Undergraduate medical education: recommendations

Chapter Four: Innovative Approaches to Increasing Primary Care Education

Introduction

Whilst appropriate funding and infrastructure to promote General Practice as a positive career destination is vital, consideration must also be given to what changes can feasibly be made alongside this to capitalise on this investment. As noted previously, research by McDonald, Jackson, Alberti and Rosenthal (2016) suggests that medical schools with greater proportions of curriculum time in general practice produce more future general practitioners. This suggests an imperative to increase this percentage, if a meaningful positive impact is going to be made to future GP recruitment.

However, increasing GP contribution to medical school curricula is not simply a matter of moving teaching from secondary to primary care. GP capacity is already stretched and limited, as was evident in the teaching capacity survey undertaken as part of this review. Therefore, there will not be only one solution to increase the proportion of undergraduate medical education in primary care, but a range of innovative approaches which can be tailored to local circumstances.

Cross-institutional discussions through the GP Heads of Teaching, and the expert workshop, have highlighted a range of existing and developing innovative approaches to teaching. This chapter highlights these innovations, as well as some from further afield, which could provide models for future primary care-based and delivered education.

These innovations can be considered on a number of levels and include campus-based and placement-based components of medical school curricula. Medical school curriculum innovations can be further divided into those directed towards the broader undergraduate curriculum and those which are targeted at the GP-focused curriculum content.

1. External Innovations

External Partnerships

Traditionally, medical students have undertaken clinical placements in secondary care, general practice, and sometimes the voluntary sector. Over time, the diversity of placements at some medical schools has increased and this diversification should continue.

Diverse placements not only provide a pragmatic solution to capacity issues, but may also facilitate students' development as holistic practitioners. This approach is in keeping with Realistic Medicine, (Scottish Government, 2016) and supports the 2020 workforce vision of a multi-professional, team-based, integrated model for primary care (Scottish Government, 2015).

Examples of creative placements outlined below indicate settings outwith GP surgeries where students can also get primary care experience and exposure to the principles of General Practice.

Community hospitals

Teaching sessions in community hospitals expose students to caring for patients with a focus on rehabilitation or palliative care. These placements provide an opportunity to teach students generalist principles at a "bridging" point between primary and secondary care.

St Andrew's students undertake day long placements in community hospitals where they benefit from clinical mentoring and opportunities to work with, and learn from, their peers in a clinical environment. GPs are paid a sessional rate to facilitate these sessions, which is at a preferential rate compared with having a student in a practice. The teaching GPs do not have the pressure of service commitment which allows them to focus on teaching. These placements aim to provide students with positive GP role models, identified as essential in promoting General Practice as a career destination within the Health Education England/Medical Schools Council (HEE/MSC, 2016) document "By choice - not by chance".

Third sector

The third sector is currently under utilised for placements and could provide a wealth of holistic, first patient contact community-based education. Many third sector bodies provide health and social care support for patients with a range of physical and mental health conditions. As well as the advantage of avoiding the need for clinically-trained teaching staff when capacity is tight, students are exposed to the breadth of the health and social care system in Scotland, highlighting the vital role of the third sector. There are many such organisations; for example, Grampian has over 700 organisations listed in which students could potentially learn.

Working with other community-based partners

In all Scottish medical programmes, students spend time with a range of providers of community-based health services, reflecting the multi-professional, team-based approach to primary care. These placements facilitate development of holistic medical practitioners and could be expanded with appropriate funding and support. Although many sectors face capacity challenges, learning from and with colleagues such as pharmacists, occupational therapists, physiotherapists and health visitors can create more informed and effective future members of primary care teams.

Out of Hours

The Out of Hours (OOH) service is another valuable learning environment, which, whilst clinically stretched, is currently under-utilised for undergraduate medical education. Variety and challenge are highlighted through the Wass report (HEE/MSC, 2016) as essential to promote General Practice; both of which are readily visible within the urgent care services.

Cross-institutional collaboration

The process of undertaking this has facilitated further productive collaboration between Scottish Heads of GP Teaching, for example the shared development of curriculum innovations and management of teaching capacity.

