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from 2002 to 2013. The number of practices involved in teaching doubled between 1986 and 2013, and while departments of general practice did not exist prior to 1968, all medical schools had them by 2002, although that number subsequently fell to under 50%.

While all students are now exposed to GP teaching, in contrast to the situation in the 1960s where barely any students experienced GP, Lancaster (Lancaster, 2015) has emphasised, taking the long view into account, that while undergraduate teaching had undoubtedly increased dramatically since the 1960s, that same period overall saw a relative decline in the numbers of doctors becoming GPs. This inevitably raises some doubt about the specific influence of GP teaching on long- term trends, which may reflect other changes in the profession or wider society.

Lancaster’s finding raises many questions about the nature of the influence of undergraduate GP teaching on deciding to become a GP. In particular: might GP teaching only have an influence on those who are already interested in GP as a career; might GP teaching be putting off some students who might otherwise have considered it later; and are specific schools particularly adept at encouraging medical students to become GPs, perhaps through their teaching? In a separate chapter we report details of the questionnaire study of applicants to the 2015 specialty selection round, which does suggest that experience of GP in medical school and particularly after medical school are important in influencing the decision to apply for GP training.

This chapter will look at a number of different issues:

1. Historical trends: How has the proportion of doctors becoming GPs changed in recent years, with ‘recent’ being defined in terms of the life-time of the older doctors working in the NHS? If proportions are stable then they may be hard to change, whereas if they are more labile then there may be more opportunity to influence them (but those forces may also put people off becoming GPs). These questions can mainly be answered by looking at doctors on the Medical Register.

2. Recent trends in applications for and completion of GP training: For cohorts graduating since about 2000 it has become possible to monitor when doctors enter the GP Register (introduced in 2006). Applicants for GP training can also be monitored for the selection rounds for 2009 to 2015 (graduation cohorts from 2007 to 2013), giving an assessment of the time of the first serious statement of intent to become a GP.

3. Attitudes and intentions towards a career in General Practice. When do students and doctors develop an intention to become a GP, and how likely is it that intentions eventually manifest as actually becoming a GP? Occasional suggestions in the literature that it might be better if some medical schools were only to train GPs implicitly assumes that would-be GPs can reliably be identified before entry to medical school. A number of studies bear on this question, including the work of the Oxford Medical Careers Research Group (MCRG), a series of three large cohort studies originating in St Mary’s in the 1980s and 1990s, and smaller studies, particularly of 16-year olds and 11-year olds.

4. The general influences of background and medical training on becoming a GP: How do demographics (sex,

ethnicity) and family background (doctors as parents or in the family) influence becoming a GP? How do intentions change through medical training, and what is the influence of perceived quality of GP training?

5. The particular influences of specific medical schools: Some medical schools produce more GPs than others, but why that is so is less clear; do the students differ when they enter medical schools (differential selection); are they influenced differently by their medical schools (differential training); and do students from different medical schools fare equally well during GP training? Once again, it is an issue going back to the Todd report of 1968:

“First year students at Oxford and Cambridge differed greatly from students in other schools, opting … considerably less often for general practice [with final year students showing the same pattern]. … Students in provincial schools in both years showed greater preference for general practice… ” (pp 359-360).

However, the Report also commented:

“Our studies do not suggest that a major effect on the part of a medical school to interest students in general practice results in a larger number choosing that career.” (Royal Commission, 1968) p.358, our emphasis).

None of the studies or the datasets to be looked at below has all of the necessary information to answer all of the questions asked above, but together, as a mosaic, they allow the broader picture to be seen.

8 .2 HISTORICAL TRENDS

Since 2006, all doctors working independently as GPs have been required to be on the GMC’s GP Register (and doctors working as other specialists have been required to be on the GMC’s Specialist Register since 1996). The GMC’s LRMP (List of Registered Medical Practitioners), which includes all doctors, whether or not they are on the GP and/or Specialist Registers, , therefore makes a good starting point for looking at the proportion of GPs and Specialists, organised by the year (cohort) in which the doctors graduated. Each doctor can be identified by their unique GMC registration number. The present analysis is based on the LRMP of May 2015, and includes both doctors who are living and practising, as well as those who no longer have a licence to practise, or who are deceased. Figure 8.1 shows the numbers of doctors in each graduation cohort, whereas Figures 8.2 and 8.3 show the proportions of doctors in each graduation cohort, broken down in each case by whether they are on the GP or Specialist Registers.

