, Terry R, Fletcher E, Salisbury C, Long L, Richards SH, et al. Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England. BMJ Open 2018;8:e019849. http://dx.doi.org/10.1136/bmjopen-2017-019849
  5. Spooner S, Fletcher E, Anderson C, Campbell JL. The GP workforce pipeline: increasing the flow and plugging the leaks. British Journal of General Practice 2018;68:245. http://dx.doi.org/10.3399/bjgp18X696125
  6. Campbell JL, Fletcher E, Abel G, Anderson R, Chilvers R, Dean SG, et al. Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study. 2019;7:14. http://dx.doi.org/10.3310/hsdr07140
  7. Fletcher E, Sansom A, Pitchforth E, Curnow G, Freeman A, Hawthorne K, et al. Overseas GP recruitment: comparing international GP training with the UK and ensuring that registration standards and patient safety are maintained. BJGP Open 2019; http://dx.doi.org/10.3399/bjgpopen18X101640
  8. NHS England. International GP Recruitment Programme. NHS England. URL: https://www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/international-gp-recruitment/
  9. Fletcher E. Moving into the GP workforce? In: University of Exeter Collaboration for Primary Care (APEx). Exeter; 2019. https://blogs.exeter.ac.uk/apex/blog/2018/10/17/moving-into-the-gp-workforce/

Don’t throw the baby out with the bathwater – asking the right questions when evaluating computerised CBT for depression in primary care

Over a third of all patient visits with a general practitioner are estimated to involve a mental health component, and 90% of these patients are primarily managed in primary

Picture By Jim Wileman – Medical School portraits.

care [1]. Due to this high demand, National Institute of Health and Care Excellence (NICE) guidelines recommend the provision of computerised CBT as an initial lower intensity treatment for depression in primary care [2]. Computerised CBT is more accessible, scalable and cheaper than face-to-face CBT and has the potential to reduce the burden of depression in primary care significantly.

Systematic reviews have confirmed the effectiveness of computerised CBT [3]. However, a randomised controlled trial published in the British Medical Journal in 2015 reported that supported computerised CBT did not improve depression outcomes compared with usual GP care alone [4]. On the back of this, the authors suggested that the routine promotion and commissioning of computerised CBT be reconsidered. I would caution against this for the following reasons:

  • First, it is unlikely that computerised CBT will reduce depression if patients do not adequately use the platform or actively engage with the cognitive and behavioural techniques offline in their day-to-day lives. The median number of online sessions completed by patients in the study by Gilbody et al. ranged from 1–2, and no data were reported concerning offline engagement. Were the negative findings due to an ineffective intervention or the lack of engagement?
  • Second, a large proportion of participants across all arms of the trial were using antidepressants (81%). It is therefore unsurprising that the trial failed to find a positive effect. The argument for computerised CBT is not that is will be more effective than usual care, but that it offers a viable alternative that takes the pressure off general practice and offers patients another treatment option that is less resource intensive.

The issues in the study by Gilbody et al. are by no means unique and are indeed prevalent across the field of computerised interventions for mental health. However, resolving these issues are fundamental to ensure we don’t prematurely reject interventions with the capacity to transform healthcare. As highlighted by the NHS -term plan, harnessing the power of technology and empowering people to take responsibility for managing their own health is vital to meet the increasing demand on healthcare services. This is well within our grasp, but we need to be asking the right questions!

Dr Jeff LambertPostdoctoral Research Associate in Primary Care, UEMS

References

  1. Ferenchick EK, Ramanuj P, Pincus HA. Depression in primary care : part 1 — screening and diagnosis. Br Med J. 2019;
  2. National Institute for Health and Clinical Excellence. Depression in adults: recognition and management. 2018.
  3. Karyotaki E, Riper H, Twisk J, Hoogendoorn A, Kleiboer A, Mira A, et al. Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data. JAMA Psychiatry. 2017;74(4):351–9.
  4. Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, et al. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015; 1–13.

Moving into the GP workforce?

Moving into the GP workforce?

