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CHAPTER What is general practice?
General practice intheUK
In 948 the National Health Service (NHS) was formed, giving free
healthcare for the entire population of the UK paid for by the taxpayer. Its
structure varies from country to country within the UK. However, GPs form
the ‘front- line’ of the NHS in all four nations, providing primary medical care
and acting as ‘navigators’ to the rest of the health/ social care system.
Workload ~97% of the British population is registered with a GP. Patients
register with a practice of their choice— whole families are often registered
with the same practice. Once registered, patients stay with that practice for
an average of 2y. GPs carry out ~300million consultations/ y in England
alone:84% at the surgery, 2% by telephone, and 4% at the patient’s home.
70% of the GP’s total workload is spent with a patient, while >20% is currently spent on administration.
Working hours Standard practice working hours are 8 a.m.– 6.30p.m.
on normal working weekdays. GP days are usually broken into 2‘sessions’,
each lasting a notional 4h 0min. Atraditional working day for a GP involves
2 surgeries seeing patients with time for home visiting and administrative
work between. However, the UK government has committed to extend
routine primary care access into evenings and weekends and dierent
models to achieve this are evolving. With these changes, the concept of
‘sessions’ and standard working hours is being lost.
Primary care provider or ‘practice’ Terms used to designate any
organization providing NHS primary care services.
Practice list All patients registered with a particular primary care pro-
vider. Lists may be open (accepting new patients) or, by agreement with the
PCO for a set period of time, closed to new patients— E p. 40.
Practice boundaries Traditionally, practices have set geographical
boundaries agreed with their PCOs. The practice only accepts new patients onto the practice list who live within that boundary. Practices are
also required to set ‘outer boundaries’ to enable existing patients who have
moved home to stay with their practice.
Patient Choice Scheme Since 205, practices in England may accept out- ofarea registrations without obligation to provide home visiting services. If
too ill to travel to their registered practice, patients can access urgent medical care via the NHS service.
Primary care contracts The provider contract with the local PCO de-
nes services primary care providers will provide, standards to achieve, and
payment they will receive. Contract models:E p. 32.
Commissioning Over the past 0y in the UK, mechanisms have
evolved to enable local commissioning of services to meet local needs.
Commissioning aims to design improved patient pathways while enabling
more ecient use of funds. The commissioning cycle involves:
• Planning Establishing what local services exist and what is needed
• Commissioning services To match resources to need
• Monitoring Ensuring that service delivery meets expectations
• Revision Regular review of services to provide best possible care
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GENERAL PRACTICE INTHEUK
Primary care/GP networks and federations Multiple practices
coming together in some form of collaboration. Many dierent models are
in operation from loose alliances to formation of companies. Working at
scale enables sharing of costs and resources, greater exibility, more protection against nancial pressures, and the capacity to oer extended or
new services for patients in the community.
Models of care in England The ‘NHS Five- year Forward View’ (204)
set out a blueprint for change in NHS England, setting out 7 new models of
more integrated care including:
• Multispecialty community provider (MCP) GPs and practices working
together in networks/ federations and collaborating with other health
and social care professionals from primary and secondary care to
provide more integrated services in the community
• Urgent and emergency care networks Emergency departments in
hospitals, working together with GP out- of- hours services, urgent care
centres, minor injury units, NHS , and ambulance services to ensure
people with urgent care needs get the right level of support in the right
place at the right time, making best use of limited resources
• Enhanced health in care homes Brings together care home providers,
NHS, and social care services to improve care for this vulnerable section
of the community
• Primary and acute care system (PACS) Asingle provider or group of
providers working together take responsibility for delivering the full
range of primary, community, mental health, and hospital services for
their local population
Sustainability and Transformation Partnership/ Plan (STP)
44 covering England. Local NHS organizations and councils working together to draw up a plan to improve health and care in the areas they serve.
