Achieving parity for general practice

RCGP Statement - March 2024

Overview

General practice is the cornerstone of the NHS. It is the first point of contact for most patients seeking medical care and is responsible for delivering comprehensive primary health care to local communities (acute, chronic and preventative care), and ensuring access to more specialised secondary care services depending on clinical need. Whilst facing unprecedented workforce and workload challenges and increasingly complex patient presentations, GPs continue to deliver more care than ever.^1,2,3 In November 2023, general practice delivered a record 31.9 million appointments, over a million appointments each working weekday in England, with similarly high levels of workload being reported across the UK.⁴ Furthermore, increasing demands on primary care, including the impact of an ageing population and rising rates of multiple conditions, exacerbate the strain on the GP profession and their practices across the UK.⁵

As outlined in our Definition of a GP, GPs have distinct expertise and experience in providing whole person medical care whilst managing the complexity, uncertainty and risk associated with the continuous care they provide.⁶ They work in, connect with, and lead multidisciplinary teams that care for people and their families, aiming to ensure all of their physical and mental health needs are met. 

General Practitioners have long faced additional burdens due to inequitable footing and treatment, compared to other specialty medical professions. Examples of a lack of parity include the significant year-to-year under-resourcing and funding of general practice in comparison to other areas of NHS services, disproportionate representation in leadership roles and system structures in the NHS, inequitable exposure to, and training in, general practice within the undergraduate medical curriculum, and a lack of opportunities and recognition in senior academic positions and clinical academic settings. When it comes to undergraduate education, the 2017 RCGP and Medical Schools Council (MSC) joint report, Destination GP (PDF file, 2 MB), recognised that whilst other medical specialties also experience the effects of denigration and widespread factionalism, general practice is the worst affected.⁷ Medical students often recount that they are afraid to declare their intention to become a GP because of this negative feedback. Furthermore, GPs are yet to have their specialist role legally acknowledged, due to the existence of two separate General Medical Council (GMC) registers for senior doctors – one for Specialists and one for GPs. 

At a time when general practice faces severe workforce shortages and workload pressures, it is vital that GPs are valued and respected, through the achievement of parity of professional esteem. GPs must be recognised as being at the same level of seniority as their consultant colleagues in secondary care. We are seeing GPs leaving the workforce early from all career stages. Workload issues and a lack of parity of esteem are jointly compounding the recruitment and retention crisis. General Medical Council (GMC) data shows that GPs are more likely than other registered doctors to report increasingly high workloads/long hours, working under pressure/time constraints, and find it increasingly difficult to deal with patient expectations and dissatisfaction.⁸ It is unsurprising under these conditions that the same study determined that GPs are at higher risk of burnout than other medical specialities.⁹ GPs must be able to access and participate equally at all levels of decision-making, in order to be able to shape the delivery of high-quality patient care, safeguard the future workforce, and facilitate positive change in the heath sector.  

Our key recommendations are summarised in section 5.1 below.

1. General practice funding and unlimited workload

Despite the NHS England Long Term Plan objectives to shift patient care out of hospitals and into the community, there has not been a sufficient transfer of NHS funding to general practice to support this approach.¹⁰ General practice urgently needs greater investment to enable more patients to be seen within their communities, to prevent ill health and reduce the rates of avoidable hospital admissions. As our population ages, the number of patients presenting with more than one chronic condition has increased greatly.¹¹ Alongside these higher rates of multi-morbidity, GPs are managing the complex interactions of symptoms, medications and lifestyle factors associated with such conditions.¹² The majority of this care takes place in the community, with GPs delivering and overseeing long-term treatment, highlighting the need for appropriate resourcing and funding.¹³

Alongside the need for funding that directly reflects the proportion of services delivered in primary care and general practice settings, the NHS and other national commissioning bodies must also consider the cost-saving value of care and interventions delivered in these environments. According to the NHS Confederation, while every £1 invested in the NHS results in the economy as a whole getting £4 back in gross value added, the greatest economic returns come from in investing in primary and community care, where £14 is added to the economy as a whole for every £1 invested.¹⁴ The Public Health England health economic evidence resource (HEER) tool used existing data to highlight that 5 minutes of opportunistic advice offered by GPs in England to patients who smoked produced £31.10 in cost savings per person, compared to no intervention/usual care.^15,16

General practice is expected to respond to limitless demand for services, while hospitals have safeguards in place to ensure safe limits. Our General Election Manifesto calls for the Government to protect patient safety by introducing a national alert system to flag unsafe levels of workload and allow practices to access additional support. The RCGP recommends that each Integrated Care System (ICS) in England should be required to establish alert systems for general practice, similar to the ‘Operational Pressures Escalation Levels Framework' (OPEL) in hospitals. As part of this, there needs to be a nationally agreed framework setting out how ICSs can support practices so that patient safety is protected as much as possible.

