Helping GPs return to practice: a look at induction and refresher schemesBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f735 (Published 19 February 2013) Cite this as: BMJ 2013;346:f735
Returning UK trained GPs to clinical practice makes sense, but the provisions for doing so are patchy. Helen Jaques examines the GP induction and refresher scheme
General practitioners (GPs) are increasingly taking time out of their medical careers, often to work abroad or to start a family. Given the cost of training these doctors, it is in the interests of the NHS to help them return to medicine, but the current mechanism for doing so is patchy and underfunded.
The GP induction and refresher (I+R) scheme provides a route for GPs who have taken time out of UK practice to return safely and confidently to clinical work. It also acts as an induction to UK general practice for doctors who qualified in the European Economic Area and for those who entered the medical register via a certificate of eligibility for GP registration (CEGPR).
Most primary care organisations demand that returning or new GPs take part in an I+R scheme. There is no requirement in legislation for this, but primary care organisations usually call for it to reassure themselves that these doctors are competent to practise in the NHS.
As a rule, GPs who have been away from UK practice for two years or more are expected to take part in an I+R placement. In some areas this is not a requirement until a GP has been away from UK practice for at least five years.
To secure a place on the scheme, GPs have to apply to the GP National Recruitment Office and complete a two part test. This is made up of a computer based multiple choice clinical knowledge test and a simulated patient survey. Both parts of the test are held four times a year and cost £100 and £750, respectively.
Applicants have to reach a minimum score on each test to be admitted to an I+R scheme. Doctors’ scores on these tests are then used to develop the education plan against which they are assessed during their time on a scheme.
GPs on a scheme spend three to six months being supervised while they work full time in a training practice. Their learning needs are assessed at the beginning and end of the scheme, and in most cases the programme is tailored to the individual needs of the GP. When a GP has completed the scheme, his or her trainer will write to the primary care organisation to say the GP can re-join the local performers’ list.
Why the NHS needs returners
Given that the UK government spends an estimated £381 000 training each GP, it makes financial sense for the NHS to encourage them back into practice.1 Richard Vautrey, deputy chairman of the BMA’s General Practitioners Committee, says the I+R scheme is the cheapest way of increasing the number of GPs. “It seems crazy not to use the skills of someone who has been extensively trained in the past and with a short induction and refresher scheme can return to the workforce and provide a service in a local practice,” he says.
Jim Morison, GP associate postgraduate dean at Severn Deanery, estimates that it costs his deanery £7900 to return a GP to the workforce, in terms of trainers’ grant and administration costs. This rises to a total of £60 000 if the returning GP is paid a salary at the bottom end of the sessional GP salary scale. “It strikes me that compared to the cost of training up a GP, for a very small amount of money you can put doctors back into the workforce,” he says.
The I+R scheme has other benefits as well, says Barry Lewis, chairman of the Committee of General Practice Education Directors (COGPED) and director of postgraduate general practice education at North Western Deanery. He says it is important for bolstering the existing GP workforce, which is already short on numbers.
He also points out that GPs will play a big role in the government’s plans to deliver more care in the community. In addition, he says that some GPs will soon be diverting portions of their clinical time to commissioning, both of which will only exacerbate the strains on the workforce.
“We’re going to find that we’re short of experienced doctors who can take on one or more of these important roles,” he says. “If we can return people to the workforce, there will be less strain overall and everything can keep running, whereas at the moment it’s creaking.”
Variation across the UK
Provision for I+R schemes varies across the United Kingdom. In England, I+R schemes were funded by the government until 2006, when central support was withdrawn and deaneries were left to pay for such schemes themselves. Scotland and Wales continue to centrally fund I+R schemes (in Scotland the provision is called a returners’ scheme), but no scheme exists in Northern Ireland.
Twenty deaneries and health boards are responsible for medical education across the UK. The BMA has collated information on I+R schemes from 13 of these bodies, having requested information from all 20 organisations. This unpublished research reveals the extent to which provision of these schemes varies across the UK.
Among the deaneries and boards that provided details of their support for GPs returning to practice, all except one said that they had an I+R scheme or equivalent. A total of 49 GPs were on I+R schemes at these deaneries and boards in 2012, with the number at any one deanery ranging from 0 to 11. Most deaneries offered an I+R scheme to GPs who had been out of UK practice for between two and five years, and all except one said that their primary care organisation automatically required GPs who had been out of practice to complete a scheme before admittance to a performers’ list.
