Career Focus

Recent developments in training for general practice

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7132.2 (Published 28 February 1998) Cite this as: BMJ 1998;316:S2-7132
  1. Katie Carter, registrar,www.rcgp.org.uk/jcpt
  1. Joint Committee on Postgraduate Training for General Practice, 14 Princes Gate, London SW7 1PU

    The regulations that enforce summative assessment for GP registrars have arrived. The joint committee's registrar, Katie Carter, outlines the new rules

    Most of the new regulations that affect general practice training are simply a consolidation of existing sets, but they differ in two important ways. They give the Joint Committee on Postgraduate Training for General Practice (JCPTGP) authority to approve all posts for general practice training both in hospitals and in GP surgeries - and the power to deselect unsatisfactory posts. Previously the posts were assessed at regional level and the committee could make recommendations only of the quality and content of the posts. The regulations also make it mandatory to pass the test of competence known as summative assessment. This article considers the development of the regulation of general practice training and outlines the current position for doctors who wish to enter general practice in the United Kingdom.

    Historical perspective

    Vocational training for general practice developed during the 1970s and became mandatory in 1981 with the first set of vocational training regulations. Since that time all doctors wishing to enter general practice as principals have had to undergo a three year training programme, one year of which has to be spent in an approved training practice with a personal GP trainer.

    A number of other acts of parliament have followed, notably the 1994 regulations, which drew British legislation into line with the European legislation of the preceding year that governs the free movement of doctors throughout the European Economic Area and the mutual recognition of vocational training certificates. The specific length and content of vocational training for general practice is now defined by both British and European Union regulations, and the committee administers those regulations for the entire United Kingdom.

    Approval of training posts

    The committee is likely to retain existing systems for the approval and inspection of posts into the coming year, and its new powers in this regard are unlikely to affect individual trainees in the short term. In the longer term these powers should mean that only posts that are appropriate for general practice are used for training, and that the quality of the education received by trainees in hospital posts is improved. The potential sanction of deselection of a post should be an incentive for the consultants who supervise those posts to ensure that the educational needs of future general practitioners are met, as well as those of specialists in training. The requirement for hospital posts to be inspected by a joint hospital visiting team that includes a general practitioner should reduce the burden of visits on trusts.

    Summative assessment

    Summative assessment has been in operation on a professionally led basis for some time and is now generally accepted by the profession. The new regulations make the passing of summative assessment mandatory for all general practitioners in training who began their registrar year after 30 January 1998. Passing the summative assessment continues to be expected by the profession for trainees who began training as a registrar before that date.

    Approved specialties for training in general practice

    • General medicine

    • Geriatric medicine

    • Psychiatry

    • Paediatrics

    • Accident and emergency medicine or general surgery, or accident and emergency medicine together with either general surgery or orthopaedic surgery

    • Obstetrics or gynaecology, or obstetrics and gynecology

    The committee is also the body responsible in law for approving summative assessment packages. The regulations describe the competencies to be tested by summative assessment. Currently there is only one method of assessment - the four element assessment administered by the UK Conference of Postgraduate Advisors in General Practice, which includes a multiple choice paper, the trainer's report, videotaped assessment of consulting skills, and an audit project. The committee has recently agreed in principle that the examination leading to membership of the Royal College of General Practitioners (MRCGP) can also be a form of summative assessment, but various legal hurdles must be surmounted before the MRCGP's examination can begin to function as a summative assessment package.

    Duration of training

    The new regulations also tighten the rules on the time spent training in particular hospital specialties that can count towards the certificate issued by the committee. Under the old regulations, experience of up to 18 months in any one of the specialties listed in the regulations was acceptable (see box). Now the maximum period in any one òshort list specialtyó that can count towards the certificate is 12 months. In addition, only six months in any unlisted specialty is allowed to count towards the award of the certificate. Both these changes seek to ensure that GPs acquire a broad range of experience in relevant specialties.

    About the committee

    The Joint Committee on Postgraduate Training for General Practice has 26 members - all doctors - drawn from a variety of bodies concerned with general practice education, including doctors in training. Created in 1976, the committee grew from a working partnership between the two main bodies representing family doctors in Britain, the Royal College of General Practitioners and the General Medical Services Committee of the British Medical Association. The committee meets quarterly, but its day to day work is undertaken by three officers - all practising general practitioners - and a team of seven full time non-medical staff. The staff work in central London offices and their contact with their constituents - general practitioners in training, and their teachers - is almost entirely by telephone and letter.

    The work of the committee falls into two distinct areas: issuing certificates of vocational training to doctors who have completed an appropriate training programme, and approving and inspecting training posts for general practice throughout the United Kingdom.

