Do you still need your licence to practice? – some reflections for British GPs

Amanda Howe is emeritus professor of primary care, Norwich Medical School and a past president of the RCGP, she is on Twitter: @AmandaCHoweRCGP

Mona Aquilina is medical educator and Chair of the RCGP LCARM group

Martin Wilkinson is a GP Appraiser for NHS England

Introduction

To practise as a GP in the UK, you must be registered with the General Medical Council, hold a licence to practise, and have the necessary professional indemnity insurance. This in itself is a complex process, as both those undertaking training in the U.K. or coming to work from elsewhere will know! Retaining a licence to practise requires a five year cycle of annual appraisal and formal revalidation; this was put in place to attempt to ensure professional competence over a working lifetime, though also aims to be supportive, developmental, and to uplift quality. However, this cycle requires active clinical service, with opportunities to undertake patient and colleague feedback, quality improvement work, and a full scope of general practice. For doctors who are doing less than 40 sessions in GP over twelve months, special low volume of clinical work guidance is available,¹ and any GP who takes a break from clinical work will need to retain enough activity to fulfil revalidation requirements, unless they are prepared to give up their licence.

In reality, there are many reasons why GPs consider this; a few examples include working outside the UK for a prolonged period, taking a break due to ill health or the need to care for dependents, or when approaching the stage of retirement from practice. The advantage of giving up a licence to practice is primarily financial – full GMC registration plus medical insurance is costly when income is not coming in. For those who intend to return to U.K. general practice at some point, consideration needs to be given to a number of factors, set out elsewhere.² In this article we out some issues for consideration both at the personal and organisational level for those considering the process of ‘retirement’. We aim to offer some experience to inform others’ thinking, and also to set out issues that bodies such as the RCGP still need to address, in order to maximise workforce potential in the LCARM (‘Late Career And Retired Members’) community.

Things to consider

Many GPs wish to reduce clinical responsibility and hours of work as they move into the last phase of their careers, and there are many ways in which they still can make active and productive contributions at this stage.³ They may wish to change scope of practice, by moving into specific service sectors such as 111 or sexual health provision. They may also wish to continue non-clinical roles such as teaching medical students, or being a GP appraiser; and to continue to offer something through their professional networks such as the RCGP. While the last of these is open to all, altered scope of practice fits badly with the current model of appraisal; and the requirements for a clinical licence vary across different roles. Our first ‘top tip’ is: if you are planning to change roles, including ending work in a general practice setting, talk to colleagues, employers and accountable officers about the implications before you make up your mind. Another tip is to be sure you understand the consequences of giving up your licence.⁴

Other considerations include a personal understanding of the psychological transition that needs to be made when leaving general practice. There is a wealth of academic psychological literature on this subject, with excellent practical summaries,^5,6 and some of our own colleagues have also shared their experience with us.⁷ The RCGP LCARM community (rcgp.org.uk/lcarm)  and its learning events is one place to share and develop our understanding of this aspect: GPs are also able to draw on their life experiences through seeing patients move through a variety of transitions over time. So tip three – learn what this can mean to you before you face the steps of retirement (and put your learning in your last appraisal CPD portfolio!!!).

Of course, even with the most balanced consideration, not all consequences are predictable in advance. The pandemic, with its urgent need for clinicians to support the workforce, threw a harsh light on the lack of a proactive plan for rapid relicensing. Many colleagues found unexpected and undesirable delays in being able to return to the NHS,⁸ and we would expect that the GMC, Royal Colleges, and NHS employers would learn from this to put a better process in place in case of a future national emergency. Colleagues have also reported meeting unexpected requirements for a licence as they seek to take up new nonclinical roles – though there is also anecdotal evidence that some organisations provide their own oversight and appraisal requirements for specific roles, which can expand opportunities and may create better alignment with their needs.