The plan must set out practical ways to achieve better health and improved
quality of care delivery within nancial constraints.
Accountable care systems/ organization (ACS) An evolved ver-
sion of a Sustainability and Transformation Partnership in England. Asingle
body— usually comprising NHS organizations ± local authorities— takes
responsibility for the entire local healthcare system. This body holds the
whole local budget and both commissions and provides services to meet
the health (± social) care needs of its local population, taking complete responsibility for resources and population health.
Integrated care in Scotland, Wales, and Northern Ireland
While the ‘NHS Five- year Forward View’ only applies to England, similar
changes are occurring across the UK with a move to larger primary care
networks of providers, providing a wider range of services over extended
hours and oering integrated primary, secondary, and social care.
Further information
NHS England (204) NHS Five Year Forward View. M https:// www.eng-
land.nhs.uk/ wp- content/ uploads/ 204/ 0/ 5yfv- web.pdf
NHS England (207) Next Steps on the NHS Five Year Forward View.
M http:// napc.co.uk/ wp- content/ uploads/ 207/ 09/ NEXT- STEPS- ONTHE- NHS- FIVE- YEAR- FORWARD- VIEW.pdf
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CHAPTER What is general practice?
Becoming a GP intheUK
GP vocational training Involves 3y full- time (or equivalent part- time)
specialty training after the Foundation years; 8mo in selected hospital specialty posts and 8mo as a GP registrar in general practice.
Recruitment and selection There are 2 rounds of GP recruit-
ment each year in the UK. Applications are made online to the National
Recruitment Oce for General Practice Training (NRO):
• All applicants meeting GP training entry criteria are invited to sit a
machine- markable test, the Multi- Specialty Recruitment Assessment
(MSRA); candidates scoring ≥575 move directly to ‘oer’ stage
• Candidates scoring <575 on the MSRA attend a selection centre at
their preferred location. Selections centres in England are the regional
deaneries; Scotland, Wales, and Northern Ireland each have a single
selection centre. Assessment comprises 3 simulation exercises and a
written exercise. Following assessment, the highest ranked applicants
are oered training places in that area. Appointable candidates without
training places can opt to select other areas with remaining places
Criteria for training practices Each region sets its own criteria for se-
lection of practices to train prospective GPs. Practices must have a suitably
qualied GP trainer, and demonstrate high- quality administration, clinical
care, and commitment/ capability to educate a GP registrar. Details of local
requirements can be obtained from regional deanery oces.
RCGP GP curriculum Consists of a single curriculum statement, ‘Being
a General Practitioner’, covering the core capabilities and competences of a
GP. This is supported by a series of ‘topic guides’:
Professionalcapabilities
• Consulting in general practice
• Equality, diversity, and inclusion
• Evidence- based practice, research,
and sharing knowledge
Stages oflife
• Children and young people
• Reproductive health and maternity
• People living with long- term conditions (including cancer)
Clinicalissues
• Alcohol and substance misuse
• Cardiovascular disease
• Dermatology
• ENT, oral, speech, and hearing
• Eyes and vision
• Gastroenterology
• Genetics/ genomics
• Gynaecology and breast disease
• Haematology
• Immunology and allergy
• Infectious disease and travel health
• Mental health
• Improving quality, safety, and
prescribing
• Leadership and management
• Urgent and unscheduled care
• Older adults
• People at the end of life
• Metabolic problems and
endocrinology
• Musculoskeletal
• Neurology
• Neurodevelopmental disorders,
intellectual disability, and social
disability
• Population health
• Renal medicine and urology
• Respiratory
• Sexual health
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BECOMING A GP INTHEUK
Membership of the RCGP (MRCGP) The MRCGP is an examin-
ation of professional competency based on the GP curriculum. Passing the 3
dierent components of the MRCGP is compulsory for all doctors wishing
to become GPs in the UK:
Applied Knowledge Test (AKT) 200 multiple- choice questions test whether the
candidate can apply knowledge in the context of general practice. Computerbased assessment held at Pearson VUE centres across the UK. Questions are
distributed as follows:clinical medicine (80%); administration and informatics
(0%); and research, appraisal, evidence- based medicine, and statistics (0%).