The lack of protected time for planning, supervision and professional development has also been identified as a significant challenge for GPs, and an example of substantial disparity when considered alongside the provision for professionals working in secondary care. Our Manifesto calls for fully-funded protected time to support GPs to deliver fundamental activities, including the supervision and oversight of multi-disciplinary team members and quality improvement activities. 

‘Unlike our consultant colleagues in secondary care, GPs don’t have contractual training/service improvement protected time.’ - The Health Foundation (2019)¹⁷

2. Merging the medical registers 

Our recently published Definition of a GP defines and explains the role of a GP as a consultant in general practice, with distinct expertise and experience in providing whole person medical care whilst managing the complexity, uncertainty and risk associated with the continuous care they provide. This definition builds upon our 2019 joint statement (PDF file, 145 KB) with the British Medical Association (BMA) and the General Medical Council (GMC), recognising that GPs are expert medical generalists, and as such are specialists in general practice.¹⁸ GPs have, as with all medical specialties, successfully completed a specialty training programme, and completed their Certificate of Completion of Training, approved by the GMC.

Regulated and maintained by the General Medical Council under the Medical Act 1983, the Specialist Register and GP Register (established 1997 and 2006 respectively) serve to provide assurance to patients, employers, and the profession that a doctor has achieved the standards, knowledge and skills required to practise safely at a senior and independent practitioner level. In line with our 2019 joint statement, the RCGP has long sought a merger of these two registers to form a single advanced medical register for senior doctors, simplifying the structure to formally and clearly assert GPs’ role as specialists alongside their other medical colleagues. 

The College will continue to engage with the GMC and DHSC to push for the relevant legislative amendments to merge the GP and Specialist registers at the earliest opportunity.

3. Addressing inequalities in training and education

GP Specialty Training in the UK is an intellectually rigorous three-year medical training programme, culminating in a tripos of clinical licensing assessments, approved by the GMC. Doctors are required to successfully complete these assessments to achieve their Membership of Royal College of General Practice (MRCGP) and be awarded with a Certificate of Completion of Specialty Training (CCT) in general practice. GPs provide expert care and treatment, responsible for delivering over 90% of all patient contact events in the NHS in England.¹⁹

Learning in general practice and about primary healthcare is vital to the education of future specialists in all disciplines, yet its proportion of undergraduate curricular time is incommensurate. Almost a quarter of all licenced doctors in the UK workforce are registered as GPs, yet previous studies found an average of only 10% of teaching time during the five-year undergraduate medical programme across UK medical schools was being spent in general practice.^20,21 A 2020 study, outlining a snapshot of undergraduate GP teaching across the UK, highlighted that the overall amount of GP teaching at the time was static or decreasing when compared against historical trends.⁹ Post qualification, only 58% of foundation doctors in England completed a general practice placement in 2018/19, and exposure rates to general practice in other areas of the UK, including Wales and Scotland, appear to be even lower.²² Progress has been made in Northern Ireland recently, as the Department of Health (NI) is working closely with Queen’s University Belfast with the support of RCGPNI, to increase the percentage of time medical undergraduates spend in General Practice from a historic level of around 7% to 25% by 2025.²³

Only 10% of the UK undergraduate clinical curriculum was taught in general practice, or by a GP, during the 2017/18 academic year - Cottrell et al., 2020

There is long term evidence of cultural undervaluing and denigration of general practice, by secondary care specialists directed to medical students, although these negative comments can also at times come from within the profession.^24,25,26,27 Both Destination GP (PDF file, 2 MB), and the Wass report By Choice - Not By Chance (2016) (PDF file, 3.8 MB), aimed to build an evidence base on medical students' perceptions of general practice, identifying how and where they may be exposed to misconceptions and negative views.^28,29 These reports highlighted the need for a cultural change in the way all medical colleagues speak to medical students about general practice, and they stressed the importance for further work to tackle the spread of misconceptions and negativity surrounding the profession. Four priority areas identified were the value of peers and role models, impact of clinical contact, the need for an accurate and informed picture of the current and future general practice landscape, and the promotion of general practice opportunities beyond the taught environment. While progress has been made, including the establishment of student-led GP Societies in the majority of UK medical schools, progress on the range of actions within Destination GP and By Choice - Not By Chance need to be revisited and progress evaluated. 