This post is a year late. Mainly, this is due to the many, louder tasks on my Primary Care research to-do list: delivering our final report on the NIHR ReGROUP GP workforce project, writing and submitting further papers from ReGROUP (see below) completing two rapid-fire projects for RCGP on mapping UK and international GP training, attending conferences of the Society for Academic Primary Care (plug: Exeter hosting next year!) and working up two major NIHR funding bids… A busy year.

Nevertheless, the UK’s GP workforce ‘crisis’ has by no means gone away, and here’s some new research findings for you.

Last summer, we surveyed our local GP registrars at the end of their specialty training, as they were ready to move into the workforce. With the help of Health Education England, we surveyed 81 trainees in the South West Peninsula region. Forty five responded (55.5%): 40% male, 60% female, mean age 35.7 years, majority white British and obtained their primary medical qualification from the UK/Ireland:

  • 82.2% (37) intended to move straight into GP-based patient care.
  • 9% (4) intended to take a career break first but then return to GP-based patient care, and one trainee intended to take a career break but ‘may not’ return.
  • A further 6.7% (3) intended to move on to ‘something else’.

Among the 42 intending to, or who may, move into GP work (initial career breaks aside):

  • The majority (28 [66.7%]) planned to work part-time in the long-term, with just 6 (14%) planning to work full-time, and seven (16.7%) who were undecided.
  • Most (32 [76.2%]) had already secured a GP-based clinical post from August 2017. Thirty of these 32 trainees (93.7%) would be working in the South West, and two outside of the UK (one in Europe, the other outside of Europe).
  • Most (34 [81%]) knew what position they would take up: four working as GP partners (9.5%), 18 as salaried GPs (43%), and 12 as locum GPs (28.6%). Three did not know what their role would be and a further five reported an ‘other’ position, including GP retainer and continuing as a GP trainee/registrar.
  • Portfolio working was a popular aim, with many interested in medical education (25 [60%]), three in research (7%), and eight in non-GP clinical work such as sports medicine (19%).
  • Many (24 [57%]) anticipated being involved in delivering out-of-hours care: nine with regular sessions, 15 with occasional sessions.
  • Morale was reported as high or very high by 16 (43%). Twenty reported morale as neither low nor high (47.6%), and four as low (9.5%).
  • A small number already knew that they were likely or very likely to permanently leave GP: three within two years (7%), and four within five years (9%).

It was a small survey and we conducted it a little last minute. But despite taking a year to write about it, the questions remain important to ask.

So, why did we do this? In part, it was because we saw Health Education England publish a similar small survey on the London trainees last summer, and it was also because we are genuinely interested in this. Current GP trainees are the imminent future of the GP workforce, an agenda that we’ve supported with our Exeter research over the last four years.

GPs do a difficult job; they manage a high (rising) and complex workload due to the ageing population and more patients having multimorbidity. Add this to decreased NHS spend on Primary Care and resources for general practice and continually changing care models – GPs are leaving, or decreasing their working hours, in large numbers. Our own survey of South West GPs indicated that 37% were highly likely to quit patient care within five years, a worryingly high figure that is in line with the most recent national figure of 39% from the GP Worklife Survey, and other similar survey findings reported elsewhere in the UK in recent years.

Efforts are focused on both recruitment and retention, across all stages of the workforce ‘pipeline’. Immediate retention of our existing GPs remains essential, and is something we have worked hard to support with our NIHR ReGROUP project. Recruitment to, and growth of, GP training places is equally critical. The government’s target is to recruit 5,000 extra GPs and train over 15,000 GPs by 2020, as well as recruiting 2,000 overseas doctors over the next three years.

It is generally already known what sorts of specialties medical students and graduates want to pursue in their long-term careers: GP is still the most popular first choice, but this is showing a downward trend in recent years compared with other specialties and the percentage of medical graduates preferring GP remains lower than the proportion required to meet workforce needs. We also know about the choices made by Foundation doctors, through the Careers Destination report published by the Foundation Programme. Again, GP specialty training is top of the list and recent growth of training places and record fill rates reported by Health Education England this year after only Round 1 all shows promising progress against government targets.

