The general practice training capacity timebomb

Pulse’s series has looked at the issues surrounding general practice workforce. Now we take a look at the what is being done about this – first, in terms of the training pipeline. But, as Jaimie Kaffash reports, there are real concerns around capacity

Training new GPs has understandably been seen as the priority when it comes to solving long-term workforce problems in England. This is probably the one area of workforce planning that could be considered a success. Health Education England – which has now been incorporated into NHS England – has been able to meet its target of 4,000 new GP trainees a year.

Number of graduates taking GP training positions

The NHS Workforce Report, launched under the previous government in 2023, made some bold commitments to increase this. It set goals to: increase GP specialty training places to 6,000 by 2031; ensure all Foundation Year doctors do a rotation in general practice; and require GP registrars to spend the full three years in general practice.

But Pulse revealed at the time that this would require training capacity for GPs to be doubled within five years, and a trebled within a decade (see below). Since we modelled this chart, there have been a number of developments that will place more pressure on training capacity. There are more ambitious plans around the training of GPs; medical students are spending more time in general practice; and there are requirements for the training of other healthcare professionals, including those that are part of the additional roles reimbursement scheme. But it also seems as though there have been little developments in increasing capacity.

Increased ambitions for GP training

The 2023 workforce report set challenging – if necessary – targets. At the time, and in response to Pulse’s modelling, GP leaders expressed concerns around capacity.

RCGP chair Professor Kamila Hawthorne said: ‘It goes without saying that alongside an increase in GP trainees, spending longer in general practice, must come sufficient resource and protected time for GP trainers… GP trainers are currently faced with unmanageable demand – with both trainees and qualified GPs stretched beyond safe limits.’

GP spokesperson for the Doctors’ Association UK (DAUK) and former GP trainer Dr Steve Taylor said that while the pledges to increase training are ‘massively good news’, training capacity will be a ‘big challenge’. Of his own practice, he said they ‘certainly haven’t got room here to take any more [trainees]’ and suggests this is likely true of most practices.

Total months spent in general practice by medical students and trainees across England

Yet it looks as though the ambitions will be intensified. Health secretary Wes Streeting’s plans to revise the NHS workforce report will have ‘a laser focus on shifting care from hospitals and into the community’. According to the announcement from the Department of Health and Social Care: ‘The original workforce plan would increase hospital consultants by 49%, but the equivalent rise in fully qualified GPs would have been just 4% between 2021 to 2022 and 2036 to 2037.’

UK medical students

There are no official figures about how much time medical students spend in general practice, but a 2020 study suggested a median average of 108 sessions across their degree. One of the study’s authors, Professor Hugh Alberti, Professor of general practice education at Newcastle University, says this figure will ‘no doubt’ be higher now: ‘Many traditional schools, like Newcastle, have increased our GP time since then and all the new schools have higher proportions.’

Much of this does depend on the medical school. Only 13% and 14% of Oxford and Cambridge graduates respectively go into general practice, compared with 34% and 32% of graduates from University of London (excluding UCL, King’s and Imperial) and Leicester, respectively. There have been several initiatives to redress this, including new medical schools that focus on general practice and financial incentives for universities.

The NHS workforce report planned to double the number of medical school places, which will likely see more demand from medical students for placements in general practice.

This comes as a time when the UK is relying far more heavily on international medical graduates (IMGs). In 2023, for the first time, international medical graduates outnumbered UK graduates among GP trainees.

Percentage of GP trainees who are international medical graduates

There is a question as to whether it matters that the majority of GP trainees are IMGs. RCGP chair Professor Kamila Hawthorne says the college has been campaigning to make it easier for IMGs to remain in the NHS as they are currently having to ‘jump through hoops’ in terms of visa requirements. However, she adds: ‘We should not be reliant on doctors from overseas to ensure we have sufficient workforce – we also need to make significant efforts to train more GPs in this country and then retain them.’

Dr Katie Bramall-Stainer, BMA GPC UK chairs adds that there must be jobs for these graduates to go to: ‘Many IMGs that are able to stay on work in areas that are difficult to recruit for and provide much needed care to patients in deprived areas.

‘With so many IMGs, their visa requirements are based on them having employment, and the current workforce crisis and lack of practice funding means there aren't any roles for them to go post-qualification. It's incredibly wasteful to train these doctors just for them to potentially have to leave the country.

‘The Government should be doing everything possible to encourage IMGs who have trained in the UK to remain and continue working in the UK. Potential positive measures that should in fact be taken include removing barriers imposed by the previous government, such as restrictions on adult dependent relative visas.’

Other professions

This all comes at a time when there is a push to train more staff across general practice. The additional roles reimbursement scheme (ARRS) has exacerbated this, as have other developments in regulations. But capacity is currently limited, and it has meant that some are struggling to get the training they need - especially practice nurses.

Practice nurse training

There is no requirement for trainee nurses to spend any time in general practice, even if they intend to pursue a career in the sector. The NHS workforce plan included measures to increase nurse training places from 30,000 a year in 2022 to 40,000 a year by 2028/29, and 53,500 by 2031/32, with an emphasis on community nursing. But this doesn’t seem to be in general practice, with an emphasis on health visitors and little mention of practice nurses.

Our sister title Nursing in Practice has reported extensively on the low morale being faced by practice nurses, with many are looking to retire in the near future. But there doesn't seem to be a training pipeline. The number of nurses trained in GP practices has been static for the past seven years – just under 200 a year.

