Longer in primary care: a mixed-methods study of the Welsh GP training model

Primary care placements

Survey results show that trainees had positive experiences in general practice settings. They considered that they were provided with relevant learning opportunities, sufficient support, and had few difficulties arranging study leave (see Table 2). Consideration of both the mean and mode values suggests that the differences between the years were not notable.

In 2022 trainees were asked to rate on a 10-point scale how satisfied they were with the amount of time work leaves for family, social, and recreational activities (1 = not at all satisfied; 10 = extremely satisfied). All trainees were on a general practice placement at this stage. The overall satisfaction mean was 7.0, an increase in the mean of 6.6 from the 2021 survey responders. Responders were also asked to rate how much they enjoyed their current placement, on a 10-point scale (1 = not enjoying it at all; 10 = enjoying it greatly). The mean enjoyment score was 7.4; this compares with an overall enjoyment mean of 7.2 from the 2021 survey data (when trainees were on a variety of specialty placements) and for general practice, 7.7.

In terms of skills development, trainers argued that spending more time in general practice enhanced confidence and managing uncertainty, facilitated the development of administration and consultation skills, and chronic disease management. Free-text responses from trainers on the 2021 survey included comments about how greater experience in general practice provided exposure to ‘a wider spectrum of cases and challenges’, enabling ‘greater chance to develop many skills needed to be a good generalist’ (TRS21). Another remarked how trainees could ‘learn more of the admin/management of general practice’ (TRS21).

In focus groups, trainees highlighted that general practice placements are invaluable in meeting educational needs because of the inherent relevance of all experience and the scope to respond flexibly to trainee needs:

‘I think that being in general practice […] you’re learning from absolutely every patient interaction.’ (TEEFG20 2)

‘My next GP rotation, I feel like I can say “give me loads of kids to see please”. And most places will try and help you with it.’ (TEEFG22 2)

Trainers held similar views, suggesting that knowledge gaps can be ‘targeted’ in primary care. For example, one remarked on the 2020 survey that ‘any shortfall in hospital specialties can be targeted in primary care’ (TRS20).

Secondary care placements

Views on the value and quality of secondary care placements within GP training were more mixed, with mean response to statements ranging from 3.4 to 4.8 (Table 3). Compared with responses presented in Table 2, higher proportions of trainees thought that there was too much focus on service provision in hospital placements. Similarly, the response to the statement about difficulties arranging study leave in hospital placements (Table 3) were less favourable compared with the responses to the same statement for GP placements (Table 2).

Service provision was contrasted with educational needs by trainees and trainers alike. Trainees tended to focus on the impact on their learning:

‘I feel sometimes in hospital you’re just there to provide a service and you’re just rattling through people without actually learning.’ (TEEFG20 5)

Trainers linked the tensions between education and service provision in hospital posts to the broader context of the NHS. Some thought that the tension was exacerbated by the pressures on the NHS and accepted that this was a necessary part of the training programme:

‘There’s a little bit too much emphasis on them providing the service than there should be, but that’s because we work in the NHS and it’s under pressure.’ (TRFG20 6)

One trainer thought that hospital placements were ‘a waste of time’ for GP trainees and suggested getting ‘rid of the hospital posts’ (TRFG20 6). Other trainers suggested a less radical change: focusing on outpatients in hospitals in order to provide a more relevant learning experience.

‘If trainees spent more time in outpatient clinics then they would be learning about conditions which they would more often encounter in the community.’ (TRS20)

Trainers noted that specialty knowledge can be acquired not only in hospital placements but also by utilising self-directed learning (SDL) time and attending outpatient and other clinics. Some thought that these other avenues of developing specialty knowledge were more relevant to general practice, diminishing the importance of extended hospital placements as a source of specialty knowledge:

‘Trainees would be better off attending outpatients, endoscopy, theatres. The knowledge and skills gained from this would be more useful for a career in GP [than hospital placements].’ (TRS20)

However, a minority of trainers indicated that spending longer time in general practice might lessen preparedness for practice. For these trainers, hospital placements were fundamental in GP specialty training and reduced exposure to hospital specialties was a notable concern. In their view, lack of experience in hospital specialties led to gaps in clinical knowledge:

‘Fewer hospital posts in the rotation means more people aren’t exposed to key areas (paediatrics, obstetrics and gynaecology and to a lesser extent psychiatry).’ (TRS21)

‘It has reduced their exposure to specialties and therefore their clinical experience, meaning there will be more gaps in their clinical knowledge.’ (TRS21)

A concern about ‘missing out on key specialties’ (such as obstetrics and gynaecology, paediatrics, emergency medicine, and psychiatry) was also expressed by trainees, especially earlier on in their training.