While the GP HOTs group will need to provide the main leadership for delivery of expansion and innovation in undergraduate general practice teaching across Scotland, it is not a formally recognised group. In order to support delivery of the desired outcomes, further development and recognition of this group and its role will be required.

Potential future collaborative developments could include:

Shared learning resources

Investment in the development of new teaching resources and sharing of existing local resources provides opportunities to share good practice and facilitates innovation. For example, GP Live (an innovation from Aberdeen) is now being introduced at Dundee. GP Live uses technology-enhanced learning; streaming GP consultations in real time from practices to campus-based groups of students, facilitated by GP tutors. Development could enable these consultations to be sent to multiple sites simultaneously.

Building on this, investment in the creation of a secure shared library of teaching consultations and other online resources could be explored. While creation of significant new resources requires investment, these could be utilised both across institutions and healthcare professions to provide economies of scale.

Placement swaps

Strategies to increase diversity in each medical school's placements might involve sharing learning environments. For example, the Universities of Glasgow and Aberdeen plan student swaps between 'deep end' and remote and rural practices so that students experience GP environments that may not be readily available from their own institution. This will support students keen to explore a diverse range of primary care placements, and may prompt students to consider future practice in underserved areas (Sen Gupta et al., 2014). Shared "accreditation" and student skills/experience passports would facilitate this initiative.

Student "Passporting"

Student "passports" are being introduced at Dundee. Passporting facilitates transitioning between health board areas and can provide reassurance that core requirements have been met regardless of which medical school students are from. For example, a passport could document requirements such as an up-to-date immunisation record, CPR certification, hand washing and occupational health assessment. Potentially, this could be extended to a competency based 'skills passport', as long as it did not detract from individual programmes' curricula, nor become too onerous for students and staff.

Shared practice accreditation

Each Higher Education Institution (HEI) has its own accreditation process for teaching practices. This involves a combination of paperwork and practice visits which may be duplicated for the small number of practices which teach for more than one medical school. Sharing HEI accreditation would create ease and efficiency of systems which could be linked with accreditation for postgraduate training or teaching of other healthcare professionals in conjunction with NHS Education for Scotland (NES).

Although shared accreditation would be less burdensome to practices and HEI staff, it is acknowledged that relationships between medical schools and practices are important (Alberti and Atkinson, 2018). Relational continuity keeps tutors and practices up to date with curriculum changes and facilitates support if student or practice issues should arise which impact on teaching capacity or capability. Consideration would also need to be given to how each medical programme would ensure its individual quality assurance processes were met through development of a formal process for sharing concerns across institutions.

Placement innovations

The traditional apprenticeship GP placement model of one student per practice gives students the opportunity for individual supervision and mentoring. This is often highly valued by students. However, this model is costly in time and resource and may inadvertently add to students' perceptions that general practice can be a lonely place to work (RCGP/MSC, 2017).

Alternative models are given below, all of which focus on maintaining the quality of the placements. Some involve a greater number of students per practice, whilst others focus on promoting general practice as a positive career destination.

Hub and spoke model / GP teaching centres

A hub and spoke model involves a practice functioning as a GP teaching centre. The hub is a GP practice in which "academic"/teaching GPs have protected time for teaching activities. The hub supports neighbouring practices (spokes) to teach, with students rotating around the hub and the range of spokes available at that locality. This model has the potential to support teaching in traditionally hard to recruit areas (e.g. remote and rural practice) by giving students experience of a variety of practices.

Cell structure

Many medical programmes have or are developing a cell structure approach to GP attachments e.g. in remote and rural or deprived areas (Dundee, Edinburgh, Aberdeen and ScotGEM). Using this model, Aberdeen organises teaching and attachments in geographically related practices and incorporates weekly day-release programmes in which locality tutors take turns to facilitate small groups of students (typically 4-6). The cell structure fosters students' independence and self-direction, and they benefit from peer support in their small groups.