But why is it important to know what GP registrars plan to do with their careers once they qualify? Surely, they have already been successfully recruited to GP specialty training and have completed the three years of training, spending huge resources gathering the required skills and experience and delivering front-line patient care in general practice?

It matters because we must be alert to the brand new GPs who do not go on to work in a GP job, or who do so on a much reduced basis. And, alarmingly, some of those that qualify are already thinking of permanently leaving GP in the not-distant future. Training a GP all the way from medical school and through specialty training costs just under half a million pounds. If our GP registrars are not moving into the workforce once they qualify, we lose vital and expensive resource.

Something seems to be happening during training. Trainees are being exposed to the issues faced by our current working GPs and that are outlined very clearly in the Wass report. Our (very small and regional) survey adds in a small way to the picture that a percentage of trainees may be lost to the workforce in some way such that growth of training places and recruitment efforts alone will never keep up. Even in the lovely South West where the sun always shines and the surf’s always up.

More work is needed to continue to improve the attractiveness of general practice and address its challenges; progress is being made in some areas but only time will really tell.

With thanks to all of the South West Peninsula GP registrars who completed our last-minute online survey last summer!

, Research Fellow

References from Primary Care Group

  • Campbell J, Calitri R, Sansom A. Retaining the experienced GP workforce in direct patient care (ReGROUP)- final report. Exeter: University of Exeter Medical School; 2015.
  • Campbell JL, Fletcher E, Abel G, Anderson R, Chilvers R, Dean SG, et al. The changing general practitioner workforce: the development of policies and strategies aimed at retaining experienced GPs in direct patient care (ReGROUP) NIHR HSDR 2019 (full ref to be assigned). In: National Institute for Health Research (HS&DR); 2019 (in press, draft available from authors).
  • Fletcher E, Abel GA, Anderson R, Richards SH, Salisbury C, Dean SG, et al. Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners. BMJ Open 2017;7.
  • Sansom A, Terry R, Fletcher E, Salisbury C, Long L, Richards SH, et al. Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England. BMJ Open 2018;8.
  • Spooner S, Fletcher E, Anderson C, Campbell JL. The GP workforce pipeline: increasing the flow and plugging the leaks. British Journal of General Practice 2018;68:245.

 

 

 

 

 

‘We are likely to “throw the baby out with the bathwater”. If we don’t value continuity’ … Reflections from Professor Phil Evans, a GP in the NHS for half its lifetime

Hi, my name is Dr Phil Evans and I have been working in the NHS for exactly half of its lifetime, and well over half of mine! Of the 70 years since the NHS was formed, I have been working for 35 of them as a doctor and I have recently retired as a GP partner after 30 years in the same practice in Exeter. The NHS has given me a wonderfully stimulating and exciting career. In my opinion, general practice really is the jewel in the crown of the NHS but nevertheless is often under-valued, as are the skills and attributes of its hard-working GPs.

The NHS has given me an amazing opportunity to practise what I preach in terms of promoting continuity of care with the same doctor and the ability to get to know patients and their families, sometimes up to four generations of a single family, over a long period of time. The phrase “from cradle to grave” sums up the whole of general practice. The privilege of meeting patients week after week, year after year and trying to address their changing medical, psychological and social concerns is at the heart of what we do. Each consultation is still however a trip from the known into the unknown.

The partnership model in NHS general practice has allowed me, as a GP partner, not just to see patients but to run our own practice as an organisation that provides high quality medical care in a way that we wished. We could invest in our practice to value patients, promote patient-centred care, but also promote the other attributes that are close to my heart, teaching and research.

The NHS has given me the opportunity to undertake my own research and gain a higher degree in the process, working in our practice to answer important research questions. More recently I have been fortunate to work with other researchers in universities and across the NHS in my national role in the Clinical Research Network (CRN) to promote research and embed research in everyday practice. The CRN is an integral part of the NHS and runs research studies across all parts of the NHS, including general practices. Other countries are very envious of the NHS and its research!

