GP education and training

The particular challenges related to GP training in areas of deprivation include the following:

Undergraduate teaching

This article outlines the key issues related to medical education in (and for) areas of socio-economic deprivation in the UK, including the constraints of the inverse care law, the distribution of teaching and training, and the particular nature of clinical work (and learning needs) in deprived areas.

Blane D.N. (2018) Medical education in (and for) areas of socio-economic deprivation in the UK Education for Primary Care 29 (5)

Postgraduate training

There are a number of challenges related to GP education and training in areas of deprivation. First, in keeping with the inverse care law there is an ‘inverse training law’, whereby there are considerably more GP training practices in more affluent areas compared to more deprived areas, as described in this research paper:

Russell M, Lough M (2010). Deprived areas: deprived of training? British Journal of General Practice 60:pp846-848 (doi:10.3399/bjgp10X538949)

This is partly explained by the higher proportion of smaller, often singlehanded, practices in deprived areas, which makes it more difficult to accommodate training requirements. The potential consequence of this unequal distribution of training experience is that trainees may feel less confident about working in Deep End practices if they have not had any exposure to them during their training.

A second challenge is related to the additional demands – on trainee and trainer – of working in deprived areas. These are clearly articulated in Deep End Report 7, which summarises the views and experience of GP trainers in Deep End Practices:

REPORT 7 General practitioner training in very deprived areas (June 2010)
Summary | Full report

A research paper on the views of GP trainers on issues concerning GP training in very deprived areas further highlights some of the challenges of being a training practice in the Deep End:

Blane, D.N., Hesselgreaves, H., McLean, G., Lough, M., and Watt, G.C.M. (2013) Attitudes towards health inequalities amongst GP trainers in Glasgow, and their ideas for changes in training. Education for Primary Care, 24(2), pp. 97-104.

A 2019 qualitative study of recently-qualified GPs’ experiences of GP training in deprived areas identified two key differences between their training experience and those of their peers who trained in more affluent area practices – heavier perceived clinical workloads and less experience of patient-centred consulting.

Cunningham D., Yeoman L. (2019) Recently-qualified general practitioners’ perceptions and experiences of General Practice Specialty Training (GPST) in deprived areas of NHS Scotland – a qualitative study Education for Primary Care

The authors suggest practice rotations and additional targeted learning may be beneficial.  An accompanying commentary draws attention to examples of tailored training to work in areas of deprivation (e.g. the North Dublin City GP training programme: https://www.healthequity.ie/education-ndcgp), the importance of supportive practice teams, and the need for targeted investment:

Blane D.N. (2019) Commentary: supporting GP training in areas of socio-economic deprivation Education for Primary Care

In addition to the challenges of GP training in the Deep End, there are challenges related to GP recruitment and retention in deprived areas (such as a higher proportion of older GPs) that may have a knock-on effect on GP training capacity. The following publication and presentation on manpower trends and future training needs of general practice in Scotland highlight some of these challenges:

Blane, D.N., McLean, G., and Watt, G. (2015) Distribution of GPs in Scotland by age, gender and deprivation. Scottish Medical Journal, 60(4), pp. 214-219. (doi:10.1177/0036933015606592) (PMID:26403569)

Recruitment and retention in the Deep End (Powerpoint) Dr David Blane

Specific CPD needs

Given the particular nature of clinical work in deprived areas, characterised by high volume of alcohol and drugs misuse, multiple morbidity, psychological distress, polypharmacy, child protection issues and a high prevalence of social problems, there are particular CPD needs of GPs working in Deep End practices.

Deep End Report 24 and a subsequent research paper summarised a NES-funded roundtable discussion on the Continuing Professional Development needs of General Practitioners at the Deep End:

REPORT 24 What are the CPD needs of GPs working in Deep End practices? (June 2014)
Summary | Full report

MacVicar, R., Williamson, A., Cunningham, D., and Watt, G. (2015) What are the CPD needs of GPs working in areas of high deprivation? Report of a focus group meeting of ‘GPs at the deep end’Education for Primary Care26(3), pp. 139-145. (doi:10.1080/14739879.2015.11494332)

The following three areas were identified as having learning resource gaps:

  1. How to address low patient engagement in health care and increase health literacy.
  2. How to promote and maintain therapeutic optimism when working in areas of high deprivation.
  3. How to use EBM effectively when working with patients with high levels of multimorbidity and social complexity. 

It is hoped that some of these gaps may be addressed by developing modules for Practice-Based Small Group Learning (PBSGL). See this webpage for more info https://www.cpdconnect.nhs.scot/pbsgl/.

A way forward?

Deep End Report 28 summarises three focus group discussions held with young general practitioners and GP trainees in autumn 2015 concerning their views on GP careers and training in very deprived areas:

REPORT 28 GP recruitment and retention in deprived areas (April 2016)
Summary | Full report

The next generation of GPs is “up for the challenge” of general practice in the Deep End, but needs to be adequately resourced and supported in the leadership roles they will be taking on. In October 2016, the Deep End GP Pioneer scheme was launched with funding from the Scottish Government’s GP Recruitment and Retention Fund. There are currently five early career GP fellows working in five Deep End practices, providing additional clinical capacity and releasing time for experienced GPs to work on service development. The fellows also have protected time for professional and service development, and all learning is shared between the practices as a non-geographical cluster.

There are early indications that the project is attractive to young GPs and has given the older GPs involved renewed enthusiasm for their work, and we believe this model could be applied to other areas to support GP recruitment and retention.

Deep End Pioneer Scheme 
www.gla.ac.uk/researchinstitutes/healthwellbeing/research/generalpractice/deepend/deependpioneer/ 

See also the summary of the following session held as part of the Day Release Programme for the GP Pioneer Scheme

Preventing burnout (21 Dec 2016)