Shared / group-based placements

Related to the cell approach, some programmes send multiples of students to individual placement sites. This reduces the number of clinical tutors required and facilitates peer support/peer learning, within small groups. It has potential financial benefits at practice level as funding is per student rather than per session. It is relatively simple to set up where space allows. As students are based at one placement location, rather than rotating through different sites, arrangements can often be built on existing teaching practices and infrastructure.

Glasgow sends 3^rd year students to practices in groups of two or three for a total of seven days across a four month period. This model works well and is particularly attractive to part-time GPs who may feel unable to commit to a 'block' of teaching due to their working pattern. It has facilitated teaching 'on days off' for some part-time GPs keen to be involved in teaching as part of a portfolio career. Where this has worked well, individual GPs and their practices have agreed various models of payment or 'time back in lieu' (Pope, 2018).

This model benefits the service as additional appointments are provided via student led surgeries and benefits the students as GPs can focus on their learning needs rather than trying to juggle teaching with their own daily clinical workload. GPs are paid on a per student basis and traditionally have been able to choose the group size. However, due to recent capacity issues, tutors who traditionally preferred taking two students have been asked to host three students.

In addition, to meet recent capacity pressures, Glasgow has sent several pairs of students to year 4/5 placements which have historically always been one to one. During a curriculum transition, to manage placement capacity Edinburgh has allocated pairs of students to placements for a one year period.

Longitudinal Integrated Clerkships

Longitudinal Integrated Clerkships (LICs) are defined as placements where students participate in the comprehensive care of patients over time, and are an evidence-based innovation that demonstrably promotes General Practice as a career (O'Donoghue, McGrath and Cullen, 2015) and leads to increased recruitment to rural and community based careers (Walters et al., 2012). This model of teaching and learning has been used for many years in North America and Australia and is now taking off in the UK and Scotland, with the University of Dundee and ScotGEM programmes at the forefront. At Dundee up to ten self-selected students are placed singly or in pairs in a practice for a whole academic year (40 weeks) and all ScotGEM students, in year 3 of their programme, will participate in a LIC.

However, it is noted that if all students in Scotland were to be given the opportunity to undertake a LIC, every practice in Scotland would have to take a medical student and targeting interested students and practices may be a more viable option. Self-selection, in itself, demonstrably increases the positive impact of a placement (Pfarrwaller et al., 2015).

While 40-week LICs require more placement capacity, it is possible for practices to host a LIC student alongside students on shorter placements. International evidence suggests LIC students make a positive contribution to the work of the practice leading to more economic sustainability (Worley and Kitto, 2001) and do not impact on GPs' consultation lengths (Walters et al., 2008).

Interprofessional education (IPE) placements

There are now more formal learners in general practice, undergraduate and postgraduate, and across health care and allied professions. Although this could be a potentially crowded environment, it allows great opportunities for interprofessional learning. Learners can be supported by a wide range of professional teachers, leading to better use of limited learning time in the clinical setting.

IPE is widely promoted and further development and roll outs of these models will need greater cross-organisational collaboration. Recent examples include a pilot of 5 different IPE models involving pharmacy and medical students from Aberdeen, Dundee and Robert Gordon Universities. Their team has undertaken work to identify common outcomes expected across healthcare professional programmes to start to inform further development of such initiatives (Steven et al., 2017). Funding for these more complex teaching models needs to be considered as currently different funding streams exist to support different learners with some learners coming with no or little funding. At a time of teaching capacity pressures, an educational hierarchy based on differential funding levels could be detrimental.

One Foundation Year doctor interviewed as part of this review noted:

One thing we did have in med school which I thought was great was that we had some things with nursing staff, student nurses, which was great; meeting with physios and stuff... Having those multidisciplinary sims was great, which we never had for GP actually and GP is just as much an MDT thing really… Maybe that would have been a helpful thing to realise GP is not just about you sat in a room seeing one person.

Near Peer learning in the clinical environment

A strong theme from the expert workshop was around trainee or junior GPs becoming more involved in teaching, both in clinical practice and in universities. Evidence of teaching is a curriculum requirement of GP trainees and Foundation doctors (RCGP, 2012; UKFPO, Academy of Medical Royal Colleges Foundation Programme Committee and UKFPO, 2016). In contrast to hospitals, where teaching by doctors in training is ubiquitous (Bindal, Wall and Goodyear, 2009; Hill et al., 2009), teaching by junior doctors in general practice is somewhat limited.