The traditional model of GP working which I have so much appreciated is threatened in the NHS changes when “bigger is better” as far as practices are concerned and there is an emphasis on speed of access rather than developing deeper relationships with patients. We are, in my opinion likely to “throw the baby out with the bathwater” if we don’t value continuity and all its proven advantages – many of which I have experienced as a doctor. We must find ways in the NHS to value continuity, firstly by measuring it, then promoting and incentivising it.

So having worked in the NHS for half of its life it has been a privilege, but I worry that the things I value as GP are now threatened as the NHS moves into its next decade.


Associate Professor in General Practice & Primary Care

‘The “front door” is not always as open as we would like….’ Reflections on the NHS at 70 from Dr Jo Butterworth, GP and doctoral research fellow

What the NHS means to me
As a GP in the NHS, I feel proud to be part of one of the largest and most impressive work forces in the world, particularly when its aim is to provide good quality healthcare for all patients in the UK, regardless of their wealth. I am also a user of this service that covers everything; from routine health screening, to antenatal checks, emergency healthcare, management of long-term conditions and end-of-life care. As one of over a million patients accessing NHS care in a 36 hour period, I felt safe and provided for; as a new mother on a hospital ward, and later at home with my community midwife.

In addition, I contribute to primary care research and to education within the NHS. Along with over 200 academic GPs in the UK, I aim to provide guidance, through research and evidence, for the future development and organisation of the UK health service. I teach, and I promote lifelong learning, to ensure a competent and confident workforce; from the medical student, to the junior doctor, to the fully-fledged GP.

What is the role of primary care within the NHS?
Primary care is known as the “front door” of the NHS as it is the first point of contact for most NHS patients. It is delivered by GPs, dentists, pharmacists, optometrists, NHS walk-in centres and the NHS 111 phone service. A whopping three hundred million consultations take place in General Practice each year. Whilst patients are generally satisfied with the care that they receive, it is often difficult to access a GP. The “front door” is not always as open as we would like.

What has changed in primary care in my career?
I qualified as a doctor in 2007 and completed my GP training in 2013. Over the last ten years I have witnessed significant restructuring of the NHS and ongoing reform of primary care services. Of note to me as a newly qualified GP, clinical commissioning groups replaced primary care trusts, with the aim of enabling clinicians to lead on the planning and commissioning of healthcare services for their local area. Many GP practices are merging with the aim of sharing knowledge and resources. However, funding for hospital services has been increasing at twice the rate of funding for general practice services and we are seeing more and more privatisation of health services. NHS staff have become demoralised; junior doctors are leaving to work abroad, senior doctors are taking early retirement and we are currently in the midst of a GP workforce crisis.

What needs to change in the future?
As the population grows, so too will the number of older patients with multiple health problems and these patients are known to consult frequently. This will put incredible strain on the NHS and we will need to be financially ready to cope with it. Patients and their carers should be involved in making decisions about their healthcare and the services that are commissioned. Healthcare needs to be patient-centred and individualised. We need to seek ways to enable continuity of care with the same healthcare practitioner and longer consultations for our most vulnerable patients.

In order to increase positivity amongst the GP workforce the workload needs to be made more manageable. However, consideration should be given to the wellbeing of GPs, and that of other healthcare practitioners, when restructuring and delivering new health services for patients.

We need to encourage more medical students, along with nursing, pharmacy, physiotherapy and occupational therapy students, into careers in primary care. We need to use their skill-sets flexibly, and in a close-knit multidisciplinary unit, to provide high quality but cost-effective healthcare. We should give undergraduates the skills to manage the uncertainties that they will inevitably face once qualified, and encourage them to become health service pioneers and leaders. We should invite them to problem-solve, look beyond guidelines and question evidence, to work cohesively with their colleagues in secondary care, and to embrace the challenge that is the future of the NHS.

The NHS at 80?
Let’s make sure it’s still here!