    All doctors who want to work in general practice in Britain must have the certificate issued by the committee unless they are exempt; the most important exemption is doctors who had been principals in NHS general practice on 15 February 1981 and re-entered the medical list before 15 February 1990. The committee issues certificates of acquired rights to doctors who have the right to practise without a certificate of vocational training. The committee also acts as the competent authority for the purposes of European law for all arrangements governing the training and employment of general practitioners in the United Kingdom, though the recognition of certificates issued by other member states is the responsibility of the General Medical Council.

    GP training in Britain

    Responsibility for the provision and organisation of vocational training rests with each deanery's director of postgraduate general practice education. Doctors who decide to train for general practice choose a formal three year vocational training scheme, construct their own programme, or choose a mixture of both. Those who hold limited GMC registration may undertake the hospital component of general practice training but must proceed to full registration before applying for a general practice registrar post. The training programme usually consists of 24 months in approved hospital posts and 12 months in general practice as a registrar. The regulations also allow a programme of up to 24 months as a registrar in general practice and a minimum of 12 months in hospital posts, but funding for extended periods as a registrar is not normally available. The hospital component is undertaken in substantive senior house officer posts; the registrar year is supernumerary. Posts held at preregistration house officer level are not accepted as contributing towards general practice training in Britain. The training may be split between different deaneries, and the posts can be undertaken in any order. Trainees are usually advised, however, to complete all their hospital posts before entering the last phase of general practice training. This ensures that the education programme in the final registrar post can place the knowledge gained in context and enable the final assessments to be completed comfortably in general practice.

    Getting the certificate

    Training that follows this stand- ard format is called òprescribed experienceó and leads to the issue of the certificate of prescribed experience. Doctors whose training does not conform to this format can apply for a certificate of equivalent experience. These certificates are equally valid for entry into general practice.

    Training leading to a certificate of prescribed experience must be undertaken in the United Kingdom in posts specifically approved for general practice training, comprise not less than 36 months' whole time employment, and be completed within the seven year period immediately preceding application for a certificate. Training must include at least 12 months' whole time employment or its equivalent part time as a GP registrar within the NHS.

    Doctors who have not completed a formal programme of vocational training, or whose programme includes posts outside the United Kingdom or posts held more than seven years ago, can be issued with a certificate of equivalent experience. When considering applications for a certificate of equivalent experience, the committee looks at the educational content of the posts held, the supervision provided, and the range of skills and experience acquired during that period. If the posts were overseas, the committee will seek confirmation of local approval and inspection by an appropriate training authority. If posts were undertaken in other countries in the European Economic Area, the committee will inquire about their approval status for general practice training from the relevant competent authority. In almost all cases applicants are expected to have undertaken a period of structured training as a GP registrar in an approved training practice in the United Kingdom. As with prescribed experience, the total period of training should not be less than 36 months' whole time, and the experience should normally be acquired in the 10 years preceding the date of application. There is no charge for certificates, and doctors can apply during the last four weeks of their final training post.

    Copies of the regulations are available from the Stationery Office, HMSO Publications Centre, 51 Nine Elms Lane, London SW8 5DR.

    Briefing

    • Staff grade doctors and others without a certificate of completion of specialist training (CCST) must satisfy the specialist training authority (STA) that they have equivalent experience and qualifications should they wish to be entered on the specialist register (and therefore eligible for a substantive consultant post). The royal colleges have recently revised their guidelines for doctors in this group, setting out the detailed criteria by which applications will be judged. The criteria vary between colleges, but broadly, candidates for the specialist register should have had at least part of their training in recognised registrar training posts; have passed the relevant college examination; and demonstrate evidence of involvement in teaching, research, and audit in the non-consultant career grade posts occupied. Copies of the new criteria are available from the royal college concerned.

    • News of a pay rise (Pay and Benefits Bulletin February 1998:13) that takes the pay of Burger King's staff to £3.50 an hour led me to calculate the on call pay of a house officer (£3.71 an hour). Still, after repaying student debt the prospects of the house officer are surely better. In the same issue comes the intelligence that the use of performance related pay for NHS managers has fallen dramatically: 7 in 10 received it a year ago; this year only a fifth have done so. Meanwhile human resources innovation at the Hartlepool and East Durham NHS Trust continues: staff there are enthusiastic about the introduction of aromatherapy massages to reduce stress (Employee Health Bulletin February 1998:9), though only a handful of its 90 medical staff have taken up the offer. The scheme's progenitor claims that this is because of time constraint rather than scepticism.

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