Teaching by trainees was thought to not only be a way to not only aid teaching capacity, but also to expose students to positive near peer role models. Previous work has highlighted an enthusiasm for teaching amongst GP trainees (Halestrap and Leeder, 2011) and interviews with FY doctors have echoed this:

I think it is quite valuable having more junior people doing the teaching because we know what is expected of medical students, whereas I think the more senior you get, you kind of forget what's important to pass exams and be a good foundation doctor.

However, there are a number of barriers to expansion of near peer teaching. These include matching learners needs with near peer teachers' expertise, trainers' perceptions of trainees' ability to teach, lack of formal training programmes for trainees teaching and practicalities such as learner overlap (Dodd et al., 2009; Silberberg, Ahern and van de Mortel, 2013; Kirby et al., 2014; Pope, 2018). A 2016 survey of Glasgow University undergraduate teaching practices identified that only 39% were also postgraduate training practices. This is similar to the figure of 45% from an England-wide study (Rees, Gay and McKinley, 2016). To ensure that all students have opportunities to have contact with GP trainees, campus-based near peer teaching needs to be further developed alongside practice-based initiatives.

Showcasing General Practice

The Unique Selling Points (USPs) of General Practice are often assumed to be implicit within clinical teaching and on placement, but have been described as unclear to some undergraduate medical students (RCGP/MSC, 2017). All programmes are working towards actively promoting General Practice's USPs and St Andrews have designed an innovative GP showcase day to achieve this. In this initiative, multiple students are sent for a day to a teaching practice identified as 'high performing' from student feedback. On these visits, General Practice is actively promoted via group discussions and learning experiences.

2. Curriculum innovations

Integration of General Practice in Broader Medical School Curriculum

The integration of general practice within overall medical school curricula sends a powerful message to students that general practice is of equal status to hospital medicine. This equality is highlighted through a number of current curriculum innovations utilised to varying extent within Scottish medical schools, addressing both the formal and informal curriculum as recommended in By Choice, not by Chance (HEE/MSC, 2016).

Contribution to systems-based learning

GPs lead on the management of most common chronic diseases in clinical practice, yet teaching on these topics is often delivered by secondary care colleagues who care for the most complex minority of patients and in a setting where the complications and inter-connectedness of multi-morbidity is not always addressed. Formats such as joint specialist and GP lectures demonstrates the equal importance of both doctors in managing common diseases, provides students with a more authentic understanding of the patient journey and care delivery within the NHS as well as exposing students to role modelling of interprofessional respect. Through a raised profile of GPs across a range of curriculum content, the breadth of a generalist's knowledge can be showcased and be seen as equally valued as a specialist's narrower yet deeper knowledge.

Case based learning

Medical schools use a combination of purpose-written and real life cases to facilitate students' learning in clinical practice. Consideration should be given to how general practice is represented within purpose-written cases. GPs should contribute to ensure cases represent the breadth of clinical presentations across primary and secondary care. For example, ScotGEM utilises a case-based learning approach, with learning centred around a case of the week in years 1 and 2 of study. Each clinical case is displayed to students on a web-based platform ("Kuracloud"), with specific linkage to student learning outcomes.

In Sheffield University, students discuss real life cases from their hospital placements in GP-led small group learning sessions. Utilising GPs to lead these sessions highlights the breadth of knowledge of general practitioners as they are able to discuss cases from a wide range of specialties and across the continuum of presentation, management, disease progression and patient experience.

Careers Days contribution

Representation of General Practice in medical school Career Days is vital. Destination GP (RCGP/MSC, 2017) highlighted that many students were unaware of possible career trajectories within general practice. Careers events should take place across all years of medical schools' curricula and should showcase the diversity of career opportunities available to GPs, including academic general practice and portfolio careers.