There is also a place for thinking up a level as to the roles that GPs could usefully play in an overstretched workforce. Some people leave because they simply cannot see an opportunity that fits their self assessed ‘best offer’. But there are many aspects of clinical practice which an experienced GP could well support,⁹ given the appropriate contract and greater flexibility in the appraisal process. The GMC allows for three options for transition into retirement: retain a licence to practise, retain registration only or give up registration (voluntary erasure).  After many years of working, jumping straight to erasure is tempting but often later regretted as it can limit other opportunities.

The second option of registration only is an ideal stepping stone into retirement, though not so well  publicised. GPs who have left clinical practice yet continue other medical related activities in their late careers may not require a licence to practise. The much cheaper option of registration only shows you are in a GP in good standing without the need for revalidation. Roles that may allow registration only include appraisal, management, some university, and some RCGP and CQC roles – though often for a limited number of years after leaving clinical practice. Appraisers considering GPs with limited non-clinical portfolios should reflect on whether a licence is required; rather than struggle on with revalidation, the appraisee can be encouraged to talk to their employer and review contractual requirements (as suggested earlier).

The problem with the current situation is that many organisations still appear to automatically require a ‘licence to practice’, even if the role is not a directly patient facing role and requires different competencies . The GMC has provided a help sheet for employees and employers to aid licence decision making¹⁰, and they, with the RCGP and the Academy of Medical Royal Colleges need to give consideration as to some revised model of appraisal that allows such areas of practice within a safe and appropriate context. 

In conclusion

The speciality of general practice is a complex and demanding area to work in, and we all come to a point where it may be neither desirable or safe to continue as GPs. At a personal level, it is important to understand both the professional and psychological processes and implications of substantially reducing or stopping clinical work – and of the formal consequences of giving up your licence to practise. The RCGP, alongside the GMC and BMA, offers members advice and support during this journey. Stepping down to registration only should be explored in late careers.  At the organisational level, the RCGP also needs as part of its strategic priority on GP workforce¹¹ to actively consider the ways in which GPs can continue to contribute to clinical and professional roles when they want to reduce their clinical workload – and when the NHS needs them. Those who are responsible for the current models of appraisal, revalidation, and licensing always have a duty to review whether these are fit for purpose, and to take on lessons from the past. We hope that the experiences of the RCGP LCARM community¹² can help to achieve this going forward.

References

1. NHS England (2019), Supporting doctors who undertake a low volume of NHS General Practice clinical work downloaded 31/8/22.
2. Bhatti N, Waqar S. The GP Induction and Refresher scheme: reflections from doctors. BJGP 2015; 65 (639): 548-549. DOI: https://doi.org/10.3399/bjgp15X687157
3. Aquilina M. Beyond the clinical coalface – utilising the transferable skills and expertise of former GPs within the NHS. British Journal of General Practice 2021; 71 (703): 74. DOI: https://doi.org/10.3399/bjgp21X714761
4. Giving up your licence to practise –https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/changing-your-status-on-the-register/giving-up-your-licence-to-practise [accessed 13/9/22]
5. See for example one brief summary at https://www.psychologytoday.com/us/blog/the-novel-perspective/201203/the-truth-about-transitions
6. Waters A. How can I prepare for retirement? BMJ 2022;377:o1528 doi: https://doi.org/10.1136/bmj.o1528
7. Rughani A. Moving On. BJGP Life. DOI: https://doi.org/10.3399/bjgp20X710561
8. Martin P. BMA News April 2020. GPs are returning to practice – but held up by red tape .
9. Liston A. Is there a role for retired GPs in the post-covid era? BJGPLife April 2022. https://bjgplife.com/is-there-a-role-for-retired-gps-in-the-post-covid-era/downloaded 10/8/22.
10. Employers and healthcare provider/doctor discussion points, GMC https://www.gmc-uk.org/-/media/documents/ckm—licence–to-practise-resources—doctor-and-employer-discussion-list—dc11372_pdf-75186179.pdf [accessed 13/9/22]
11. See for example The RCGP Strategic Plan 2020-2023 https://www.rcgp.org.uk/about-us
12. RCGP, Later Career and Retired Members, https://www.rcgp.org.uk/your-career/later-career-retired-gps [accessed 13/9/22]

Featured photo by Sigmund on Unsplash