Here, we outline some of the context within which this evaluation was conducted. General Practice has a history of employing innovative approaches to selection, so it is important to be mindful of changes that have been implemented in the last two decades. A historical perspective is required to understand the data upon which this report is based: to track trainees from graduation from medical school, working through Foundation then GP training requires a minimum of five years, and often considerably longer. We start with the political context, both in terms of the need for more GP trainees and the different pressures in different parts of the UK.
1.2.1 Political context
A major impetus for this study is the view that more GPs need to be trained. Failure to recruit sufficient GP trainees has been widely reported as a “looming crisis” in the medical press and national newspapers2. The mandate to Health Education England
in May 2013 included “Ensuring that 50% of specialty trainees choose to enter GP specialty training” as a longer term objective (Department of Health, 2013, p17). In 2014, this mandate was worded, “HEE will ensure that 50% of trainees completing Foundation level training enter GP training programmes by 2016” (Department of Health, 2015, p17). As well as setting a date, this changed wording focused on UK trained doctors. The precise targets to be attained by GP recruitment in the UK have though continued to remain unclear, and as the Centre for Workforce Intelligence put it in 2014, “although the Government’s desire for a significant increase in GP training numbers is clear, the magnitude … of the increase is open to interpretation” (p.21). In Chapter 8, we give a detailed consideration of recruitment trends and include two important caveats regarding this 50% target: first, that not all doctors enter GP or specialty training; and second that increasing numbers of doctors are delaying entry (including those training in another specialty directly after Foundation before entering General Practice), so that it could be several years before we know whether the target is (eventually) met.
An awareness of a continuing shortfall in the numbers of GPs being trained, with about 2,700 GP trainees being recruited annually, resulted in the establishment of the GP Taskforce, chaired by Dr Simon Plint, which reported in 2014. “The GP Taskforce was established by Medical Education England (MEE) and the Department of Health (DH) to recommend how the system could achieve the longstanding workforce target for 3,250 trainees to enter GP training in England each year by 2015” (Plint
2014 p3). The taskforce also reported further issues concerning increases in part-time working, significant numbers of GPs approaching retirement age and women in their 30s leaving the profession early. They also noted the extra demands being placed on general practice and concluded, “there is a GP workforce crisis which must be addressed immediately…” (op. cit. p6). Nevertheless, the Migration Advisory Committee felt the GP shortage was insufficiently severe to include General Practice on the Shortage Occupation List as “any shortage of GPs can be addressed by changing the incentive structure such that the GP route becomes more attractive relative to the hospital consultant route” (Migration Advisory Committee, 2015, p2)3.
Despite this political landscape suggesting a sense of urgency, discussions with our Advisory Committee and several other stakeholders gave us a strong message that we should be academically rigorous, avoid knee-jerk conclusions, and consider options regardless of whether they are quick-fixes or longer-term solutions.
From discussion with stakeholders, we understand that the ‘recruitment crisis’ applies much more strongly to some parts of the four countries within the UK than others. We have endeavoured to take a UK perspective throughout, but acknowledge that some parts of this report may not appear relevant to all parts of the UK. Indeed the mandate and taskforce referenced above were focused on England. The target recruitment for England in 2016 is 3,250 trainees. With no significant concurrent increases in post numbers for Northern Ireland, Wales or Scotland, this amounts to approximately 3,750 posts available across the UK . Our modelling suggested an average of 3,014 posts filled per year from 2011 to 2014 across the UK, when the number of posts available across the UK averaged 3,250 per year. Therefore the England target of 3,250 (and 3,750 posts UK-wide) means that filling these posts will be particularly challenging. In Chapter 5, we apply the average number of posts available in the UK for 2011 to 2014, 3,250, when we consider the consequences of using alternative approaches to selection that enable more (or all) posts to be filled, although the methods we describe for evaluating selection methods in this chapter could be applied to any targets. In Chapter 7 (the economic evaluation), both the 3,250 and 3,750 targets are considered. Like Simon Plint5 and his team, we hope that the analyses and recommendations in this evaluation are useful to GP educators
throughout the UK.
1.2.2 Historical perspective of recruitment to GP training in UK “Those who cannot remember the past are condemned to repeat it”
- George Santayana
This section draws upon the reflections of Roger Price, based on his experience of GP selection since 1987.
Prior to about 2000, GP selection was undertaken in local regions of UK and was primarily practice or programme led. Such processes did not have explicit governance, or evaluation by external bodies or candidates. How appointment decisions were made was neither transparent nor explicit; there were no competency-based processes. The interview panel would have read the application which included a CV and biography. Questions asked were often about GP practice of which the candidate may well have had no experience. The approach used by these panels could vary between interviews and interviewers, and certainly between different regions.
Roger was not aware of any training for panel members, other than for basic Equality and Diversity; nor was there calibration of panel members. Trainees were subsequently appointed to a 2-3 year rotation by the local Vocational Training Scheme (VTS) programme, or a group of such schemes acting together in a deanery. An individual training practice might appoint a doctor who only required a single year in practice as a trainee, usually without any external input to the process: this stopped when the Gold Guide was introduced and the Certificate of Completion of Training (CCT) was required.
3 The Plint report advocates such changes, too.
4 Posts available for 2016 are at https://gprecruitment.hee.nhs.uk/Recruitment.
5 In the forward to the taskforce report, Simon Plint wrote: “The statistics and recommendations in this report refer to England, unless specifically stated otherwise,
Since the late 1990s, GP training has undertaken a long process of becoming more explicit and systematic. For example, Pat Lane from Sheffield initiated work in 1996-8 to share knowledge of appointment process and evaluate outcomes between the GP directors and deaneries. With this transparency and evaluations, progress could be made. The three deaneries of North, South and Mid Trent began to use a regional assessment centre to select trainees in 2000. This evolved into a nationally-led recruitment process managed by the GP National Recruitment Office (GPNRO). The national GP recruitment process was based on a multi- source, multi-method assessment derived from a job analysis which enabled the competencies required for success as a GP to be identified (Patterson et al. 2000); this has subsequently been updated and used to revise the selection process (Patterson et al., 2013). (We describe the current selection process in detail in Chapter 2 of this report.) As part of initial development, work was undertaken to determine how the required competencies could be evaluated in written tests of clinical problem solving and situational judgement (also termed Professional Dilemmas), and in an assessment centre (Patterson et al. 2001, Patterson et al. 2009). A systematic approach to training and calibrating assessors was also developed and continues to be used. A number of evaluations of the GP recruitment process have been published (see https://gprecruitment.hee.nhs.uk/Recruitment/
Selection-System-Research-Evaluation), although these have been led by the team responsible for its development and thus
may not be fully independent. We do not summarise all of these studies here, but refer to them in later chapters as appropriate. Roger’s view, in 2015, was that the GP selection system is not perfect, but there is very positive feedback from all involved, including the candidates. Ongoing internal and now external evaluation helps to ensure continuous improvement.