BMedSci in Health Sciences - Primary Care

A recent innovation has been the creation of BMedSci Health Sciences - Primary Care option for students at Edinburgh University. This has proven popular with 15 students choosing to undertake this course in academic year 2018-19. It highlights that general practice is an intellectually and clinically stimulating discipline, and aims to foster GP academics. (see details below) Although this option may help promote a variety of careers in general practice, this or any similar courses which might be developed are not currently eligible for GP ACT funding as they are considered 'out of programme' opportunities.

The BMedSci - primary care course comprises:

• A compulsory 'Research Skills in Health Sciences' course (20 credits)
• A Primary Care Course (20 credits)
• A Clinical Placement (10 credits)
• A taught elective course (20 credits)
• A Literature Evaluation and Review (10 credits) undertaken prior to a research project
• A 10-week research project. (40 credits) - Projects will include preparation of a dissertation and an oral presentation.

New curriculum models

New curriculum models, such as LICs and ScotGEM aim to create new and exciting opportunities for students to learn in general practice. More recently, 3 further Scottish medical schools have been awarded additional student places from 2019, each aiming to promote general practice in differing ways:

• 30 additional places at the University of Aberdeen: all students will undertake an enhanced GP programme, with a set minimum of teaching time and an additional range of GP options. This is a multi-pronged approach, integrating GPs into the formal teaching curriculum at the Medical School within clinical blocks alongside secondary care colleagues, and implementing a number of new experiences, including embedding students in the Third Sector and Out of Hours care. Alongside these changes they are developing the role of existing GP tutors in the community and expanding opportunities for GP mentorship. Clinical teaching is transferring from traditional ward based settings into Primary Care, including community hospital teaching and case based learning.
• The University of Edinburgh is developing a new MBChB programme for existing healthcare professionals aimed at training graduates who will be more likely to enter general practice postgraduate training. Commencing in September 2020 for 25 students, it is unique in that its target students are existing healthcare professionals, who will study part-time (for the first 3 years), and most of the time they will be learning remotely. Their clinical contact in the first 3 years will be almost exclusively in general practice, then they will join the mainstream programme for the final 2 years.
• Glasgow is taking a two-pronged approach to strengthening the role of general practice in their curriculum. Firstly, there is expansion of contribution from general practice and GPs throughout the 5 years of the course for all students e.g. via the New Year 3 GP teaching week (see below). Secondly, the creation of the new COMET (Community Orientated Medical Experience Track) offers 30 students the opportunity to participate in a GP focused stream within the MBChB programme. Successful applicants will experience an enriched programme of immersive primary care in a range of practices with the aim of inspiring the GPs of the future.

ScotGEM: Generalist Clinical Mentors

ScotGEM offers a four-year MBChB training focused on 'rural generalists' for graduate entrants. The course is therefore atypical in that it has licence to select students from the outset interested in this more community-based approach with an explicit emphasis on general practice.

Based upon the need to offer a truly generalist experience that aligned with a Case Based Learning curriculum it was concluded that the only clinicians who could do so, including accessing a full range of patients for teaching, were GP's. The programme thus prioritised expenditure on a GP led clinical programme throughout years one to three. Though this aligns extremely well with many aspirations within the Wass report it also necessitated a new approach of sufficient appeal to recruit portfolio career GP educators

Generalist Clinical Mentors (GCM) teach the Clinical Interaction Course (all consultation, clinical and procedural skills) for half a day within the medical school, have groups of 6-8 students in practice for a day each week and have half a day preparation time. The aim being to provide core teaching by enthusiastic role models based in community practice demonstrating a clear bridge with more structured aspects of their learning. The CLIC teaching is structured and focused with a two-year competency-based learning outcomes plan. The 'GCM Days' are designed with local opportunities in mind (e.g. access to a community hospital ward or not) and blend the weekly CBL start/wrap up with a broad range of GP based learning.

