Editor Jaimie Kaffash on the dangers of opening up general practice to any doctors
The biggest issue in general practice this year has been, without a shadow of a doubt, the role of the physician associate. As I said before, I’ve rarely seen such debate and anger on a single issue.
But – to poorly paraphrase GPC England chair Dr Katie Bramall-Stainer – the toxicity around this debate will look tame compared with what we may be seeing in the near future.
According to the GPCE chair, a recent change to the performers list may have serious repercussions for the profession with a move to ‘primary care doctors’ joining general practice. In April, NHS England made permanent the Covid regulations that stated that doctors do not need to be on the GP register in order to work in general practice. This was a change made in a bid to allow staff and associate specialist (SAS) doctors to join general practice – a move that has been promoted by both the GMC and NHS England.
I’m not going to get into the rights and wrongs of the SAS scheme. I can understand the reasoning behind it, but I can also understand the problems with it.
But more importantly, I feel as though this might be a Trojan Horse. Because if we open up general practice to any doctors, we may well open up the Wild West (if you can ignore the mixed metaphors).
Basically, anyone with a medical degree and foundation training – or the equivalent – would be eligible to work in general practice as a ‘primary care doctor’. Dr Bramall-Stainer laid out what this could mean: doctors finishing foundation training; doctors out of programme for clinical experience; internationally-qualified GPs; international doctors who are not qualified GPs; doctors who have failed MRCGP; SAS doctors; or consultant doctors.
Now, doctors within each of these groups have skills that would benefit general practice. But, crucially, they have not gone through UK GP specialist training. And by having a number of doctors who have not gone through GP specialist training working in general practice, we risk diluting what a GP is.
GPs possess skills that no other doctor has. When we ran our ‘Building a Better General Practice’ campaign in 2021, we tried to nail down the essence of general practice. GPs are the specialists when it comes to undifferentiated illnesses – which comprises the vast majority of activity in the NHS. They are the patient’s advocate. They are the experts when it comes to management of long-term conditions.
Sadly, many of these skills are being worn down – or at least not being fully utilised – thanks to the pressures in general practice. These pressures have already destroyed continuity of care.
But we can’t allow them to be worn down any further. And by adding all these other doctor groups to the mix, I fear that is what will happen. Because if you think there is currently confusion among patients around what a PA is, wait until they are seen by someone who has been through only foundation training but has the title ‘Dr’.
This might be paranoia. It might be that the various authorities are not looking to bring other doctors into general practice (although Dr Bramall-Stainer did refer to a number of ongoing pilots that are looking to introduce these ‘primary care doctors). Or, it might be that if general practice does incorporate these doctors, it will be with very specific, well-defined responsibilities that match their skillsets and training.
But the introduction of PAs doesn’t fill me with much hope. In an environment where practices are underfunded, the temptation to hire less- or differently-qualified doctors at lower costs to perform GP tasks may be too much. It will simply lead to the continued slow deterioration of general practice.
We can’t let go of what being a GP means. So we must all keep an eye on these plans for ‘primary care doctors’ – because the last thing we want to see is doctors turning on each other.
Jaimie Kaffash is editor of Pulse. Follow him on X (formerly Twitter) @jkaffash or email him at editor@pulsetoday.co.uk
What is the point of the MRCGP, if anyone with a medical degree can work in Primary Care?
It is up to the Partners to politely decline employing these doctors over fully-qualified GPs, whatever the “cost savings”, just as they didn’t when it came to PAs!
I disagree with the GPC stance and wonder whether they have political motives. Of course, the details of this move will be important but the concept is no different to general practice up to around 1980 when medical graduates could straightaway become a GP and learnt on the job. (In fact, when I was a GP trainee in the 90s, one of my older GP trainers, a lovely chap from whom I learnt the lifetime art, simple but also difficult, of skilfully just listening, had gone straight into general practice after graduating).
It’s only in the 80s they introduced 3 year programmes and the JCPTGP (which I got), and later MRCGP/CCT.
GPs are not born into the unique emergent nature of general practice in which they become a “specialist” but are made by the years of practice which over time (ie not from books) teach them how to become an excellent GP, learning from doing and from patients and colleagues, from making mistakes, from hospital letters feedback etc. A GP is not about “being” but “becoming” which is a life time’s work.
I have no problem with doctor graduates, say SAS Dr or post-FY2, coming into general practice and beginning to learn the specialist emergent nature of GPs work – they’ll be gobsmacked at how uniquely difficult a GPs job is. Appropriately funded, this could be a quick fix for the crisis in GP numbers.
Is it a reciprocal arrangement? I’d quite like to expand my portfolio and do some gastro or ortho work.
I fear it’s too late. Without a VERY focused policy to reverse the process (which is already well underway), the river will be difficult to stop and as good as impossible to reverse. Your GP is going and you wont see their return. We can thank Jeremy Hunt. This is his legacy.
