Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan
Can you put a price on producing a GP? Producing and packaging a fresh out of training GP will accumulate costs at the individual and societal level. In an era where difficulties in GP recruitment and retention are having significant impacts on the workforce, will knowing the ‘value’ of a GP give us any clues as to the projected cost in terms of loss to the system if that GP eventually leaves the NHS?
Personal costs
The personal costs of medical school are ‘bewildering’ to work out as they depend on which of the four UK countries students ordinarily live, whether medicine is being taken as a second degree, and personal circumstances such as age and domestic income.1 Currently in England, medical students pay tuition fees for four or five years of medical school at the rate of £9250 per year. These tuition costs have ramped up steadily since 1998, and again from 2012 with the tuition fee hike ,and accordingly, the burden of student loan debt for tuition and living costs has accelerated over the past two decades. Students graduating from higher education in England in 2022 have an average student debt of £45,150, more than three times the average of those graduating in 2009.2 This average across all undergraduate degrees doesn’t reflect the range of debt for medical students who pay an additional one to two years of tuition compared to those on three year courses, with some medical students amassing debts of over £100,000. The fun doesn’t stop upon qualifying from medical school for those entering GP training, with mandatory registration to the General Medical Council, training portfolios and the cost of exams.
The cost to the individual is hugely variable and dependent on several personal and contextual factors, but the overall personal cost of becoming a GP can easily top out over £100,000. This high personal cost is an investment in a career with a fairly guaranteed and competitive income (at least at the point of completing training – just ask the junior doctors striking for pay restoration).
National costs and a loss of investment
Aside from the cost to the individual, substantial training costs to ‘make’ a GP are borne by the government (and therefore in essence the taxpayer), the wider NHS and individuals providing the training. What is the societal cost to train a GP?
…will knowing the ‘value’ of a GP give us any clues as to the projected cost in terms of loss to the system if that GP eventually leaves the NHS?
Training a GP costs money in terms of infrastructure and time investment from educators and patients. Each year, a team of researchers based in Kent and York produce the Unit Costs of Health and Social Care report, and their 2022 analysis suggests that the total investment to ‘create’ a GP including tuition, overheads and salary costs is £430,540.3 This is an investment that is made, I suppose, with some expectation that this GP will contribute back to the public through working in service, in the NHS. But the options for GPs completing their training and thinking of leaving the NHS are numerous. Medical degrees and the MRCGP are highly portable qualifications, and GPs are highly sought after in Australia, New Zealand and Canada, where working conditions and salary may be more attractive for some. General practice is in the midst of a workforce crisis, with up to a third of GPs planning to leave direct patient care in the next five years through alternatives such as early retirement or moving into the private sector. Can these losses be mitigated?
A number of initiatives, including ‘New to Practice Fellowships’, the ‘Induction and Refresher Scheme’ and the ‘GP Retention Scheme’ aim to maintain and increase high levels of participation in the primary care workforce. These schemes are not cost or time neutral, for instance, the New to Practice Fellowship pays to release GPs from a clinical session each week to participate in Fellowship activities. Do the costs of these schemes pay off against the potential losses within the workforce? An cost-effectiveness analysis published in the BJGP suggested that the cost of the induction and refresher and retention schemes was £1240 per expected subsequent year of work, compared to £4430 for the Retention Scheme, and much less than the £11600 per year cost of the GP training scheme, so these schemes operate at a cost many will argue is worth paying to retain a skilled workforce.4 This analysis didn’t look at the direct retention effects of these schemes, or the cost-effectiveness of some of the newer initiatives, so in order to understand their effects they do need close evaluation.
But what is the true value of a GP, and the real loss if they leave the workforce? Can you really put a price on any of it?
The true value of a GP
This has been a discussion of some of the numbers. But what is the true value of a GP, and the real loss if they leave the workforce? Can you really put a price on any of it? John Berger wrote, that ‘…we, in our society, do not know how to acknowledge, to measure the contribution of an ordinary working doctor. By measure I do not mean calculate according to a fixed scale, but, rather, take the measure of.’5 In her updated look at another ‘fortunate’ doctor, Polly Morland argues that we need to both measure the value of general practice by calculating its value and taking the measure of it, to see the true value of what GPs provide to their communities and to know why general practice is something worth fighting for.6 The personal cost of training is an investment each GP makes in their own future, but if they leave the NHS, the societal cost of their training and the true lost value to their local communities is a sunken investment that is unmeasurable.
References
1. Medical student finance: British Medical Association; 2023 [Available from: https://www.bma.org.uk/advice-and-support/studying-medicine/becoming-a-doctor/medical-student-finance.
2. Student Loans in Englang: Financial Year 2021-22: Student Loans Company; 2022 [Available from: https://www.gov.uk/government/statistics/student-loans-in-england-2021-to-2022/student-loans-in-england-financial-year-2021-22.
3. Jones KW, H.; Birch, S.; Castelli, A.; Chalkley, M.; Dargan, A.; Forder, J.; Gao, m.; Hinde, S.; Markahm, S.; Ogunleye, D.; Premji, S.; Roland, D. Unit Costs of Health and Social Care 2022. Canterbury: Personal Social Services Research Unit; 2022.
4. Harris M, Morison J, Main P. GP induction and refresher and retainer schemes: are they cost-effective? Br J Gen Pract. 2014;64(618):46-7. https://bjgp.org/content/64/618/46
5. Berger J. A Fortunate Man: The Story of a Country Doctor. Edinburgh: Canongate Canons; 2016.
6. Morland P. A Fortunate Woman: A Country Doctor’s Story. London: Picador; 2022.
Featured photo by Elena Mozhvilo on Unsplash
Thanks for an interesting and thought provoking article.
You say: “the total investment to ‘create’ a GP including tuition, overheads and salary costs is £430,540, This is an investment that is made, I suppose, with some expectation that this GP will contribute back to the public through working in service, in the NHS.”
But does this take into account the monetary value of the trainee’s service element throughout FY & their Trainee years? (This, surely, is the main reason for the salary?) Should not this value be subtracted from the £430K “cost” of training a GP in order to calculate a true cost? (Or has this already been done?)
Thanks @David – good point and I’m not sure the salary component in the Unit Costs of Health and social care (available here: https://kar.kent.ac.uk/100519/1/Unit_Costs_of_Health_and_Social_Care_2022%20%287%29.pdf, page 116) takes into account the monetary value of the service provided by trainees. I expect, as it’s presented in this document, that it’s just the investment cost, but I could be wrong.