The value of positive and visible GP role models should be fully realised to combat historical denigration, and encourage the next generation of GPs to pursue future roles in academia, leadership, partnerships and wider opportunities.^30,31 In our Fit for the Future: Workforce Roadmap (PDF file, 709 KB) published in 2019, we highlighted that access to substantial high-quality educational placements in general practice promotes student enrolment into specialist GP training, and called for greater opportunities to be in place by 2025.³² The RCGP advocates the need for better support for GPs to offer high-quality student placement experiences in general practice, and the ability to deliver such experiences is limited by significant resource and infrastructure inadequacies, highlighted in our recent infrastructure report (PDF file, 1 MB).³³ There is insufficient capacity to support the current levels of medical students, GP trainees, and other learners, let alone meet NHS England Long Term Workforce Plan (LTWP) proposals for expanding training numbers. Significant and urgent investment in sustainable physical and digital infrastructure, alongside protected learning and supervision time, is critical to fulfil these Government aims to increase the number of GP specialty training places by 45–60% by 2033/34 and the total number of GPs to 53,000 FTE GPs working in the NHS by 2036/37 (LWFP).^34,35

The RCGP has worked closely with the Society for Academic Primary Care (SAPC) to reverse the historical underfunding of undergraduate general practice teaching compared to secondary care. Changes to undergraduate medical funding for clinical placements in England and Wales which were brought into effect in September 2022, with an uplift to reflect inflation for 2023-24, are a first step towards more consistent national resourcing of medical student clinical teaching irrespective of setting.³⁶

There is also concern with respect to the limited funding and opportunity for academic training for GPs. The National Institute for Health Research (NIHR) in England currently funds an average of just 12 GP Academic Clinical Fellowship (ACF) programmes per year, compared with over 40 for surgery and 18 for psychiatry, from a total annual allocation of approximately 280 fellowships.³⁷ NHSE supports very limited numbers of locally funded GP Academic Clinical Fellow programmes and we have heard anecdotal concerns of these having been disincentivised following the incorporation of Health Education England (HEE) within NHSE.

Secondary care specialist training has no provision for training time in general practice, while GP trainees have traditionally spent between approximately 50% to 70% of their time in hospital placements. Recently, the amount of training time spent in general practice for post-graduate GP specialty training increased from 18 months to 24 months, intended to provide trainees with improved placement experiences, promote personalised care, and facilitate relationships with patients, practices, and communities.³⁸ This is something the College had called for and it is a positive step in the right direction. 

Looking ahead, the College is pleased to see the NHS England LTWP proposals to provide all foundation doctors with access to at least one four-month placement in general practice by 2030/31, and possibly to allow GP trainees to spend the entire three years of training in primary care. However, it is disappointing that these improvements will likely take a further five years to be implemented. Building on this, all hospital specialty training programmes should include some time spent in general practice; so that all doctors can understand and effectively navigate the interface between primary and secondary care, working collaboratively to optimise efficiency and patient outcomes.³⁹

4. Academia and research

Providing roles across professions with dedicated time for research drives best practice and evidence-based care; and can also boost retention - LTWP (NHSE)⁴⁰

There is a long-standing lack of research funding and academic focus on general practice compared to other health settings. Most medical research is either laboratory-based, or centred around trials of treatments within a secondary care environment. There is a significant gap in the evidence base looking at general practice and what it contributes to the health of our nation, and how this could be strengthened even further. Examples of impactful research within a general practice context have included the evidence for the benefits of continuity of care, and the responsible use of antibiotics in treating infections while reducing antibiotic resistance. 

Academic GPs play a vital role in the development and delivery of primary care education, research and evaluation, leading to improved outcomes for patients, practice, and the NHS.⁴¹ This was evidenced recently through the primary care trials of treatment options for COVID-19.⁴²  As highlighted in the NHS England LTWP, clinical academics are essential to training future generations of healthcare professionals, and producing insights and innovation through research. These research outputs can drive improvements to the quality, efficiency and sustainability of care delivered within local, regional and national health services across the UK. 