Clinical Skills Assessment (CSA) Mock surgery in which patients are played by
actors. The candidate performs 3 consultations each of 0min duration
while being observed by an examiner. Only available at RCGP Euston; takes
place in February, May, and November each year.
Workplace- Based Assessment (WPBA) Continuous qualitative assessment of
performance in training based on the Trainee ePortfolio (TeP) and trainer’s
report. Evidence collected is reviewed ≥×/ 2mo by the deanery Annual
Review of Competence Progression (ARCP) panel to ensure the trainee is
ready to move to the next year of training.
Certication of Completion of Training (CCT) During training,
on completion of each placement, the clinical supervisor completes an
assessment of the trainee’s performance. The GP educational supervisor
signs this assessment o as conrmation that there has been satisfactory
progress in acquiring the relevant curriculum competencies. The portfolio
of assessments is reviewed and endorsed by the deanery at least annually
(ARCP review). Submission of this portfolio together with successful completion of the MRCGP enables a GP in training to apply for the CCT via the
RCGP certication unit.
RCGP Certication Unit Evaluates general practice training and makes
recommendations forCCTs to the GMC. Anyone undertaking a training
programme leading to a CCT should register with the Certication Unit.
Certication of Eligibility for GP Registration (CEGPR) An al-
ternative route for doctors who have completed the CCT programme and
passed either the AKT or CSA after leaving the programme, or are not eligible for a CCT but believe that their training, qualications, and experience
are equivalent (e.g. all or part of their training was outside the UK, or in a
non- approved training post). Trainees who begin a 3y planned programme
for a CCT and decide to shorten it, by including posts not in their GP programme, must also apply for a CEGPR. This type of application is more
complex and time- consuming than the CCT route. Application is online to
the GMC with submission of a portfolio of evidence.
Further information
National Recruitment Oce for General Practice Training (NRO)
M https:// gprecruitment.hee.nhs.uk/
RCGP F 020 388 7400 M www.rcgp.org.uk
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CHAPTER What is general practice?
Education inprimarycare
Education is vitally important in primary care to keep healthcare professionals up to date with both clinical and administrative/ managerial parts of
their roles, and to provide career development and direction.
Teaching in general practice Many GPs are involved in teaching:med-
ical students, foundation doctors, GPs in training, new practice sta, and/ or
their peers. Teaching can be very rewarding but also brings stresses (e.g.
preparation of material). Payments are available to GPs who take medical
students, foundation doctors, and/ or GPs in training into their surgeries for
teaching and there are a few teaching posts within UK universities for GPs.
0 As a teacher it is your responsibility to ensure you are competent to full
the task. Take steps to acquire prociency in teaching skills. Local medical
schools often run courses for prospective teachers.