By the way, if anything’s threatened the GP role over the last decade, aside from the Govt itself, I’d say it’s the clueless BMA/GPC representation we’ve had. A special interest/special register grouping many times at odds with the founding principles of the NHS…
I cannot imagine the RCGP would be happy to lose all the income from the MRCGP exam and membership fees!
And hospitals stand to lose their captive GPVTS trainees doing service jobs in SHO posts.
And could people with a JCPTGP or MRCGP reclaim costs of doing those ‘compulsory’ expenses and service posts, if they become uncompulsory?
Hmm .. I’m in the not sure I agree camp. I always felt one of the huge benefits of General Practice is that there is a role for everybody.
I started out as a surgical trainee and after getting sidelined by modernising medical careers in the early 2000’s took an an SAS role in ENT with a 15 year side interest in Emergency Medicine. This became a dead end so initially with the intent of working in ENT in the community I retrained as a GP – did my 2.5 years extra and MRCGP.
Community ENT never flew and tired of working under managers I have freelanced for the last 15 years.
My ENT background has been frequently utilised in surgeries and I am the first to say I am no expert 1n classic chronic disease management but have colleagues who are so I use their experience . I do however have many other skills and work in UTC/WIC /OOH /Prisons/Asylum seekers/Homeless Healthcare/Admission avoidance/rehab wards/ community inpatient wards/GP in ED services all of which are primary care and I agree with one of the above that i have learned a lot of my trade on the job not because I passed MRCGP – my residential GP registrar course involved building sandcastles and holding hands!!
I know many highly qualified GP’s who I would suggest are not that great and I think I am proof that SAS doctors can easily blend into the GP role and often add to it with our prior training, skills and knowledge.
So we can have a more old fashioned GP structure and nomenclature…
Those who are LEARNING HOW TO BE A GP
– Student GP (based at uni/medical school, doing a medical degree, not a qualified medic, on an attachment in general practice being taught)
– Student Apprentice GP (linked to a uni/medical school, doing a medical degree as an apprenticeship, otherwise as above)
– GP Trainee (qualified doctor at FY1 / FY2 or ST 1-3 level training to become an expert generalist aka GP)
ACTUAL (QUALIFIED) GPs
– GP (newly qualified GP with CST in GP / MRCGP, still finding their feet in independent practice eg first 5 years (pro rata, if you are like me and had 2x 6 months maternity leave and some years of part time family friendly working, 5 years worth of GP experience might take 10 years of time)
– Consultant GP (Feet definitely under the table, competent, experienced, starting to providing support to non-GP colleagues, perhaps also teaching students & VTS GPs, or developing GPwSI roles)
– Senior Consultant GP (Still in the game after 15 years or more – full of experiential wisdom, supporting the whole practice or hub team, majoring on providing continuity of care, expertise and advice both in specific GP fields, and for patients with the most complex needs/co-morbidities)
PRIMARY CARE DOCTORS (PCDs) who would NOT be “GP”s because they haven’t had specialist training to BE a GP
Affiliated to practices or, possibly more likely given the way the NHS is going, working in primary care same day hubs…
They might include those who have completed FY1&2 but can’t get onto a GP VTS – we could call them
“Apprentice” GPs – they would need supervision at a similar level to VTS GPs though their working patterns might be different
They could be doctors with Primary Care experience elsewhere ie not in the UK so no GP qualification as such
They might be SAS doctors (or Hospital Consultants) who want to spend some time in a primary care/community role – so a PCD with special interest in… (PCDwSI)
I would be worried to see GPs who have failed MRCGP/GP exit exams coming into general practice to work independently – they either need further support to overcome whatever the hurdles are that have made them fail, or they need support to work out where in medicine they would be better suited.
Would we want Surgeons who have failed MRCS doing solo operations without back up ?
Would we want Hospital Medics who have failed MRCP being the duty consultant in A&E, or on the Same Day Emergency Care unit, or working in clinic as if they were consultants but without their knowledge or expertise and without support or oversight ???
GPs are already looked down upon by Hospital doctors often because of the old fashioned belief that anyone , including those who have failed in other specialties can become a GP
This plan will exacerbate this belief and has the danger of lowering standards in General Practice
Penny, above. Nicely structure and rational. However I think patients are blind to all this. They still confuse one of my lady colleagues as a nurse, despite being a “senior” GP. Our NP is often referred by patients as a doctor. They still think they were seen at home by a GP instead of a Specialist Paramedic, and they STILL sometimes think our local Chiropractor is a medic. This is an entirely internal discussion for the profession. Our patients won’t get it. This, despite all my clinical staff being at pains to declare their role explicitly, obviously. Can’t speak for the Chiro of course…