Senior academic GPs make up less than 10% of the UK clinical academic workforce, despite representing almost a quarter of all licenced doctors on the GMC register. There has been only a small increase in the number of UK senior academic GPs, from 224 FTE in 2015 to 263 FTE in 2022.⁴³ Data from the Medical Schools Council (MSC) Clinical Academic Survey reported the proportion of clinical academic GP roles in England, (defined as positions at the professor, senior lecturer, and lecturer level), as remaining 'stubbornly low' with just between 0.6% and 0.7% of total numbers of GPs over a ten-year period (2011 to 2020).⁴⁴ In 2021, only 0.7% of all clinical academics were GPs, versus 5.7% of NHS consultants in England.⁴⁵

The number of academic units of general practice has reduced greatly over the past two decades, with many being subsumed into departments of public health. We have heard anecdotally that pay-scales available for clinical academics are usually lower in comparison to full-time GPs, disincentivising people from taking on such positions. These two factors contribute to the stagnating number of academic GPs. 

The situation for Clinical Excellence Awards to general practitioners is summarised below:

4.1 Statement from Professor John Campbell: Recognition of academic general practitioners 

Senior academic GPs (SAGPs) are eligible to apply for National Clinical Excellence Awards (CEAs), but, unlike all other senior clinical academics and their hospital-based consultant colleagues, do not have access to local awards. SAGPs have been successful in their applications for national CEAs, but with overall lower success rates than for senior doctors across all clinical specialties. Absolute numbers of national CEA award holders are tiny amongst SAGPs, given that GPs represent approximately 40% of the medical workforce. Gender, ethnic background, and pattern of working are all factors known to be of some concern in predicting success in application for national CEAs, with female SAGPs appearing to be particularly disadvantaged. Detailed, reliable, and publicly available data is required to allow for robust comment and comparison regarding the effect of these important variables amongst SAGPs in England and Wales.

Note. According to NHSE Guidance, the National Clinical Excellence Award (NCEA), which applies across England and Wales, is now known as a National Clinical Impact Award (NCIA). 

5. Representation of general practice at a leadership level

Early career GPs do not feel adequately trained for system-based healthcare leadership - Loftus, et al., 2022⁴⁶

It has been estimated that 40% of all fully trained doctors in the UK are enrolled in specialist training for general practice,⁴⁷ yet there appears to be an absence of equivalent numbers of GP representatives in Government, NHS England and other national and representative bodies. The GP Partnership Review report (2019) (PDF file, 393 KB) recommended that general practice must have a strong, consistent and fully representative voice at system level, supported by the implementation of  'By Choice - Not By Chance' (PDF file, 3.8 MB).⁴⁸

Integrated Care Boards (ICB) have a much higher representation of secondary care specialties than of primary care. Boards are required to have only one primary care representative, meaning some ICBs may have no general practice representation at all.⁴⁹ The Fuller Stocktake report (2022) (PDF file, 3.4 MB) recommends a shift to system leadership as the key driver of primary care improvement and development of neighbourhood teams in the years ahead.⁵⁰ The College has long advocated for this approach, with GPs at the centre of system leadership, supported to work within integrated multi-disciplinary health and care teams to ensure patients receive appropriate and timely care for their health needs.⁵¹

Similarly, to ensure maximum impact from the key influencing work undertaken on behalf of the profession, the RCGP is reviewing its officer nomenclature to avoid prevailing confusion between the ‘Chair’ and ‘President’ of the RCGP as compared to other Royal Colleges, who all have a ‘President’. This is subject to an internal review of governance processes and its findings will be put to a vote at a future AGM.

6.1 Summary of recommendations and priority areas:

Priority areas of action

Parity of esteem is an ongoing area of high importance for the College and continuously feeds into the work that we do now, and in planning for the future. It is essential in ensuring that general practice has a proportionate share of NHS resources and development funds and is valued. It also is essential in ensuring that general practice and primary care are consistently and meaningfully included in health service planning and redesign. Our key recommendations are summarised below. 

RCGP also has a key role to play in promoting the importance of the GP role, as set out in our recently published Definition of a GP. We will continue to champion the impact of GPs and the unique and essential role they play in managing the health of the population. We will also continue to highlight the need for GP role models in academic and leadership positions, to enhance the perception of these diversified roles and to promote career opportunities in general practice

Acknowledgements

This position statement has been prepared following a member motion, proposed to UK Council in June 2023 by Prof. Sir Sam Everington, seconded by Dr Gail Allsopp. 

Input has been gratefully received from numerous contributors, and we wish to specifically acknowledge expert guidance from the following people:

• Dr Victoria Tzortziou-Brown
• Professor Kamila Hawthorne
• Professor John Campbell
• Professor Johnny Lyon-Maris
• Professor Joanne Protheroe
• Professor Joe Rosenthal
• Dr Nicholas Thomas
• Christey Blythen
• Ruth Ellenby
• Danielle Fisher
• Mark Thomas