The Wass report: moving forward 3 years on

GENERAL PRACTICE RECRUITMENT: POLITICAL DRIVERS AND THE ROLE OF MEDICAL SCHOOLS

The UK healthcare system is delivered with primary care at its heart, but despite this auspicious role in the NHS, recruitment and retention into the general practice profession in the last decade has been difficult. There are strong policy drivers to facilitate recruitment into general practice: Health Education England (HEE) have mandated that 50% of all new medical graduates enter general practice;¹ the new General Medical Council’s Outcomes for Graduates has provided additional primary care and population health requirements;² and league tables revealing which medical schools are ‘the best’ in recruiting their graduates to the GP profession are now published.³

However, despite this political noise, there is still a recruitment and retention crisis in the profession, with 39% of GPs indicating a high likelihood of leaving direct patient care in the next 5 years, with this rising to 62% in GPs aged >50 years.⁴ This is on a wider background of retention challenges in the profession generally, with only 47% of newly qualified doctors exiting the Foundation Programme entering any kind of speciality training.³

In 2016, a critical moment arose where HEE and the Medical Schools Council supported a collaborative task force to expose and explore the role medical schools should have in addressing the crisis in the profession. The By Choice not Chance report chaired by Professor Val Wass, now widely referred to as the ‘ Wass report’, published a series of recommendations giving medical schools guidance and strategies to enable recruitment of their graduates into general practice.⁵ This report arose from discussions with a series of educators: the British Medical Association; the RCGP; the Society for Academic Primary Care; trainees; undergraduate Deans; and students from medical schools across the country.

The Wass report made a number of important recommendations that offer a sound foundation for medical schools to develop and build on; however, there is an increasing risk that these recommendations are becoming accepted as static articles of faith with little academic discussion to develop them further. It is imperative that we keep moving forward.

We’ve highlighted five key areas, from the Wass report and from our recent experience, that need urgent action: the parlous state of funding for primary care placements; widening participation; the ‘bait and switch’ of the portfolio career; and the missed opportunities of generalism and role modelling.

FUNDING: AN ONGOING SCANDAL

There is well documented evidence that student experience in general practice is strongly associated with subsequent career choice.⁶ Funding for GP placements has a direct impact on both the quality and quantity of GP placements a medical school can offer, which in turn affects medical schools’ ability to authentically inspire students to opt for GP as a potential career.

A detailed costing exercise, just published in the BJGP, has shown that GP remuneration is just over half (54%) of the real cost.⁷ The current payment to primary care stands in stark contrast to hospitals where, after the agreement of a secondary care national tariff in 2013, payments can be nearly double that currently offered to GPs. There currently exists a systemic bias and a lamentable structural inequality that frustrates curriculum development and could transform undergraduate medical education in primary care. Robust, determined, and forceful advocacy is needed from medical schools and politicians to address this scandalous funding gap between primary and secondary care medical education placements. While there are ambitions to continue to increase the proportion of general practice in undergraduate education, this funding crisis threatens the viability of existing courses. There is a real risk of stasis as funds need to be wrestled from hospitals to primary care.

WIDENING ACCESS TO MEDICAL SCHOOL: A CROSS-SPECIALITY CONVERSATION

The Wass report refers to prior experience and selection of medical students. This is a pressing concern: there is a marked social gradient with medical school places dominated by the more affluent.⁸ The medical profession needs to unite to offer meaningful opportunities to become a doctor to all sectors of society.

Yet, it feels the Wass report is conflating two different conversations: widening participation (WP) in medicine and recruitment into general practice. It is accepted that promoting diversity in all medical specialties is a valuable and desirable outcome; however, it is essential that the WP debate is a cross-speciality conversation. Promoting general practice alone to WP pupils carries a risk that school pupils feel they have limited possibilities as future doctors, which is clearly neither fair nor equitable.

GP CAREERS: MORE THAN A ‘LIFESTYLE’ OPTION

There is also a risk that the carrot of a ‘GP portfolio career’ is waved at school children and medical students in a desperate attempt to lure them into the profession, selling general practice as the ‘lifestyle’ option. Arguably, when presented out of context this undervalues the speciality and mis-sells what the working life of a GP entails in our current climate.

It is true that general practice affords unique opportunities that are more difficult to find in other specialties; these include teaching, research, focusing on population health, varied portfolio and flexible working, and a scholarly and rigorous approach to clinical care that should be celebrated. These need to be backed up with investment in academic general practice that is accessible at all career stages and dovetails with frontline clinical demands. Medical students and young doctors are committed to the intellectual demands of generalism and we need systems that support those aspirations and passions, rather than selling general practice as simply offering an easy life.

GENERALISM AND PLACEMENTS IN PRIMARY CARE: NOT JUST FOR FUTURE GPS

We propose that the Wass report is missing the opportunity to introduce the concept of generalism and distinguish it from a career in general practice. The Wass report states:

‘The distinction between “generalism” and “being a General Practitioner” is blurred. This failure to define and represent general practice as an academic speciality in its own right within the curriculum can be addressed.’

It doesn’t, crucially, expand on the need for all doctors to understand the principles of generalism and holistic integrated care in view of our current population needs. The experience of primary care and general practice as an undergraduate needs to go beyond promoting career choice. There are benefits for all future doctors, being a fertile ground to teach students skills in clinical reasoning and generalism that our complex ageing patients will increasingly require, and exposing them to the opportunities and challenges of integrating care across different healthcare settings.⁹

By equating time spent in general practice as an opportunity to convert students to general practice risks some medical schools (and some students) simply opting out, choosing not to be the type of medical school that only trains GPs. It may also result in push back from students who are unlikely to welcome pressure and coercion into career choices by manipulation of curricular design.

ROLE MODELLING: MOVING FROM DOING TO BEING

Role models are well known to have significant impacts on students’ professional identity and their subsequent career choice.¹⁰ Rather than focussing on role models solely by speciality type, other characteristics such as sex, ethnicity, and socioeconomic background could serve as more powerful drivers for students to relate to, helping them go beyond what type of speciality they want to do, to what type of doctor they want to be when they qualify.

The hidden curriculum was exposed recently and powerfully by the recent Destination GP report commission by the RCGP.¹¹ Professional denigration at any level and in any direction, GP to speciality or vice versa or indeed GP to GP, is unhelpful and confusing for students as they try to make sense of their role models and career choices. Undoubtedly, general practice and psychiatry are repeatedly over-represented with such derogatory comments; however, a more equitable and acceptable approach would be to upskill all students, trainees, and doctors in the harms that these behaviours incite more broadly, rather than focussing on a few ‘special case’ specialities.

SUMMARY

General practice has always been, and remains, a demanding and intellectually stimulating career. The Wass report provided us with seminal guidance on what and how to implement strategies to promote generalist practice and general practice to our students.

However, three years on, with the political and professional landscape in flux, it is timely to take action on the important areas raised within the report. The funding gap in undergraduate medical education in primary care poses an existential threat to general practice curricula and we must advocate for radical change. At the same time we can’t lose sight of the need to attack the damaging prejudices of denigration, while building networks and systems that support generalism, role modelling, and fulfilling careers in general practice.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.