Six of the nine English deaneries that said they had a scheme funded it themselves. This was mostly from deaneries’ own training and education budget, rather than using money directly from their local strategic health authority. The proportion of this money that reached doctors on the scheme varied hugely across the country, however, and a considerable portion of the money went towards trainers’ grants.
The full time equivalent salaries paid by deaneries varied from £24 000 to £60 000 a year. Some areas offered a GP specialty trainee year 3 salary or salary on the lower part of the salaried GP pay scale. Three of the nine deaneries in England with I+R schemes did not provide salaries to the GPs on their scheme, and one expected the practices to pay a “nominal wage.”
London Deanery, for example, offers GP returners an “educational grant” of £50 per clinical session. Julia Whiteman, director of appraisal revalidation and performance in London Deanery’s Professional Development Department, acknowledges that this is a problematic situation. “I would dearly love to be able to offer people a salary, and I’m aware that people struggle [on the current funding],” she says. Difficulties arise because deaneries receive money for training, not re-training, and have to stretch their per capita budgets for specialty training to fund an I+R scheme, she says.
Wales Deanery provides GPs on its scheme with an “educational grant” of £2500 a month from the £24 000 it sets aside for each GP’s six month placement. Health boards in Scotland receive funding towards the scheme direct from NHS Education for Scotland (NES), some of which goes towards the salaries of GPs on the scheme.
Vautrey believes the risk of having no salary or a below average salary is likely to dissuade GPs from taking career breaks and from returning to practice if they do take time out. “If [GPs are] not supported appropriately, then that makes it very difficult for them to return into the workforce,” he says. “Doctors should be treated fairly. If they are employed, in whatever capacity, they should be paid appropriately.”
Variation in provision of I+R schemes could disproportionately affect women GPs given that many women take time out to start a family at some point in their careers, says Fiona Cornish, president of the Medical Women’s Federation and a GP principal in Cambridge.
In fact, the federation encourages women not to take more than two years out of clinical practice if possible. “We get distressed enquiries from people who, for example, have been away in Australia for six years and come back and are told they have to go into the scheme,” she says. “I think people need to be better informed that if they take a two year break they’re going to be in trouble.”
Women will make up more than 50% of the medical workforce by 2017.2 Cornish argues that it is therefore critical that women are retained in clinical practice. “It must be feasible for [female doctors] to have families and work,” she says. “Workforce planning needs to be creative so that schemes are available for women to be retained in the workforce.”
The ongoing healthcare reforms in England, and their effect on how funding for education and training is collected and distributed, could either solve the problems with I+R schemes or lead to the death of such schemes.
Deaneries and primary care trusts will cease to exist on 1 April 2013 and be replaced by local education and training boards (LETBs) and the NHS Commissioning Board, respectively.
The Department of Health has said that under the new system LETBs will be able to decide for themselves whether or not to fund an I+R scheme, in the same way that deaneries do now. A spokesperson said: “It is an important principle that decisions on training and development of the healthcare workforce, including the best use of funding, are taken locally, as LETBs are best placed to assess the health needs of their local community.”
Lewis, on the other hand, thinks that the NHS Commissioning Board should centrally fund the I+R scheme in England. But he says that the board may well use the independent contractor status of GPs to absolve itself of this responsibility. “My argument is that [the NHS Commissioning Board] has a duty to make sure that there is an adequate workforce for it to commission services from,” he says.
Consistency is needed across the country though, says Vautrey, and that Health Education England, the new national body that will be in charge of medical education and training from April, could take a role in overseeing this. Alternatively the NHS Commissioning Board could take responsibility for greater standardisation of the scheme, he says, because it will be in charge of performers’ lists for all GPs in England.
Whiteman believes it would be “absolutely fantastic” if the Department of Health centrally provided funding, as it did before 2006. “If you look at the plans for the development of the health service or healthcare delivery, primary care is expanding, or the demand for primary care is expanding,” she says. “The government needs to make sure that it’s got the workforce in place to meet this need.”
Everyone seems to agree that the main issue is that the government and all the new organisations that will be in place from April this year make returning GPs to the workforce a priority for the NHS. “Once absent GPs hit the two year mark and people demand retraining but there’s no money for it, then they’re lost to the NHS,” says Lewis.
Competing interests: None declared.