Undergraduate medical education: recommendations

Introduction

This report reflects a great deal of work done over the past year by the Increasing Undergraduate Education in Primary Care group. I would like to express my thanks to all members of the group for their contributions and commitment to this work.

Change in undergraduate medical education in Scotland is needed because of increasing numbers of people with complex multimorbidity and because of the rapid demographic shift in our population towards older people. This has substantially increased demands for health and care services in hospitals, primary care and in the community. There is a consensus, supported by robust evidence, that developing primary and community services is better for older people and better for population health. High quality accessible hospital care is certainly required, but its delivery is supported and best facilitated by admitting only those whose health and care needs cannot be delivered in the community. This requires that clinical capacity within general practice based primary care is expanded, a key aim of Scottish Government policy. This also requires a focused approach to increasing the GP workforce.

There are several strands to increasing the GP workforce. This report focuses exclusively on the potential contribution of increasing undergraduate education in primary care. The last few years have seen two major UK reports, By Choice, not by Chance (HEE/MSC 2016) and Destination GP (RCGP/MSC 2017) which give clear guidance for what needs to be done in Scotland. Addressing tribalism and negativism, changing financial models underpinning education, providing quality placements in general practice that demonstrate the difference it can make, and providing positive role models for students are all essential. Increasing near peer teaching is imperative. Academic general practice leadership is vitally important so that students recognise the breadth and complexity of general practice care, and so that they become aware of and are stimulated by the complex intellectual challenges. The establishment of the short life group on academic training pathways in general practice in Scotland reporting to the Board for Academic Medicine, under Professor Frank Sullivan as Chair, is an important parallel development to this group's report.

It became clear, during the course of the 15 months of the life of this group, that a strategic approach to address these issues that have to date limited general practice education, and setting out practical ways to address them, was needed. In addition, the recommendations offer an opportunity to look creatively at expanding placements in both remote and rural practices and areas of deprivation. Out of hours GP services, though currently under workforce pressures, have great potential for more undergraduate general practice education.

It is also very clear that developing improved working across and between many of these organisations will be necessary for an increase to be achieved and maintained. In particular, the output of this group offers an opportunity to strengthen links between undergraduate and postgraduate medical education, and between Universities and Health Boards. Several examples of this are given in the report.

My recommendations, informed by the work of the group, cover three areas: addressing the issues identified by the teaching capacity survey, strengthening the GP educator workforce to deliver increased capacity to teach, and monitoring and evaluation of the required changes.

The teaching capacity survey showed that lack of space in primary care is a major issue, exacerbated by the growing multidisciplinary workforce. Further investment in premises is urgently needed. Policy should dictate that any new capital developments must always include provision for educating the primary care workforce of the future.

Digital infrastructure is improving rapidly through the roll out of the Scotland-wide Area Network (SWAN). However, coordination between this programme and the R100 Scottish Government project ("Reaching 100%" or R100 commitment) to provide super-fast broadband to all Scottish homes and businesses by 2021, would enable symbiotic success of these related activities. Access problems which interfere with education and assessment persist, especially in remote and rural areas. A survey of teaching practices to identify issues raised by students and faculty and a plan to address these within 12 months is needed.

The number of GP undergraduate teachers across Scotland is falling; inadequate reimbursement is a directly contributing factor. The valuable work undertaken by the NES Primary Care ACT review suggests that the category A tariff for clinical teaching should rise to £85 per session. The complex Category B tariffs require further work to produce a simplified range within 12 months.

More undergraduate teaching in primary care requires a strengthened voice for GP educators within medical schools. Each medical school should further develop their current commitments to expand undergraduate teaching in primary care, outlined in chapter five, as well as developing a strategy for developing and growing the GP educator workforce that will be needed to deliver this. A national level group for GP Heads of Teaching is proposed to strengthen educational leadership, encourage innovation and contribute to monitoring progress on these recommendations.

These substantial changes of investment require both monitoring and rigorous evaluation. I suggest six monthly monitoring reports to the Scottish Deans' Medical Educator Group with review by the Board for Academic Medicine. Evaluation should include educational research into the attitudes of students and graduates, as well as detailed tracking of career intentions and choice through UKMED.

All medical schools are, of course, required to produce pluri-potential doctors who meet the GMC Outcomes for Graduates. An increase in exposure to general practice and primary care will contribute to all graduates having a better understanding of how the NHS works as a system and how primary, secondary and social care can best collaborate for the benefit of our patients. As a senior medical educator in Scotland has suggested, these proposed changes can help to produce 'not just more GPs, but really good doctors.'

There is now a real opportunity to achieve this through an evidence-based approach to undergraduate medical education, founded, in Sir Lewis Ritchie's words, on 'pulling together'. It is important that we grasp it. Carpe diem.

Professor John Gillies OBE FRSE FRCGP FRCPE
Deputy Director, Scottish School of Primary Care
Chair, Increasing undergraduate education in primary care group
August 2019