Intended for healthcare professionals


Combining specialist and generalist training could improve GP recruitment

BMJ 2014; 349 doi: (Published 28 July 2014) Cite this as: BMJ 2014;349:g4806
  1. Neil Munro, visiting professor1,
  2. Mike Bewick, deputy medical director2,
  3. Simon Jones, professor and chair1,
  4. Simon de Lusignan, professor of primary care and clinical informatics1
  1. 1Department of Healthcare Management and Policy, University of Surrey, Guildford, Surrey, UK
  2. 2NHS England
  1. neil.m.munro{at}


Neil Munro and colleagues say that offering doctors the chance to combine a specialism with a generalism could increase general practitioner recruitment and help manage rising workloads in primary care

Current medical career structures in the United Kingdom do not sit comfortably alongside either the service needs of an ageing population or the career aspirations of many medical students and doctors.

The diminishing attractiveness of UK general practice to recent graduates also threatens to undermine government efforts to devolve more care into community settings.1 Increasing workload, falling real income, and continuing negative press from the media contribute significantly to the current decline in popularity of general practice.2 Data from the recent Centre for Workforce Intelligence’s report into the general practitioner (GP) workforce shows a doubling in the number of hospital consultants trained between 1995 and 2011 and a 50% rise in other non-GP specialists, compared with only a 30% rise in the number of GPs.3 The target of half of all graduates entering GP training programmes by 2015 has already slipped.4

The recruitment problems in general practice are compounded by students and graduates seeking to train in specialties where employment opportunities, either here or abroad, align more closely with career preference than with service needs.5 This year, for the first time, Health Education England has announced that general practice is to have a third recruitment round.6

A solution of directing graduates into general practice training paths by restricting specialist training could generate unfulfilled practitioners and is risky if adopted as the single strategy going forward.7 Medicine is a global profession, and well trained graduates could seek training and work elsewhere if appropriate roles are not available in the UK.

Although there is a solid base of people who are determined to pursue a career in UK general practice, there is no formal opportunity for doctors to follow dual training paths that might include general practice as a principal element.1 Doctors with specific skill sets, recognised as such by their peers, patients, and relevant colleges, will be needed to meet the increasingly complex needs of an ageing population. The current system, with clear division between generalist and specialty training and careers, may inhibit the development of the tailored clinical skills needed for enhanced future care in the community as well as delaying closer integration of services.

There has been little research into whether combined career and training opportunities might be attractive to some doctors not primarily considering a career in general practice.8 Formally assessing interest in such career paths among medical students and graduates may assist in staff planning.

Students and graduates with interests in both specialism and generalism are currently required to choose one direction or another early in their professional careers. As the duration of working life lengthens it is conceivable that established practitioners may embark on training in another specialty later in their professional career.9 In a study of the career intentions of UK medical graduates, half of the respondents did not see their career choice as definite three years after graduation.10

More recent evidence suggests that uncertainty in career choice persists immediately after qualification but may lessen in later years.11 It remains likely, however, that being able to vary career direction or combine careers would be of interest to a considerable number of doctors and medical students.12


There are many potential obstacles to combined specialist and GP careers. Specialists may believe it reduces the value of their specialism, and generalists may reject moves that erode the concept of generalism.13 A strong case can be made for specialists working in generalist settings, even though their specialist training may provide only scant experience and expertise in general practice. Although some people regard GPs with special interests as tailored for the tasks in hand, others point to the lack of consistent training and governance processes.14

It is possible that many of the structures that underpin quality across the professions must adapt, or perhaps promote, integrated specialism. Royal colleges may regard such moves as challenging to their craft ethos, higher professional examinations, and political structures. Deaneries and trusts may struggle to deliver training for those wishing to pursue parallel paths while maintaining existing career structures. They may also regard these paths as expensive and potentially wasteful.

Staffing planners may find the possibility of doctors combining careers, or even switching midway, awkward in terms of anticipating future medical staffing requirements, and practices and hospitals will not cherish the prospect of increasing numbers of part time workers in their organisations with the associated difficulties of fragmentation of care. Individual clinicians may find the challenge of dual training (for example, basic core medical training followed by general practice training) and combined qualifications (such as membership of the Royal College of Physicians and membership of the Royal College of General Practitioners) daunting and there could be difficulty establishing and maintaining appropriate working patterns.1516

Dual training could attract more GPs

Offering clinicians the opportunity to combine a specialism with a generalism may be one mechanism of attracting the additional general practitioners needed to cater for large scale shifts from secondary care. It would also help to manage the increasing clinical workload in primary care resulting from an ageing population. In addition, dual training provides a way for the career specialist to gain experience and qualifications in generalisms that might enhance their expertise and interest in family medicine.9

Gauging the level of interest in combined careers, particularly among medical students and recent graduates, could be an important first step in improving recruitment to general practice and further promoting integration of healthcare services throughout the UK.


  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: NM is associate specialist in diabetes at the Chelsea and Westminster NHS Trust and a visiting professor at Surrey University; he worked as a GP in Surrey before retiring from this role in October 2013. MB, SJ, and SdeL have no interests to declare.


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