Foundation doctors E p. 20 GP training E p. 6
Principles of self- directed and adult learning The learner takes
responsibility for dening learning needs, setting goals, identifying resources,
implementing appropriate activities, and evaluating outcomes. Adults are
motivated by education that:
• Is based on mutual trust and respect
• Can be immediately applied in practice
• Involves cycles of action and reection
• Allows them to take responsibility for their
own learning
• Is based on, and builds on, previous experience
Learning style It has been proposed that understanding an individual’s
learning style helps tailor educational activities to be most eective— but
this has been contested as we all apply dierent learning styles in dierent
situations. Several learning style models are used and relate to personality
traits. Examples:
Honey and Mumford’s learningstyles
• Activists Get involved, open- minded, enthusiastic
• Reectors Stand back, think, cautious
• Theorists Look for principles, logical, perfectionist
• Pragmatists Practical, experimental, down to earth
Kolb’s learningstyles
• Divergers ‘Why’ (concrete, reective)— learn best when they know why
something is relevant and how it will apply to their work
• Assimilators ‘What’ (abstract, reective)— learn best when given plenty
of time to think and link dierent concepts in their minds
• Convergers ‘How’ (abstract, active)— like to work actively on well-
dened tasks and learn by trial and error
• Accommodators ‘What if’ (concrete, active)— learn best by applying course
material in new situations and solving problems they create for themselves
Continuing professional development (CPD) Aims to help GPs
to provide high- quality patient care throughout their careers. Doctors need
to demonstrate that they have up- to- date knowledge across the spectrum
of general practice to become a registered GP and then need to show they
• Actively involves them
• Is perceived as relevant
• Is focused on problems
Have an
e
generalizations
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EDUCATION INPRIMARYCARE
are continuing to update and expand their knowledge to meet the requirements of appraisal and revalidation (E p. 10).
Personal development plans (PDPs) Outline areas of knowledge
in need of update and ways those needs can be met. PDPs are an integral
part of junior doctor training, GP training, and the appraisal process. Ask:
• What you need to learn— specic, measurable objectives (Box .)
• Why you need to learn it and how you plan to learn it
• How you will know whether you have learnt it
• How your intentions link to past and future learning
Box . ‘SMART’ criteria— learning objectives should be:
Specic
Measurable
Achievable
Realistic
Timed (i.e. there should be a deadline for achieving them)
Experiential learning— Figure .. Learning through experience is a
continuous process. It is the largest single source of learning for professionals throughout their working lives. To optimize learning, it is important
to actively seek appropriate experiences, ask for feedback, relate the experience to your existing knowledge base, and reect.
experience
pply the ideas
Reect on th
experience
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Develop
concepts/ideas/
Figure1.1 The Kolb cycle of learning
Reection This is an inherent part of professionalism. It enriches experi-
ential learning and challenges assumptions, enabling experience to be transformed into knowledge, skills, and attitudes. The Gibbs reective cycle can
be a useful tool to facilitate reection:
• Description What happened?
• Feelings What do you think and feel about the event described?
• Evaluation What was good and bad about the experience?
• Analysis What sense can you make of this situation?
• Conclusion What did you do well? What else could you have done?
• Action plan What are you going to do as a result? If the same situation
arose again, what would you do dierently next time?
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CHAPTER What is general practice?
Appraisal andrevalidation
Appraisal Requires all doctors wishing to practise medicine in the UK to
undergo a formal review on a yearly basis. It is the basis of revalidation to
maintain a licence to practise and aims to:
• Set out personal and professional development needs, career paths, and
goals, and agree plans for them to be met
• Review the doctor’s performance and consider the doctor’s
contribution to quality and improvement of local healthcare services
• Optimize the use of skills and resources in achieving the delivery of
high- quality care
• Oer an opportunity for doctors to discuss and seek support for their
participation in activities
• Identify the need for adequate resources to enable service objectives
to be met
Supporting information The supporting information that doctors need to
bring to the appraisal falls under 4 broad headings:
• General information— provides context on all aspects of work
• Keeping up to date— maintaining/ enhancing quality of work
• Review of practice— evaluating quality of current practice
• Feedback on practice— how others perceive your work
Based on the GMC’s document ‘Good Medical Practice’, there are six types
of supporting information GPs are expected to provide and discuss at the
appraisal at least once in each 5y cycle. They are:
• Continuing professional development
• Quality improvement activity
• Review of complaints/ compliments
The Appraiser Responsible ocers of designated bodies are accountable for
ensuring appraisal takes place. Appraisers are properly trained to carry out
this role and are in a position to undertake appraisal of a doctor’s whole
practice, including clinical performance, and where appropriate, specialist
aspects of performance, e.g. research, service delivery, or management
issues. Appraisers for GPs will generally be other GPs.
