Introduction

The world is changing at unprecedented rates and the general practice model needs to change, just as it always has. Our future GPs must be equipped with the right skills and resources to meet the ever-shifting needs of their patients. They must also be provided with a vision for a fulfilling and rewarding career in general practice.

General practice is the bedrock of the National Health Service, with more than 90 per cent of NHS contacts taking place within primary care. General practice in the United Kingdom is internationally renowned, and the UK model of GP Specialty Training (GPST) is seen as an exemplar by many countries seeking to develop a primary care-based healthcare system.

This report seeks to revitalise GP training by outlining a vision of GPST that is fit for purpose and for a future of sustainable general practice careers, ready to best deliver the established curriculum through quality GP training programmes and placements, delivered within available capacity. This reform programme is the product of evidence review, piloting, engagement and reflective review between December 2019 and December 2022.

The most recent significant change to the delivery of GP training came in 2007, with the recognition of general practice as a specialty and GPST programmes replacing Vocational Training Schemes (VTS). The balance of time in practice increased to 18 months of the 36-month training, and the membership examination of the Royal College of General Practitioners (RCGP) became the mandatory standard assessment.

When Health Education England was formed in 2013, recruitment to GPST was challenging, with some areas of the country struggling to appoint any trainees. Since then, a series of innovations have led to an increase in the number of doctors accepting training places to become GPs – from 2,671 in 2014 to 4,000 in 2021 – with all programmes now full. The scale and pace of this expansion has been quite unique.

Health Education England (HEE) has done much to transform the future general practice workforce over the last decade, including the establishment of an independent Primary Care Workforce Commission (Primary Care Workforce Commission, 2015), which set out a vision for the primary care workforce and called for greater collaboration across organisations. That vision is now a reality.

The number of UK graduates going into general practice by choice is set to increase following the commission of By choice – not by chance (Health Education England, 2016), jointly published with the Medical Schools Council, and the expansion of English medical schools. In addition, many excellent international medical graduates are recognising the diverse opportunities available in GP careers. A cohort of additional English medical school students will graduate from the foundation programme in 2025, representing a key opportunity to expand the GP workforce further, which must not be missed.

Alas, all is not rosy. The number of GPs qualifying and entering practice is counterbalanced by the number of established GPs reducing their working week or leaving the profession, with many finding the workload and work intensity unsustainable. This reality provides a moral driver for this reform work: it is vital that doctors joining and training in general practice can see lived examples of rewarding and sustainable careers.

Public and patient satisfaction has fallen, perhaps inevitably with the workforce failing to keep pace with increasing demand. Although satisfaction remains high, this barometer movement should be seen as a storm warning. Descriptions of this emerging situation as general practice being broken are taking a further toll on the morale of GPs, and it is vital that these challenges are addressed to support care for those we serve and to ensure a sufficient and sustainable workforce.

HEE has been funded to combine the expansion of GPST programme numbers with a move to 24 months in general practice during that training. This provides an ideal opportunity to ensure that general practice training is based in general practice, where trainees can learn about general practice, and serve the citizens and patients that general practice best serves, both as individuals and as populations.

GPST is built around the Royal College of General Practitioners (RCGP) curriculum, which is approved by the General Medical Council (GMC) and delivered to its standards. While the RCGP curriculum is UK-wide, and the Certificate of Completion of Training (CCT) transferable across nations, there is increasing recognition of the importance of local contextual learning, regional variations in need, and the different models of supervision available. Additionally, postgraduate doctors in GP training (GP DiTs) report increasing desire to be part of, give value to, and feel valued by the communities they serve.

There is an opportunity to move to a more flexible model of training that meets the needs, skills and experiences of the trainee, as well as the needs and nuances of local populations.

Principles

The principles of this reform work are:

• the development of an adaptable future primary care workforce;
• a place-based approach to educational governance, quality and faculty development, and alignment and integration with local models of care;
• opportunities crafted around the individual needs of the trainee.

These principles would be supported by:

• increased emphasis on the core capabilities of ‘being a GP’,
• enhanced skills in digital technologies,
• leadership development,
• meaningful quality-improvement activity and skills development,
• more use of credentialing post-CCT for specialised areas of primary care.

Surveys of GP DiTs exiting training showed that doctors are seeking portfolio careers and wish to work flexibly (Dale, et al., 2017), and that an increasing number of GP trainees are seeking less-than-full-time working (Kings Fund, 2022). Current trainees have called for a programme that provides targeted experiences more relevant to their future roles than currently afforded by a fixed ‘time’ spent in varying medical specialties.

General practice is recognised and valued as a team comprised of many administrative, clinical and managerial colleagues. This reform programme is about future GPs and current specialty trainees, so the focus will necessarily be medical. However, it is in the context of the excellence of the expanding interdisciplinary team in and around practice and primary care networks (PCNs), and the opportunities of integrated care systems (boards and partnerships), not least as outlined in the Fuller Stocktake report (Fuller, 2022).

Furthermore, these reforms are in the context of the ongoing COVID-19 pandemic and its effect on services, care, the workforce and society, and are informed by the development of key drivers including the refreshed HEE Strategic Framework (Health Education England, 2017), the Long-Term Workforce Plan (not yet published), the refresh of the NHS Long Term Plan (NHS, January 2019), and the Messenger Review (Messenger, 2022).

GPST is consistently the most highly rated specialty training programme in the GMC National Trainee Survey. However, newly qualified GPs are less likely to enter partnership and are seeking reduced sessional commitment. While the evidence is that this is due to the intensity of work in general practice in its many guises (Kings Fund, 2022), the GPST reform programme is intended to ensure that the graduates of GPST are best prepared for future service and for varied and sustainable careers.

Process

During the reflective review process, priority areas were identified and workstreams established based upon them. Each workstream, chaired by a senior GP educator, engaged key stakeholders and brought together experts including patients, trainees, educators and providers. The work of these groups included literature reviews, SWOT analyses and theme-specific engagement.

HEE local teams created place-based pilots to test educational models. Some case studies of these pilots are appended to this report. These examples inform the content of the reform discussion and provide key evidence.

Crucially, stakeholders of all types were consulted and engaged with throughout the process, internally and externally, locally and nationally. All priority leads conducted virtual engagement sessions focusing on the workstream areas. These groups were diverse and independent in thought and included GP trainers, GP DiTs, newly qualified GPs and those in later stages of their careers. Through listening exercises, ideas for improvements began to form and existing work was shared that has already changed the way GP training is delivered.

With the demands of COVID-19 taking priority, it was a year after the virtual engagement sessions that a large-scale, face-to-face engagement event was held in London. This rejuvenated the thinking and ideas were able to be tested with a wide range of stakeholders at local level as part of an iterative engagement process. We thank them for their excitement and interest in this work and as such have listed as many as possible in the acknowledgements at the end of this report.

Throughout this report, we refer to postgraduate doctors in GP training as GP DiTs, adopting the terminology most commonly used among those trainees we engaged with.