One of the main problems is there is little incentive to train them: from the universities’ point of view, there is no obligation for nurses to spend time in general practice so it is far easier for them to place nurses in secondary care, which has the infrastructure to take on hundreds of students rather than the one or two that a GP practice can accommodate; from practices’ point of view; the clinical tariff a trainee nurse attracts is £5,519 – or around £150 a week, for what would be a two-week placement.

Asha Parmar, an ANP in North Central London, says: ‘I’ve been trying to get a GP nurse trainee for two years across two practices and have had push back on renumeration of the nurse and lack of space with little room for flexibility on working patterns.’ In the battle for training capacity, nurses seem a low priority.

Pharmacist training

In December 2024, regulations were changed to allow GP practices to act as the employer for trainee pharmacists. Practices are to be given a training grant of £26,500 a year from 2025/26 to employ trainee pharmacists in their one-year foundation programme.

From this year, all pharmacists who qualify this year will be required to have prescribing skills, which will involve 90 hours of training from a prescriber. They are far less likely to get this training in community pharmacy, meaning there will be more demand for training within general practice.

It is not yet clear what the arrangements will be for this. It could mean more trainee pharmacists being employed by practices. Unlike trainee GPs, whose salaries are covered by NHS England on top of a training grant, trainee pharmacists will be on the open jobs market. Primary Care Pharmacy Association president Graham Stretch says this could be attractive for GPs as pharmacists can start consulting one-to-one with patients within about four months.

Nursing associate training

There are currently more than 650 nurse associate trainees in general practice. Their role involves clinical tasks including venepuncture and ECGs, taking blood pressure, temperature, respirations and pulse rate, and supporting patients who receive bad news, for example. Nursing associates need a foundation degree, typically taken over two years, which usually takes the form of an apprenticeship. The entry requirements for the degree are pass marks in maths and English GCSE or equivalent.

PCNs and practices receive funding to employ these trainees – a training grant worth £4,000 a year (£8,000 for the two-year course), or £7,900 a year if more than 50% of their time is spent with patients with autism or learning disabilities. On top of this, their salaries are funded through the ARRS.

The aim of the role is partly to ‘allow nurses to concentrate on more intricate clinical tasks’. But as one nurse training co-ordinator put it: ‘Many practice nurses feel under pressure to train our replacements.’

Physician associate training

Again, there is again no requirement to spend time training in general practice. However, they must do 1,600 hours of clinical training, including 350 in general hospital medicine. But practices and PCNs are heavily incentivised on a local basis to take on training for PAs. For example, in the Greater Manchester Training Hub, they are offered £555 a week to take on a PA, compared with just £130.96 per week for a nurse.

Paramedics and physiotherapy training

There are currently no requirements for paramedics or physiotherapists to do pre-qualification training in general practice. But the professional bodies of both are expecting an increase in demand. A Chartered Society of Physiotherapy (CSP) spokesperson says: ‘To achieve CSP accreditation, students and apprentices are required to complete 1,000 hours of practice-based learning as part of their degree programme. Practice-based learning must be organised to reflect the increasing presence of physiotherapy services in primary care and community settings.’ Meanwhile, the Health and Care Professions Council says: ‘We consider it best practice that pre-registration paramedic programmes include non-ambulance practice-based learning.’

Few developments in increasing capacity

Despite all these professions vying for training resources in general practice, there is little sign that anything has been done to increase capacity since the 2023 workforce plan. The plan itself admitted ‘the number, spread and quality of clinical placements is a concern across healthcare education and training’ and that growth in placements ‘has been challenging for several years’. Yet the solution was underwhelming: ‘We will work with stakeholders, informed by the issues we identified through a discovery exercise in 2022/23, to ensure clinical placements are designed into health and care services, and placement providers know what core standards they need to meet.’

It included an ‘Educator Workforce Strategy’, which was a number of vague principles such as factoring capacity into plans, supporting development, protecting time etc. Details were due to be made clear this month.

In the meantime, deaneries have also been tasked by NHS England with developing plans to increase training capacity. 

We asked the seven deaneries across England what they were doing to address capacity issues. There were a few common strands. All the deaneries who answered pointed to the Blended Learning Programme, which involves trainees combining technological and digital approaches to learning with practice-based training. In its report on blended learning. They also pointed to their accreditation of practices and PCNs as Unified Learning Environments (ULEs), enabling them to take on medical students or trainee doctors and healthcare professionals in a more streamlined fashion.

But practices and PCNs are still having to prioritise, given the limited capacity. There is only so much physical space for each staffing group. Trainees may not always require their own space, but they certainly will if they are to contribute to service delivery and patient care alongside their training placements.

A key problem is the number of trainers and their available time. According to the GMC, there are 7,940 GP trainers in England, but they can’t specify how many are providing training. One potential positive is that current trainers seem quite happy in their role. Of the 830 GPs who responded to Pulse’s September survey, 23% were trainers and 16% were considering becoming a trainer. It found that the average age of trainers was 49, compared with 52 for non-trainers, while the average age of those considering becoming a trainer was 45. Meanwhile, the average time they wanted to remain as a trainer was seven years.

But the fact remains that capacity needs to be increased, both in terms of training numbers needed and the physical space – especially if the Government is serious about ‘moving care from hospital to the community’. Mr Streeting’s revised workforce plan has much riding on it. 

To download the full Cogora report, which includes all the data and the methodology, click here