‘The drawback [of the 1+2 model] is that now people are getting only two hospital rotations. Whereas I had three and what you lose out on is a whole specialty.’ (TEEFG21 09)

Benefits and drawbacks of spending more time in primary care

When asked about the benefits and challenges of the 1+2 programme, trainees had more to say about the benefits. Participants often expressed that general practice is the best place to learn to be a GP, therefore, more time spent in that setting was valuable:

‘We’re training to become GPs, so the longer time you have in GP practice, the better.’ (TEEFG22 5)

‘Learning to be a GP in GP land is more relevant than trying to learn to be a GP in hospital.’ (TEEFG22 3)

‘The best place to learn to be a GP is in GP!’ (TRS21)

Trainers highlighted that sufficient time in general practice is important because the role is increasingly complex as health needs of the population change:

‘Trainees need more time in general practice as it is getting more complex […]. We are taking new responsibilities, newer roles, eg., managing chronic health conditions, anticoagulation, comorbidities, and 18 months is not enough to have good experience in all modalities of general practice now.’ (TRS20)

In addition to the clinical knowledge, trainees need to learn about existing resources, make links with colleagues, and develop competence in running a business:

‘I really welcome the change to two years in general practice because there’s so much to learn […]. Knowing what community resources are there. Linking in with other professionals. […] Understanding how practices work, how they generate income.’ (TRFG20 2)

However, trainers also noted that an increased number of trainees place greater demand on the time and attention of GP trainers, and on the physical space in general practice surgeries:

‘Ideally would need more rooms/larger premises/more GP trainers. More time in general practice means more trainees in general practice and a lot more burden on surgeries. This is time-consuming and very stressful for trainers.’ (TRS20)

In the surveys, trainees were asked to indicate the extent to which they agreed or disagreed with the statement: ‘I am confident that at the end of my programme I will be prepared to practise as a GP.’ In 2022 the mode was 6 (strongly agree) and all bar one at least slightly agreed (see Table 4). These results represent a small increase in the level of agreement compared with 2021 (when the mode was 5) and those results were very similar to 2020. When responses were cross-tabulated with the model of programme (traditional or 1+2), the pattern was broadly similar. Numbers disagreeing were too small for statistical analysis.

When asked in 2022 whether a reduction in the number of hospital posts would weaken a trainee’s preparedness for practice, about half disagreed (53% gave a rating of 1 or 2; the percentage disagreeing was lower in 2021, 45%). A complementary statement read ‘two years in general practice will improve trainees’ preparedness for practice’. The great majority agreed or agreed strongly with the statement in 2022 and the mean was 5.3. The results were similar to the 2021 survey, where the mean was 5.2.

When asked in 2022 whether the benefits of the 1+2 model outweigh the drawbacks, all agreed. This represents an improved response compared to the 2021. All agreed (at least slightly) in 2022 that GP posts are the best place to develop the knowledge and skills needed for a career in general practice. These results are very similar to the previous survey. At the end of the focus group discussions in 2022, we asked trainees to indicate their preferred model of training. Thirty-one trainees preferred the 1+2 model over the traditional model, with only one trainee favouring the traditional model. The focus groups provided further indication that trainees changed their opinion during training increasingly favouring the 1+2 model as they progressed through the placements:

‘At the beginning of the rotation, I felt a bit apprehensive about the 1+2. Because at that point you feel like you want more hospital postings, like that will prepare you to be a GP. But now in retrospect, I think the 1+2 actually […] addresses what you need as a GP trainee.’ (TEEFG22 1)

Trainees highlighted the benefit of gaining experience in an additional general practice placement. Working in more general practice settings allowed them to experience different working cultures, administrative processes, and work with different types of patients. These varied experiences could have a notable impact on how confident they felt about their career choice:

‘The 1+2 is very good for going to three different GP practices over time. […] it puts you in a much more powerful position to know what you want personally. What deprivation group, whether you want to go and work in the wealthy areas or the poor areas.’ (TEEFG22 2)

Trainer views about the impact on the 1+2 model were more ambivalent. The proportion of trainers indicating that benefits of the 1+2 model outweigh the drawbacks dropped from 74% in 2020 to 59% in 2021 (see Table 5).

The idea of a 4-year training programme was discussed and proved to be a divisive topic among trainers and trainees alike. Trainees who began specialty training immediately after foundation training were receptive to the idea of extended protected training time. Trainees who had experience in other specialties or were less-than-full-time tended to be somewhat resistant to the idea of extending the training programme. Trainers also highlighted that moving to a 4-year training programme would have implications for those on the current 3-year programme.