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Reflections on thirty years of GP training

Huw Morgan, GP Training Programme Director, Bristol

Tuesday, 6 March 2012

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I did my GP training in one of the then fairly new three year schemes from 1977 to 1980. Going straight into a partnership as a principal with my shiny new MRCGP diploma, I became a GP trainer in 1984 and a VTS course organiser in 1987, a post I held in various forms until 2002 when I left the NHS to work in developing countries in GP education. I returned to the NHS in 2009 and have again been a GP training programme director (the latest title for what used to be ‘course organiser’) in the same training scheme as previously.

" Back in the late seventies, [GP training] had a ‘creative cottage industry’ feel about it. [...] Horrifying as it now seems, compulsory GP training was not on the statute books until 1981. 

 

 

 

It is interesting to look back and note the change and development that has occurred in GP training in my professional lifetime. Back in the late seventies, it had a ‘creative cottage industry’ feel about it. This reflected the nature of General Practice at the time, which was in the middle of what is now regarded as the ‘golden era’ that lasted from the positive legislative changes of 1967 until the first of the ‘new’ contracts in 1990. Horrifying as it now seems, compulsory GP training was not on the statute books until 1981, when a year as a trainee became compulsory, rapidly followed by mandatory three year programmes in 1983. These allowed great latitude in the types of jobs that could be regarded as appropriate for GP training, and many doctors constructed their own schemes and did jobs in many parts of the country, even getting SHO posts in Australia and New Zealand to count. The authority at the time was the JCPTGP (Joint Committee on Post-Graduate Training for General Practice), who decided whether or not a job could be counted as part of a three year scheme. The role of the training scheme organisers back then was to try to stitch together a rotation of suitable jobs based on the local hospitals so as to offer a three year programme to a small number of those who wanted it, as well as co-ordinating the much larger number who turned up in the area wanting just to do their trainee year in a local practice, and run suitable weekly educational sessions for both these categories of trainees. There was no end-point assessment in those days other than a sign-off by the trainer in the practice where the trainee had been for their final year.

" The emphasis then was entirely on clinical standards, and hardly at all on educational input.

Selecting and monitoring of training practices was a big part of the local course organisers’ role then, the biggest issue being whether the putative training practice had adequate numbers of satisfactory record summaries to make them safe and accessible for a trainee to come in and see what was happening with their patients. Reading and counting record summaries was a major issue on every training practice visit (this was gradually superseded by the advent of computerised records). There were other ‘criteria’ that training practices had to meet, decided by local committee but with some degree of national co-ordination. These included disease registers and adequate numbers of various preventative and screening measures such as cervical smears. The emphasis then was entirely on clinical standards, and hardly at all on educational input.

" In the early 1990’s, (following the tragic death of patients apparently at the hands of recently signed-off new GPs) compulsory summative assessment as an end point to GP training was introduced.

In the early 1990’s, (following the tragic death of patients apparently at the hands of recently signed-off new GPs) compulsory summative assessment as an end point to GP training was introduced. This altered the nature of GP training, and the half-day release programmes (universally referred to as ‘play school’) run by course organisers had to become more focussed on preparing trainees to pass the video component of summative assessment. The late eighties and early nineties had been a time of exciting development of educational expertise for VTS course organisers, many of whom gained significant skills as educators and small group facilitators that enabled them to take a lead in training trainers and stimulating good teaching beyond the confines of General Practice and the NHS. Their expertise was sort by development agencies helping the post-communist ‘restructuring’ countries to establish British style General Practice.

" There was a gradual shift from focussing on the clinical standards of training practices to the development of educational standards [...] The advent of Clinical Governance [...] temporarily created a ‘what are we going to do now?’ feeling amongst the great and the good who controlled the various training monitoring committees.

During this time there was also a gradual shift from focussing on the clinical standards of training practices to the development of educational standards, and the importance of the teaching time-table and weekly tutorials started to take centre-stage on the training practice visits. This shift was cemented after the 1997 general election and the endless cycles of NHS management change began in earnest. The advent of Clinical Governance initially rather took the wind from the sails of the post-graduate GP training establishment, as all practices now had to demonstrate defined clinical standards. (I remember being amused by this at the time, as it temporarily created a ‘what are we going to do now?’ feeling amongst the great and the good who controlled the various training monitoring committees.) The emphasis then appropriately shifted to educational criteria and standards for trainers and training practices, and courses to prepare new trainers and support existing trainers continued to be stimulating and innovative educational events. The new Foundation Year doctors were now doing 4 month placements in General Practice, which was a new and stretching challenge for trainers.

" The next big thing was the inevitable evolution of summative assessment to the nMRCGP as the compulsory end point of GP training.

The next big thing was the inevitable evolution of summative assessment to the nMRCGP as the compulsory end point of GP training, in parallel with the establishment of a national recruitment process and fixed compulsory three year schemes in each region. I was working overseas when all this happened, and returned to a UK GP educational world dominated by a series of new initials – AKT (applied knowledge test), WPBA (workplace based assessment), CSA (consultation skills assessment) and the weekly struggle with the eportfolio that records each trainees progress in painstaking detail. These massive changes not surprisingly temporarily dominated trainers’ educational events, but have now largely been absorbed and the focus on facilitating learning has been restored (at least until the next seismic upheaval).

" Personally I can look back with gratitude on a career in GP education that has not only allowed me the privilege of facilitating the learning and development of many young colleagues, but has also been a rich source of personal and professional growth through working with many like-minded souls.

The changes in that have occurred in training in the last thirty years are rather like those in General Practice itself. Continuing top-down management has altered many working practices, set national standards and targets resulting in generally improved patient care (perhaps), but hasn’t really altered the fundamental nature of the doctor-patient consultation. So in GP training there is much more standardisation, control and monitoring, but the core task of facilitating professional growth and attitudinal self-awareness in young doctors has remained the same. Personally I can look back with gratitude on a career in GP education that has not only allowed me the privilege of facilitating the learning and development of many young colleagues, but has also been a rich source of personal and professional growth through working with many like-minded souls, and has opened doors to other cultures and educational interactions with doctors in many diverse nations.

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