GENERAL practice forms the largest sector of the NHS, with 90% of all patient contacts occurring in the primary care setting. Almost half of qualifying doctors will specialise in general practice, and there are around 56,000 GPs working in the UK – more than all consultants in all specialties combined.
The aim of general practice has always been to treat patients holistically, offering continuing care to patients and their families. An intrinsic and unique part of the GP role is that of ‘co-ordinator’, dealing with patients who often have complex health needs and a requirement to access several health and social care systems simultaneously.
Training in general practice was only formalised in 1956, with The University of Edinburgh being home to the first independent Department of General Practice in the world. Virtually all medical schools in the UK, and many in the developed world, have since followed suit, recognising the importance of this element in the teaching of undergraduate medical students.
With few other specialties offering the variety and scope of this arm of medicine, it is no surprise that entry into GP training remains highly competitive. However, an ageing GP workforce has led to an increase in the number of medical school places and various incentives to encourage GPs to work in underresourced areas.
On completion of foundation training, doctors apply to undertake a Certificate of Completion of Training (CCT) Programme to specialise in general practice. Prior to, and during, the application process The National Recruitment Office for General Practice assesses eight qualities deemed essential in a good GP:
• Ability to care about patients and their relatives
• A commitment to providing high quality care
• An awareness of one's own limitations
• An ability to seek help when appropriate
• Commitment to keeping up to date and improving the quality of one's own performance
• Appreciation of the value of team work
• Clinical competence
• Organisational ability
Since August 2007 the Royal College of General Practitioners (RCGP) is responsible for setting the training curriculum for general practice, and completion of the College’s assessment, known as the nMRCGP, is now compulsory. Successful completion of the 3-component assessment, in conjunction with the CCT, grants doctors the eligibility to practise independently as a GP. Throughout the training programme trainees will work for two years in a variety of approved hospital training posts and a minimum of one year asa GP registrar in a training practice. Flexible training options, including part-time, are also available.
Ultimately, most GMS (General Medical Services) GPs work in practice within a primary healthcare team consisting of GPs, practice and community nurses, health visitors, midwives, practice managers and administrative staff.Since the late 90s there has also been the opportunity to become a GP with a Special Interest (GPwSI). This includes working in chronic disease management, dermatology, palliative care and respiratory medicine. The aim of the GPwSI is to decrease the burden on secondary care and bring more services in-line with the ‘community based’ ethos. Further opportunities include academic GPs, media doctors, police surgeons and armed forces. Some GPs will also work on a sessional basis as a locum covering sessions as and when required over a number of practices.
There have been many reports in the press recently of GPs routinely earning in excess of £150,000. More realistically, a salaried GP can expect to earn between £50,000 to £80,000. The salary structure has changed recently under the new GMS contract and practices now receive a global sum for the services provided and additional payments if they meet quality markers as laid out in the Quality and Outcomes Framework (QOF), for example in the management of patients with common chronic diseases such as asthma and diabetes, or extra services offered such as child health and maternity services. These figures can therefore vary greatly dependent upon practice activity.
There are many challenges facing today’s general practitioners, with increasing patient expectation and the intense glare of the media spotlight fixed eternally on the NHS. The RCGP vision of the future is that, following improvement and a ‘federated approach’, virtually all health problems will be dealt with in the primary care setting with the lines between ‘primary’ and ‘secondary’ care becoming increasingly blurred. But many GPs and the College oppose the introduction of the ‘polyclinic’, fearing that continuity of care will be compromised. It’s a controversial area that will no doubt be so for a long time yet.
Cherryl Adams is Associate Editor of FYi
Q&A - Dr Andrew Thomson, general practitioner
• What attracted you most to general practice?
The opportunity to provide a level of continuity of patient care that is simply not possible within hospital practice, so-called ‘cradle to grave’ care. I also value being part of a close multi-disciplinary team while maintaining career flexibility, making portfolio working and work-life balance real possibilities. Add to this limitless clinical diversity and the ability to lead, direct and develop a small business thus improving the services provided to your local community, then a career as a GP seemed the only logical step.
• Now that you’re in the job what do you enjoy most?
Seeing patients… getting to know them and their families; coping with challenging situations or patients, the so-called ‘heartsinks’, is what makes me tick. Another GP challenge and highlight for me is managing patients’ undifferentiated illnesses. Then, like a detective, I can hunt for that elusive diagnosis.
• Are there any downsides?
Stop the clock!! Time pressure and pigeonholing patients into 10 minute slots can be the most challenging and frustrating element of the job. Feeling isolated – when you’ve not left your consulting room all day, having had more interaction with your computer than the team. Incessant external pressure to change can also be very frustrating, especially when you feel that this has more to do with politics than patients, quotas than quality.
• What’s your most memorable experience so far?
It’s difficult to pick a single experience as there are many but they tend to relate to moments of realisation that you have made a difference; whether that is a result of gratitude from a patient or their family or reaching a timely or unusual diagnosis. Often it is picking up on the nonverbal queues in a consultation that can deliver the most rewarding moments.
• Has anything about the role surprised you?
I’ve been surprised by the huge value that patients place on personal continuity of GP, even in an age where information continuity is easily delivered. Another surprise is the speed with which patients develop a trust in you and your decisions – first introductions to life changing decisions in a 10 minute consultation.
I was also shocked by the paperwork – measured by the ton/gigabyte! Results, outpatient/secondary care letters, medication requests, medical reports etc – with this significant daily burden you must develop workflow systems to stay up to date with and for your patients, hopefully never missing that important result.
• Are there any myths about general practice that you’d like to dispel?
The 21st century GP practice bears little resemblance to Dr Finlay’s casebook. GPs provide community hospital, specialist chronic disease review clinics and a host of other services that were a secondary care remit only a few years ago. The other important myths to dispel are that this is not a Monday to Friday, 9-5 option and we don’t all earn over £100K…sorry.
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