“The Fellowship is breaking, it has already begun”*

James Bennett is a salaried GP in North Yorkshire and an NIHR In Practice Fellow

Joanne Reeve is a GP and Professor of primary care at Hull York Medical School

Life moves fast in general practice. Things can pass you by. The last year has been a time of great uncertainty, and as we begin to ‘work to rule’ it is not slowing down soon. Amongst the changes, you may have missed the decision to cease funding the newly qualified GP fellowship program.¹ For GP trainees and those passionate about the programme this was met with an audible groan of despair.

The New to Practice Fellowship Programme in England was commissioned as one solution to improve workforce retention of early career GPs. Local training hubs designed educational programmes that met the needs of their GPs in the first twelve months of their qualified careers. They provide further education and support, helping those GPs develop the extended skills and confidence needed for sustainable careers in a rapidly changing context. From discussions with colleagues who have been through the programme it works. They are happier, more motivated and feel valued by primary care. Those no longer able to access the programme describe feeling let down and increasingly frustrated before they even qualify. Are we in danger of throwing the baby out with the bathwater on this one?

The potential impact of the programme goes beyond improving GP morale. Patients meet clinicians who can better address their increasingly complex needs in a truly generalist way, helping them navigate the challenges of multimorbidity and evidence-based medicine. Upskilling these GPs potentially reduces the burden of healthcare on individual patients. Retaining those GPs in their practices helps too. We all understand the benefits of continuity of care within clinical teams. Relationship-based medicine makes consulting easier, improves patient outcome, and saves the NHS a lot of money in unnecessary investigations and referrals.²

Earlier this year it was reported that patient satisfaction with general practice has fallen further, a worrying trend since 2018.³ In part due to the struggles patients face with access to care, exacerbated by the steady decline in full time equivalent GPs. Perhaps most concerning is that alongside those taking early retirement the greatest reduction in hours is seen in First5 GPs.⁴ Given this pattern it is reasonable to reflect on why this might be, and how further education and training could help.

Vocational training is mandatory to qualify as a GP, and the shortest speciality training program on offer. Given what is at stake it is trainees quite reasonably focus on passing their assessments and qualifying. Afterall, we need them to! What may be sacrificed is the nuance of applying knowledge in practice as a consultant in primary care. Perhaps this is part of the problem driving newly qualified GPs away from the significant stresses of independent clinical practice.

Addressing the ongoing crisis within the GP workforce requires a combination of innovative approaches. The decision to open ARRS funding to GP recruitment appears sensible, and shows people are listening to the concerns of those at the coalface, but lets not pretend this is anything more than a small funding bolt on. A short term sticking plaster. It will not fix the core issues within the workforce, or acknowledge that newly qualified GPs benefit from increased support in the first few years of their careers.

I am certain that educational intervention needs to be a cornerstone of any future changes to support and nurture newly qualified colleagues. It is up to us to say what we need. Trainees, trainers, First5 GPs and those employing them need to be heard and listened to. We need to learn from the current fellowship programme and consider what comes next. After all, as Gandalf reminds us in a more enduring fellowship, “…he that breaks a thing to find out what it is has left the path of wisdom…”⁵

Perhaps instead we expand – a fellowship scheme for all newly qualified GPs designed into the GP contract. Moving beyond traditional CPD, using education to nurture and hone the skills they possess to enable them to have long and happy careers in the NHS as expert generalists. As NHS England considers what will replace the current program, rather than something completely different maybe we just need fresh water.

*Authors’ note: Last Galadriel’s warning to Frodo in the 2001 film adaptation of The Fellowship of the Ring, by JRR Tolkien.

References

1. Mahase E. NHS England cuts national GP retention schemes in favour of local “support” BMJ 2024; 384 :q135 doi:10.1136/bmj.q135
2. Jeffers H, Baker M. Continuity of care: still important in modern-day general practice. Br J Gen Pract. 2016;66(649):396-397. doi:10.3399/bjgp16X686185
3. D Jefferies, D Wellings, J Morris, et al. Public satisfaction with the NHS and social care in 2023 Results from the British Social Attitudes Survey. The King’s Fund and Nuffield Trust. March 2024. https://assets.kingsfund.org.uk/f/256914/x/48c40ea52b/public_satisfaction_nhs_social_care_2023_bsa_2024.pdf
4. https://www.instituteforgovernment.org.uk/performance-tracker-2022-23/general-practice [accessed 9/9/24]
5. The Fellowship of the Ring by J.R.R Tolkien (Harper Collins 1991) pp.248-254

Featured image by James Lee on Unsplash