The appraisalprocess
• Before the interview Doctors must prepare an appraisal document
containing information and supporting evidence about their practice
and personal needs. Folders should be submitted to the appraiser ≥2wk
prior to appraisal interviews to allow adequate time for preparation.
Various electronic toolkits and portfolios are available
• At the interview Doctor and appraiser agree a summary of
achievement in the past year, objectives for the next year, key
elements of a personal development plan, and actions expected of the
organization
• After the interview Asummary document is produced and a joint
declaration signed that the appraisal has been carried out properly
Licence to Practise In the UK, the GMC introduced licences to practise
in November 2009. All registered doctors were able to request a licence to
practise; all doctors eligible for registration with the GMC since November
• Signicant events
• Feedback from colleagues
• Feedback from patients
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APPRAISAL ANDREVALIDATION
2009 have also been licensed. The GMC licence (rather than GMC registration) signies to patients that a doctor has the legal authority to write
prescriptions and sign death certicates etc. GPs working in the NHS, either
on a permanent or locum basis, need to be:
• Licensed by the GMC
• Listed on the GMC’s General Practice Register
• Included on an NHS Performers List
Revalidation Revalidation was formally introduced in December 202.
All licensed doctors need to be relicensed every 5y.
Process of revalidation Doctors need to provide supporting information that
shows that they keep up to date and remain t to practise. GPs are accountable to their local ‘designated body’ and ‘responsible ocer’. In order for
responsible ocers to recommend maintenance of a GP’s licence to practise, they need to be satised that:
• The GP has participated in an annual appraisal process that covers all of
their medical practice
• There are no unresolved concerns about the doctor’s performance
Responsible ocer recommendations totheGMC
• Positive recommendation The doctor should be revalidated and his/ her
licence to practise continued
• Deferral:insucient information Revalidation cannot be recommended
because the doctor has not provided enough information; the doctor
will be asked to provide additional information
• Notication of failure to engage The doctor has failed to engage with
local systems and processes that support revalidation
The GMC will withdraw a licence topractise if
• The doctor tells them that it is no longer required
• The doctor does not pay the appropriate fee
• The doctor does not take part in the revalidation process when asked
• AFitness to Practise Panel directs that the doctor’s registration should
be suspended or erased
0 Doctors have a right of appeal against any decision to withdraw, or refuse to restore, their licence to practise or specialist certicate.
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H Concerns about performance Any GP with concerns about their
own, or a colleague’s, performance should discuss the matter condentially with the secretary of their LMC, the clinical governance lead/ performance information manager of their PCO, or the GMC.
Further information
GMC M Revalidation. www.gmc- uk.org/ doctors/ revalidation.asp
RCGP (204) Principles of GP appraisal. M www.rcgp.org.uk/ - / media/
Files/ Revalidation- and- CPD/ CPD- Credits- and- Appraisal/ The- Principlesof- GP- Appraisal- for- Revalidation- 204.ashx?la=en
RCGP (206) Guide to supporting information for appraisal and revalidation. M www.rcgp.org.uk/ - / media/ Files/ Revalidation- and- CPD/ 206/
RCGP- Guide- to- Supporting- Information- 206.ashx?la=en
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CHAPTER What is general practice?
GP workingarrangements
Primary Care Performer List List of all doctors deemed competent
to provide primary medical care held by the PCO.
Partnership Traditionally, GPs in the UK have worked as independent,
self- employed contractors providing core primary healthcare services and
additional services as negotiated within their contract.
Groups of self- employed contractors working together for mutual benet
are termed partnerships. Apartnership can become a primary care provider as long as ≥ partner is a GP. Although traditionally partnerships are
made up of GPs only, practice managers, nurses, allied health professionals,
and pharmacists can be included within partnerships.