Glasgow's Year 3 GP teaching week

Phase 3 of course is based on a specialty week structure (e.g. cardiology, respiratory). From 18/19 a new GP 'week' has been added to this phase of the curriculum. This 'week' is comprised of 3 GP led teaching days, the content of which has been based on 3 key documents: SAPC and RCGP Curriculum Guide 'Teaching General Practice'; GMC Guidance 'Outcomes for Graduates'; and Realistic Medicine

The content aims to highlight key principles of good quality primary care at the heart of which is working in partnership with patients and generalist principles. The format includes:

• Inspirational talk from a carer and presentations from leading academic GPs on topics such as social determinants of health, multi-morbidity, treatment burden, polypharmacy and self-management.
• Case focused lightning talks from early career academic GPs - to promote academic GP as a career and also to demonstrate how we use evidence to inform decision making
• GP ST delivered Case Based Learning Sessions to highlight key principles of primary care
• Student presentations feeding back learning from multi-morbidity Case Studies
• Senior GP academic revision GP surgery - highlighting GPs use learning from all the other specialty weeks in their daily work.

GP Teaching Fellows

In recent years, there has been a large increase in the number of hospital-based clinical teaching fellows (Furmedge et al., 2013). The current separate funding streams for postgraduate and undergraduate training and teaching make creation of a similar scheme in primary care challenging. These roles are beginning to appear in England and have been positively evaluated (Thampy et al., 2018). It is proposed that their cognitive and social congruence with medical students not only makes them effective teachers but also positive role models for choosing a career in general practice.

ScotGEM GP Teaching Fellows: a potential catalyst for increasing capacity

ScotGEM is generating excitement and enthusiasm, offering options to innovate with many GPs considering the programme a strong prospect for building the workforce. There is an urgent need for new solutions as more of the same will not suffice and this might include a policy of growing our future educators. The suggestion of creating UG Teaching Hubs has particular resonance in rural areas where there is no nearby university department and are typically 'hard to recruit' Consequently, ScotGEM is exploring ways of supporting such developments with their particular boards as a means of developing new capacity and future educators.

The proposed model could involve strategically sited early career GP Teaching Fellows, co-funded with boards, as part of a Teaching Hub supporting a small number of 'spoke' practices or teaching delivered within health centres or community hospitals in specific geographical locations. For instance, supporting a group of Longitudinal Integrated Clerkship students via a local GCM tutor. The aim is to aid rural recruitment and free more experienced local GPs to teach as well as aligning ScotGEM with the national goal of increasing capacity and enabling it to play a key role in catalysing innovation at a local level. These one-two year appointments would include a mix of clinical service, teaching and personal development opportunities.

GP-focused curriculum content

Consideration also needs to be given to GP-focused curriculum content. This includes both core curriculum content and the variety of options available for additional GP exposure. There is significant variation across UK medical schools in the quantity of their curriculum which is GP-focused (Alberti et al., 2017). Creation and delivery of new content should be informed by 'Teaching General Practice', a joint SAPC and RCGP guidance document, and should aim to highlight the evidence base underpinning general practice as well as generalist principles (Harding, Hawthorne and Rosenthal, 2018).

Curriculum options/ electives/ student selected components

All medical school curricula include a degree of 'self-selected' content i.e. opportunities for students to choose areas they are interested in studying while demonstrating the learning outcomes required of them (GMC, 2015). This includes, but is not limited to, electives, student selected components (SSCs) and intercalated degrees.

Historically, in some medical schools, general practice has been underrepresented within these options due to minimal or absent funding. These options are often popular with students e.g. SSC focusing on Remote and Rural Practice (Aberdeen). The greater flexibility this teaching format can afford facilitates creation of engaging and relevant student learning experiences such as undertaking BASICS training, mountain rescue and coast guard experience. Opportunities such as this can excite students about a career in remote and rural general practice.

The role of Student GP Societies

A key recent development has been the establishment of student GP societies across all Scottish medical schools. Supported by both RCGP and the HEIs, a factor in the success of these groups has been that they are student-led. Planning, managing and delivering a range of activities, students' enthusiasm for general practice can be harnessed. Working in partnership with medical schools, these students can help inform curriculum innovations going forward and can provide useful insights into the perceptions of general practice in the wider student body.

