Career Focus

Bridging the gap after vocational training

BMJ 1998; 316 doi: (Published 20 June 1998) Cite this as: BMJ 1998;316:S2-7148
  1. Jamie Harrison, GP tutor and GP Career Start Scheme Organiser, County Durham,
  2. Tim van Zwanenberg, director of postgraduate general practice education
  1. Postgraduate Institute for Medicine & Dentistry, University of Newcastle NE2 4AB

    A step? Or a quantum leap?((1)) The transition from GP registrar to principal is a big one. Jamie Harrison and Tim van Zwanenberg describe the schemes designed to ease the transition

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    General practice used to be the most popular medical career choice, and attracted the brightest and the best of medical graduates. In recent years, however, there has been a fall in the number of doctors enrolling for vocational training and real difficulty in recruiting general practitioners to some parts of the country. The explanations extended to explain this loss of popularity include higher patient expectations, low general practitioner morale, increased workload, and expanding bureaucracy and out of hours work.

    Although the extent of this recruitment crisis has been disputed, several studies report a reluctance among general practitioner registrars to enter general practice partnership immediately on completing vocational training.((2)(3))

    The reasons general practitioner registrars fail to make this transition to partnership are complex. Many feel inadequately prepared for the wider dimension of being a general practitioner. While confident about consulting with patients, the business side of practice and general practitioners' growing responsibilities in the NHS are a worry; the registrars perceive a lack of exposure to such issues in their training practices.

    There is also a generational factor. The current generation, and this applies not only to doctors, seems less willing to “settle down”. They are less inclined to take on the financial and administrative responsibilities associated with being a partner straight away. Most newly qualified general practitioners are women, and all, both men and women, want to have a life as well as a job.

    Common features of general practitioner post-vocational training schemes

    • Salaried posts

    • Fixed term contracts (of one to three years)

    • Protected time for further education

    • Mentoring

    • Collective small group learning

    • Opportunities to learn new clinical skills

    • Exposure to (a small number of) different practices

    • Opportunities to learn about non-clinical general practitioner activities in management or research

    In the past four years a number of post-vocational training schemes have appeared, arising out of different contexts. These include recruitment problems, the desire to raise standards in inner city practices, and the need to develop academic general practice careers. Whatever the original motivation, each scheme seems to be meeting a need in young doctors, in addition to providing some help to hard pressed practices and recruiting doctors to work in the traditionally less popular areas. The schemes have a number of common features (see box above).

    Post-vocational training schemes

    • GP Career Start in County Durham

      Dr J H Harrison

      Cheveley Park Medical Centre, Belmont, Durham DH1 2UW

      (Tel: 0191 386 4285)

    • Parachuting general practitioners in the North West

      Dr Roy Woodward, Primary Care Initiative, Liverpool Health Authority, Hamilton House, 24 Pall Mall, Liverpool L3 6AL

      (Tel: 0151 235 4747)

    • Vocationally Trained Associate (VTA) Scheme in South London

      Julia Chant, Room 10 Gassiot House, St ThomasÑs Hospital, London SE1 7EH

      (Tel: 0171 922 8250)

    • London Academic Training Scheme (LATS)

      Department of General Practice and Primary Care, Medical Sciences Building, Queen Mary and Westfield College, University of London, London E1 4NS

      (Tel: 0171 295 7906)

    • Sunderland

      Dr Colin Waine, Professional Development Scheme, Sunderland Health Authority, Durham Road, Sunderland SR3 4AF

      (Tel: 0191 565 6256 ext 45322)

    • Tees

      Mr D Ross, Career Options (COPS), Primary Care Resource and Development Centre, Grey Towers Court, Stokesley Road, Nunthorpe, Middlesbrough TS7 0PN

      (Tel: 01642 304190)

    The schemes result from local initiatives, increasingly the combined effort of the local health authority and its general practitioners. There is as yet no national scheme, although the recent facility for creating salaried general practitioner posts may enable some health authorities to develop similar post-vocational schemes. New schemes are developing, and interested doctors would be well advised to contact the director of primary care at their local health authority or their director of postgraduate general practitioner education.

    Advantages and disadvantages

    The schemes offer young doctors a guaranteed salary and a structured induction into general practice, providing protected time for continuing education, both clinical and non-clinical, and some personal support through mentoring. The doctors gain experience in a range of settings, often being given the opportunity to implement a service development or to undertake a project or to do research. In particular, most trainees seem to appreciate the protected introduction into the wider dimensions of being a general practitioner.

    One disadvantage is that the trainees can lose ground financially compared with colleagues who become partners immediately. Another is that a more permanent job will still be needed once the fixed contract period is over.

    The schemes offer health authorities the chance to support practices that are under pressure. In some cases the post-vocational salaried doctor has been an important catalyst in bringing about much needed changes in a practice. In other instances the established principals have been able to make use of the lightening of their workload to engage in professional development activities or pursue service developments in their practices. Ultimately, health authorities may anticipate that their general practitioner recruitment problems might be solved. Indeed, there is no longer a recruitment crisis in County Durham, although so far only one doctor has left the GP Career Start scheme early to take up a partnership. Perhaps other doctors recognise and respond to the cultural change, whereby health authority and general practices come together to nurture the development of the practices in a locality. The health authorities' main difficulties are in funding the schemes and finding suitable general practitioner educationalists to manage them.

    For the profession, and for patients, the potential benefits of post-vocational training are considerable, though difficult to quantify. Arguably, the schemes produce doctors for the future, who are better able to manage themselves, to provide good clinical care, to contribute to management and leadership (not only in their practices but also in the NHS more widely), to become lifelong learners, and to help in the academic development of the discipline. There is, however, no academic recognition at the end of the process. The doctors are becoming “fit for purpose” not “fit for award,” although a number of them have taken accredited courses in a range of subjects. Higher professional education

    The three year vocational training programme was always a compromise. The original recommendation from the (now Royal) College of General Practitioners proposed a period of five years including two years in general practice.((4))

    Rather than extend the period of vocational training, the college has stated more recently that it should be augmented by a period of higher professional education.5 The length of the period of higher professional education, the college asserts, should not be fixed, although a minimum of two years would seem appropriate. The college has been asked to consider how the completion of such higher professional education might be recognised so that the doctors would be seen to be equivalent to a consultant in other disciplines.

    Specialists undergo a minimum of five years' training as specialist registrars before they become accredited.

    Future prospects

    These local solutions seem to offer considerable benefits for health authorities and general practitioners, both young and old. Furthermore, the young doctors have repeatedly drawn attention to the difference between being a general practitioner registrar and a general practitioner principal. Extending vocational training will not change that, and some form of structured but flexible induction process is increasingly required, particularly as different and larger primary care organisations emerge from the pilot projects of the Primary Care Act and the new primary care groups.


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