Doctor apprenticeships: a dilemma for the future of general practice in the NHS

While the United Kingdom was at the mercy of the COVID-19 pandemic, the hegemony of the medical profession, stooped in traditionalism, was subject to reorganisation: doctor apprenticeships. The announcement triggered a gripping debate: could an apprenticeship replace the medical course? It is prudent to explore the dilemma this novel hypothetical career journey poses for the future of the NHS.

Traditionally, admission to medical school is incumbent on both humanistic and cognitive traits. ¹ The public and the profession alike regard knowledge and up-to-date information as a priority for a ‘good’ doctor, reflecting the medical school selection criteria based on stringent academic requirement. Yet, the apprenticeship for medical training potentially undermines this trust. The proposal for the doctor apprenticeship detailed a 60-month course open to 100 students with A-levels in at least Chemistry, and often Biology, and a third scientific subject. ² It is reasonable to mention the danger of creating a two-tier system; there is the risk of a manifest divide between the qualifications, and possibly clinical abilities, of apprenticeship doctors and traditionally trained doctors. The BMA itself appreciates the relevance and likelihood of this danger. ³ The medical profession relies heavily on intra-professional and multidisciplinary teamwork: disruption to this workflow could weaken patient care.

The programme would be subsidised by the apprenticeship levy, a 2017 government fund available for apprenticeships in England; this would provide a paid part-time opportunity to practice medicine. ⁴ Medicine is at a discord with the general population. In 2016, the Social Mobility Commission reported that only a meagre 4% of doctors came from a working class background, ⁵ and between 2009 and 2011, 50% of UK schools did not have a single applicant to medical degrees. ⁶ The impediments to accessibility to higher education for students from more deprived backgrounds are multifarious and symptomatic of the wider injustices of society. These inhibiting factors are: (1) institutional barriers: arising from the unresponsiveness of educational institutions or a lack of flexibility in the provision on offer, such as inappropriate scheduling or content of provision. (2) Situational barriers arising from an adult’s personal and family situation, such as time pressures and financial constraints. (3) Dispositional barriers: relating to the attitudes, perceptions and expectations of adults, such as believing they are too old to learn or lacking confidence or interest. ⁷ It is the cumulative impact of these factors that hamper accessibility. It is, therefore, naïve to think the doctor–apprenticeship in singularity as a solution to the complex issue of social mobility and widening access to medicine. Rather: more inclusive financing to higher education for those from deprived backgrounds, long-standing scholarships, additional bursaries and a greater focus on aptitude and situational judgement parameters would have a more favourable impact on accessibility.^8,9

The medical profession has expressed suspicion that the doctor–apprenticeship may simply be a proposal to increase the number of qualified doctors. With 22% more patients to see than in 2015, primary care is facing tough challenges in the increased workload pressure; encouraging a proportional surge in the GP workforce could be the rationale behind the development of the new training scheme. With the incessant cuts to the NHS over the last decade, the NHS labour market already faces a precarious state with just 2.8 doctors per 1000 population, lower than the European average of 3.4/1000. This is a worsening trend: with a failure to meet the target of 5000 additional GP posts, conversely seeing a fall by 1% over the last five years; 60% of hospital consultants intending to retire at or before the age of 60 and 50% were less likely to do extra sessions. ¹⁰ American insurance groups are managing an ever-growing number of GP practices, while the Cleveland Clinic plans to expand with what could become the largest private hospital in London, with a separation from the usual model of contracting doctors for private work to employing permanently salaried doctors instead. ¹¹ There are concerns these new private jobs with lucrative salaries will drain the already-depleted NHS workforce of doctors. A further worry of the apprenticeship model is the ‘international exportability’: would these newly crafted doctors be forced to stay in the United Kingdom because of a lack of recognition of the apprenticeship qualification? On the other hand, doctors with ‘exportable’ degrees could be seeking opportunities in other parts of the world with higher salaries and better job satisfaction. This could exacerbate the very issue the scheme seems to aim to address; a vicious cycle could ensue, with doctors leaving the UK only to be replaced by new apprenticeship-trained medics.

The apprenticeship dilemma seeks diversity, yet causes division; this policy proposal – with a possible political intention – could be motivated by monopoly. The healthcare world needs to stand united in the face of this inadequate solution to a far deeper, ideological question.

ORCID iDs

Cecilia Cirelli https://orcid.org/0000-0002-1918-5776

Jatinder Hayre https://orcid.org/0000-0003-0473-686X