GP Societies in Scotland

The Wass recommendation (10) taken forward in Scotland in the shape of a Discover GP conference in Aberdeen in February 2019. There were plenary sessions delivered by prominent GPs, including Carey Lunan, Chair of RCGP Scotland. There 109 attendees, including 92 students, 14 foundation doctors and 3 physicians associates.

• Collaborative effort from all Scottish GP societies, supported by the RCGP Discover GP team and the local faculty.
• 34 GPs who volunteered their time to run sessions and inspire the next generation of general practitioners
• Part of an annual programme of seven regional conferences bid for by GP
• Feedback was excellent with many people saying that they were 'inspired' and 'excited' by the 'diversity', 'flexibility' and 'breadth' the specialty offers.
• 95% of attendees stated that the event had quite positively or really positively changed their perception of what a GP does
• 90% stated that the event had quite positively or really positively changed their perception of the future of general practice
• 100% stated that the event had quite positively or really positively changed their perception of becoming a GP

This successful event demonstrated the real value of raising the profile of GP societies through well publicised events for students and FY doctors. Such events are likely to be of value in increasing numbers of medical students who pursue a career in general practice.

3. Innovations in developing GP teaching workforce

Diversity of teaching opportunities

The GP workforce is changing - fewer GPs are becoming partners and more GPs are working part time or seeking portfolio careers (NHS NSS, 2018b). To increase teaching capacity, teaching opportunities must be available to all GPs. New models such as the creation of the Generalist Clinical Mentor model (GCM) are one way of doing this. The options of fixed commitment or flexible teaching involvement is another.

Developing the GP academic workforce

GP academics play a crucial role in promoting a career in general practice to students. The decline in the number of GP academics within Scottish medical schools over the past six years is a cause for serious concern. GP academics provide profile for the discipline within medical schools as well as being role models for future GPs and GP careers. They undertake much needed research in primary care for the rapidly changing and ageing population of Scotland and focus on evidence-based solutions to problems. Perhaps most importantly, in the face of recent evidence (RCGP/MSC, 2017) of the impact of denigration of general practice on students' career choices (destination GP), GP educators can challenge prevalent negative attitudes to general practice careers held by many students and clinical academics. In Holland, recruitment to general practice is good, and there are strong links between academic departments and provision of primary care. Raising the visibility of academic general practice may be important in encouraging curiosity and improving recruitment (Wass, 2019; Mulla, 2018).

Strengthening primary care educational leadership

Throughout the duration of the working group, the GP Heads of Teaching group (GP HoTs) has demonstrated the value of sharing ideas around undergraduate education and working collaboratively to innovate. Working in partnership with their medical school teams, they are forging the future of undergraduate GP education in Scotland. This aims not only to produce more future general practitioners but also to create a future medical workforce with a greater understanding and respect for the pivotal role of general practice in the NHS.

GP Champions in NHS Tayside

NHS Tayside has recently created a post of "GP Champion". The overall purpose of the role is to support GP-based learners in the secondary care setting. In particular, the GP Champion will support undergraduate learners who are on Dundee School of Medicine's Longitudinal Integrated Clerkship (DLIC) programme (year 4 Dundee students and ScotGEM year 3 students), by facilitating access to learning in secondary care settings, contributing to planned teaching sessions and assessment within the programme. DLIC students self-direct their learning, linked to the patients they see and attend services individually to meet their self-identified learning needs. As this is often with short notice, or none at all if a patient is admitted with an acute illness, this kind of support will greatly ease their access to secondary care learning environments. The Champion will also raise awareness and understanding in secondary care of the DLIC and its requirements.

A secondary aspect of the role is to support GP Specialty Trainees working in the hospital. This group have individual educational needs which are different from those of hospital based specialty trainees. The post holder will liaise with the GP TPDs/APGD in the deanery to define GP Trainees' learning needs in secondary care, and identify and facilitate relevant educational opportunities. We expect that this initiative will enhance the learning of both undergraduate and postgraduate GP based learners by making it easier for them to access relevant secondary care experience and teaching.