Figure 8.1 shows the numbers of doctors on the LRMP from each graduation cohort, separated into UK and non-UK graduates. The various stages of expansion of UK medical schools are readily seen. Numbers of non-UK graduates are more complex as doctors only come onto the GMC LRMP when they are permitted to practise in the UK, which may not be until they start specialty training (or later). Doctors on the GP Register are shown in green, those on the Specialist Register in red, a very small number on both Registers in orange, and those on the LRMP but on neither Register in grey.

Figures 8.1a and 8.1b are not easy to interpret, not least because the number of doctors from each cohort varies, typically increasing with year. Figures 8.2a and 8.2b show the same data but with the proportion of doctors on the GP and Specialist registers shown. Considering UK graduates, doctors graduating before about 1970 are less likely to be on either Register, probably due to them retiring before the registers were introduced, and they can be ignored for present purposes. Proportions on the Registers after about 2000 for the Specialist Register, and about 2006 for the GP register are confused by doctors not always having had time to get onto the Register by 2015, the date of the recent LRMP which was used. However from 1970 to 2000 several patterns are very clear:

1. Those on neither Register: About 15% of UK graduates are not on either Register, suggesting that their

practice or careers did not involve seeing patients or making clinical decisions, or were practising in roles that did not require GP or Specialist Registration. This proportion is surprisingly constant, but highlights the importance of correctly interpreting the DoH[England]’s target that “[I]n future at least half of doctors going into specialty training will be training as GPs.” [2008] (Department of Health, 2008) (p.15, para 36, our emphasis). However Peile’s interpretation of the target as “... 50% of new medical graduates should be recruited to general practice” (Peile, 2013) (p.565) would increase the target by 7.5 percentage points.

2. The GP register: For graduates from about 1974 to 1987 about 46% of all graduates were on the GP Register, and indeed 54% of those taking any form of specialist training were on the GP Register. From 1974 to 1987, therefore, the DoH [England]’s post-2008 target was being met. The proportion of GPs then falls quite quickly for four or five years from 1987 to 1991, and then again is stable for graduates from about 1991 to 2005, averaging about 36% of all graduates entering the GP Register (and they are 42% of all those completing GP or specialty training). That change can also be seen clearly in the longitudinal data from the MCRG for the 1983 and 1988 graduation cohorts (Lambert et al., 2002).

3. The Specialist Register: The proportion of doctors on the Specialist Register largely mirrors that of doctors

on the GP Register, since the proportion of doctors on neither Register remains fairly constant, of all those completing GP or specialty training). That change can also be seen clearly in the longitudinal data from the MCRG for the 1983 and 1988 graduation cohorts (Lambert et al., 2002).

4. Non-UK graduates: The picture for non-UK graduates is more complex, and harder to interpret. About

40% of doctors are not on either Register, a higher proportion than for UK graduates, presumably because more of them take Specialty Doctor roles. For graduates from about 1962 to 1974 about 31% were on the GP register, but that proportion fell quickly between about 1974 and 1982, after which the proportion then was stable once more at about 13%. The result is that amongst recent graduates, only about 30% of those on the GP Register are non-UK graduates, compared with about 50% of those on the Specialist Register. These figures suggest that GP is less popular amongst non-UK graduates than Specialty training

» Figure 8.1: The numbers of doctors in each graduation cohort on GP and specialist registers3_{: (a) UK graduates, total}

numbers; (b) non-UK graduates, total numbers3_.

(a) (b)

GP register

Specialist register

3 _{The cohorts labelled in Figures 8.1 (a) and 8.2 (a) relate to cohort studies described later in this chapter.}