Partners not only have responsibility to provide medical care, they also have
management responsibilities for sta, premises, and equipment. Most receive a prot share, so the amount each partner is paid depends not only
on income to the practice, but also expenditure:
Income
• Income from the NHS GMS, PMS, or APMS contract work
• Private work Includes private appointments (e.g. clinical assistant,
industrial appointments); insurance examinations/ reports; private
medical examinations and certicates (e.g. HGV licence applications)
Expenditure
• Running costs of the practice Sta salaries; premises (rent, rates,
repairs, maintenance, insurance); service costs (heating, water,
electricity, gas and telephone bills, stationery and postage); training
costs etc.
• Capital expenses Purchase of new medical and oce equipment
Salaried GP AGP employed by a PCO, practice, or APMS. PCOs and
GMS practices are bound by a nationally agreed model contract, with a
salary within a range set by the Review Body. PMS practices and APMS providers can make their own arrangements. Salaried posts have advantages
for those who do not want to take the nancial risk or commit to long- term
working within practice.
Freelance GP or locum Provides medical cover on an ad hoc basis.
Tend to be self- employed and may work independently, or through a locum
chambers or agency. Acharge is made for each session worked. Long- term
locums should make their own pension provision or apply to join the NHS
scheme.
GP with Extended Role (GPwER) AGP doing work that is:
• Beyond the scope of GP training and the MRCGP, and that a GP cannot
carry out without further training, or
• Undertaken within a contract or setting that distinguishes it from
standard general practice, or
• Oered for a fee outside of care to the registered practice population
(teaching, training, research, occupational medicals, medico- legal
reports, cosmetic procedures, etc.)
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GP WORKINGARRANGEMENTS
With expansion of care provision out of hospital, increasing numbers of
GPs are taking up GPwER roles. Anational accreditation scheme is currently being developed by the RCGP.
GP Registrar E p. 6
Flexible career schemes In a bid to make general practice a better
career option for doctors, in many areas of the UK exible career options
are being oered to both GPs just nishing their training and established
GPs. Dierent schemes exist in dierent locations, but most combine parttime traditional general practice with another role, e.g. leadership, education, or a specialist clinical role.
GP Retention Scheme Provides opportunity for GPs who might
otherwise leave the profession to remain working in general practice. GPs
are eligible if:
• They hold full GMC registration, are on the Performers List, and want
to change, or have changed, their hours due to caring responsibilities,
because they are approaching retirement, or to enable them to take up
other work within or outside general practice
• Aregular part- time role does not meet their need for exibility (e.g.
need for short clinics or annualized hours)
• There is a need for additional educational supervision (e.g. pro rata
study leave is inadequate to maintain professional competence)
Retained GPs work – 4 sessions/ wk (of 4h 0min) for up to 5y subject to
annual review of eligibility; they receive an allowance of £000– £4000/ y
depending on number of sessions worked plus usual pay. Employing practices receive a sum for each session worked (currently £76.92).
Further information
BMA GP Retention Scheme:step- by- step guide. M https:// www.bma.
org.uk/ advice/ employment/ gp- practices/ general- practice- forward- view/
workforce/ retained- doctor- scheme
GP Induction and Refresher Scheme Scheme for qualied GPs
who are not currently on, but wish to join, the Performers’ List. 2 routes:
• Refresher/ returner route— for GPs who have previously been on the
GMC Register and Performers List and would like to return to general
practice after a >2y career break or >2y spent working abroad
• Induction route— for GPs who have qualied outside the UK and have
no previous NHS experience
Separate schemes operate in England and Scotland which dier in their detail. Both schemes oer practical help, supervision/ mentoring, and nancial
assistance including bursaries to pay for placements, and help with indemnity ± relocation costs.
Further information
Health Education England The GP Induction and Refresher Scheme.
M https:// gprecruitment.hee.nhs.uk/ induction- refresher
NHS Scotland GP Induction and Returner Programmes.
M www.scotlanddeanery.nhs.scot/ your- development/
gp- induction- and- returner- programmes
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