Guiding principals — general practice and career choices

Like all specialties general practice waxes and wanes in popularity. In the 1980s, soon after mandatory vocational training for general practice was introduced, it was a very popular specialty only to decline in the 1990s. The advent of the 1990 contract for general practice was not well received by the profession and medical students learning in general practice frequently encountered GPs reluctantly striving to meet immunisation and cervical cytology targets.

At about the same time the ‘Calman reforms’ for specialist training were introduced, promising shortened training together with an expansion of the specialist workforce. The result was increased recruitment into most hospital specialties and a decline in the popularity of general practice training, so that by 1995 only 18% of a graduate cohort study group had decided on a career in general practice.¹

During the last decade considerable effort has been made to improve the quality of community-based learning for undergraduates and this, together with the realisation that general practice offered better career prospects compared to many hospital specialties, resulted in an increase to 33% from the same group of graduates deciding on a career in general practice by 2004.¹

The importance of strong general practice is recognised in the new White Paper: Our health, our care, our say: a new direction for community services',² in which it is envisioned that more patients will receive care outside the traditional hospital settings and that GPs with a special interest (GPwSI) will be accredited for their specific skills. Whether this aspiration becomes a reality or remains a ‘fairytale’³ will depend very much on general practice attracting able young doctors who are motivated to deliver high quality patient care.

Modernising Medical Careers⁴ is an ambitious plan to deliver more effective postgraduate medical education, moving from a system of accreditation on the basis of time served to one of structured programmes and assessed competencies. All doctors graduating in the UK will spend the first 2 years after graduation in structured foundation training programmes and from there enter a period of specialist or general practice training. General practice has developed a new curriculum for the modernised training programme, together with an assessment strategy to determine a series of competencies prior to accreditation as a fully-fledged GP.

The first cohort of doctors (other than those already involved in widespread pilot studies) began their foundation programme in August 2005. New funding has been identified to create opportunities for 55% of the 2005 cohort and 80% of the 2006 cohort to spend 4 months training in general practice during their second year. We are therefore on the brink of realising a long-standing ambition for all doctors to experience a period of postgraduate training in general practice. However, already suggestions are being made that the training opportunities should be transferred to meet the increased pressure in emergency departments.⁵

One of the essential planks of Modernising Medical Careers is a more structured approach to training programmes with less time spent in posts that are unlikely to contribute towards the certificate of completion of training (CCT) and clear entry points to all programmes. This will need expert careers information and advice so that young doctors enter a programme that will equip them to work in a specialty which will suit their aspirations and ability. Young doctors will have new opportunities to understand their preferred working environments, enabling them to make more informed career choices.

Modernising Medical Careers has opened new opportunities for GPs to take a more active role in the development of all doctors; general practice educators are beginning to work more closely with their hospital colleagues to deliver the foundation curriculum. We can therefore open new vistas on the potential opportunities that the White Paper and changing patterns of healthcare delivery will offer and the role that high quality general practice will play. As the role of the GPwSI increases, hospital-based specialists are likely to become more specialised, managing acutely ill patients or providing expertise for patients with chronic disease that fall outside the capabilities of the GPwSI.

The study from Yorkshire⁶ has identified a significant group of future GPs who do not aspire to become principals and who are not enthused by administrative tasks. Their preference at this stage of their careers is to focus on providing high quality clinical care with slightly more interest in developing a teaching role than become a GPwSI.

These findings mirror a study of young principals, undertaken a decade ago where considerable anxiety was expressed by the doctors about their lack of ability to manage the practice and cope with complex clinical problems.⁷ As more patient care moves to the community there will be an increasing need for effective teachers with a strong clinical background, thus it is important that the profession recognises the preferences of this group of new GPs and includes them in the plans for the future delivery of health care and medical education.

However, general practice has always excelled at organisational development. The characteristics of the ‘small business’ and the potential to achieve change rapidly, painlessly and without bureaucracy has attracted some of the most able doctors into general practice. We should not lose the opportunity to ensure that these aspects are presented in a positive light and we must continue to develop strategies for leadership skills development in trainees and young principals.

General practice is well placed to promote itself as an exciting and interesting career within medicine, offering opportunities for clinical medicine, specialist general practice, teaching and management. The North Western Deanery has coordinated experience for school leavers considering a career in medicine,⁸ allowing them to work in a practice without the risk of them encountering friends or family from the local community.

We also have much greater opportunities to present the positive aspects of general practice to medical students while teaching them about clinical care. Foundation training brings new openings, allowing us to explain and enthuse about general practice to those who intend a lifetime in hospital practice, so that any hidden curriculum⁹ encountered later in their training is minimised. However, this may not be sufficient.

All deaneries have been allocated funding to develop initiatives in careers management for foundation training. General practice needs to communicate balanced messages on recruitment and appointment ratios and what might be expected from a career in general practice now and in 10 years' time. It is also important that GPs are actively involved in local careers activities so that foundation trainees who are contemplating a career in general practice can gain appropriate advice within their foundation programme.

As to the future, maybe GPs will be best placed to advise hospital practitioners who are considering developing a special interest in working in the community.