Julian Le Saux
Julian has been working as a practice manager in Cranbrook, Kent, since 1990. It’s a small surgery, and he still works in
reception several mornings a week
Dr David Hindmarsh, the principal GP in the practice where I work, has been a trainer since 1996 and a course organiser since 2002. Naturally, quite a few registrars have come and gone through our practice in the last 11 years, but it’s only recently that I’ve developed anything more than the vaguest idea of what their training involves.
This is at least partly due to the fact that there was never a defined curriculum laid out for them, and their training therefore tended to be rather nebulous, not to say disorganised.
Last year, however, the Royal College of General Practitioners (RCGP) introduced the GP Curriculum, which defined for the first time exactly what registrars are meant to have learnt by the time they finish their training. This is a massive change to the way GPs are trained in this country, but the Curriculum itself is very long, quite deterring and not especially easy to understand.
Dr Hindmarsh and I therefore decided it would be a good idea to publish a potted guide to the Curriculum, written in plain English, and with some jokes in it. The end result, called Dr Hairy’s Guide to the GP Curriculum, was published via a self-publishing website called Lulu (see Resources) in December 2007.
As stated above, the Curriculum sets out for the first time what registrars are supposed to learn. Perhaps just as importantly, it also attempts to define how this knowledge is meant to relate to their work as GPs. One of its effects has therefore been a shift of emphasis away from clinical knowledge for its own sake and towards the knowledge and skills that are most useful in general practice.
This means that practice managers with registrars in their surgeries are more likely to become involved in their training, because by the time they qualify the registrars are supposed to have acquired at least a rudimentary understanding of practice management issues.
Registrar training revamp
There have also been some changes to the timetable of registrars’ training. In the old days, their time in general practice was often divided into two six-month stints. In our area, the usual pattern was for the registrar to start with six months at the surgery, then go and do various six-month placements in different hospital specialties, and finally come back for a concluding six months with us.
Under the new scheme, registrars will still spend at least 12 months based in general practice, but in one long spell rather than two short ones. This is probably a better arrangement from the practice manager’s point of view, because it means better continuity of patient care, and less fiddling about with p45s, contracts of employment and what have you.
But moves are also afoot to increase the total amount of time registrars spend in surgeries, since the general feeling among registrars, trainers and newly qualified GPs alike is that this experience is more valuable than hospital training; so in the future, spells of 18 months may become commonplace.
Complex web of learning
The GP Curriculum itself can be seen at the RCGP’s website (see Resources). Be warned, though – it’s enormous. If you actually print it off, it comes out at around 600 pages. It’s also organised in a slightly odd way – into 15 “curriculum statements”, six “domains” and three “essential features”.
The tricky thing to grasp is that these statements, domains and essential features aren’t meant to be learnt independently from each other, but in combination. To put it another way, registrars are supposed to learn about all 15 of the curriculum statements, but while they’re doing so they’re supposed to keep relating whatever they learn to the six domains and three essential features, which are key aspects of general practice. In this way (hopefully), their learning won’t just be decontextualised clinical information, but relevant to their work as GPs.
Let’s say a registrar was learning about sexual health (statement 11). Of course, there’s a lot of clinical information to be absorbed about AIDS, chlamydia, contraception and what have you – but in general practice this information always has to be applied in the context of “Community orientation” (domain 5).
What this means is that if you’re working in an area with very high underage birth rates then your experience of dealing with sexual health issues will probably be quite different from what it would be in a community of very strict Muslims. At the same time, registrars will also need to be aware of “Attitudinal aspects” (essential feature 2) – if they should happen to be strict Catholics or Muslims themselves, for example, then they will have to be self-aware about how their beliefs might influence their attitudes towards underage sex, birth control, abortion and so on, because without such self-awareness they might find themselves dealing with certain patients in an unhelpful or even prejudiced way.
Here is the complete list of statements, domains and essential features:
- 1. Core statement – being a GP.
- 2. The general practice consultation.
- 3. Personal and professional responsibilities.
- 4. Management.
- 5. Healthy people: promoting health and preventing disease.
- 6. Genetics in primary care.
- 7. Care of acutely ill people.
- 8. Care of children and young people.
- 9. Care of older adults.
- 10. Gender-specific health issues.
- 11. Sexual health.
- 12. Care of people with cancer and palliative care.
- 13. Care of people with mental health problems.
- 14. Care of people with learning disabilities.
- 15. Clinical management.
- 1. Primary care management.
- 2. Person-centred care.
- 3. Problem solving.
- 4. Comprehensive approach.
- 5. Community orientation.
- 6. Holistic approach.
- 1. Contextual aspects.
- 2. Attitudinal aspects.
- 3. Scientific aspects.
Clearly, practice managers are not going to be expected to involve themselves in all aspects of this curriculum – something like “Clinical management” (statement 15), for instance, which includes the subsections “metabolic problems”, “respiratory problems” and “neurological problems”, is well beyond their preserve.
On the other hand, when it comes to something like “Management” (statement 4), which has two subsections entitled “management in primary care” and “information management and technology”, it’s very unlikely that the registrar will be able to get a proper understanding of the subject without at least talking to the practice manager.
But there are other, less obvious areas where the manager may have to get involved too. Statement 3 (“Personal and professional responsibilities”) includes a subsection entitled “patient safety”, which is bound to involve health and safety issues, often regarded as the manager’s preserve rather than the doctor’s (usually so the doctor can pour toxic substances down the sink without worrying about the consequences).
Statements 13 and 14 (“Care of people with mental health problems” and “Care of people with learning disabilities”) both require a working knowledge of the Mental Capacity Act, which again is often something the manager knows more about than the doctor (my doctor had never even heard of it). And essential feature 1 (“Contextual aspects”) involves all sorts of things like the surgery’s financial record keeping, the new contract, practice-based commissioning (PBC), Choose and Book, and so on. In other words, the whole context of patient care in general practice.
Exactly how much input from the practice manager will be sought with regard to these aspects of training will probably vary quite a lot from practice to practice and from registrar to registrar. My past experience has been that most registrars would rather have their teeth pulled out than sit through one of my boring chats about the new contract.
Where managers can help
One thing to bear in mind, though, is that you may be contributing more to your registrars’ training than you realise just by showing them how things are done at your surgery. Every time you say something like, “There’s a quick X-ray service at the cottage hospital – the PBC group set it up, it’s a walk-in clinic, and the results come back to you within three days,” you’re contributing to their awareness of contextual aspects; a piece of advice such as, “Don’t go down the Dives Estate wearing that red and white scarf – they all support City down there,” is helpful in terms of community orientation; and “Will you stop coming in 40 minutes’ late with a hangover every Monday morning? I had five complaints about it this week” is very constructive in terms of personal and professional responsibilities.
Another thing to bear in mind is that the summative assessment process, which used to determine whether registrars became fully qualified GPs or not, has now been scrapped, and in its place the MRCGP (Member of the Royal College of General Practitioners) qualification, which used to be optional for registrars, has been made obligatory and revamped so that it relates directly to the GP Curriculum. It’s now called the nMRCGP, with the “n” standing for “new”.
What this means is that registrars will be very keen to cover all aspects of the curriculum, including practice management, in order to get through their final exams, which means that they will be much more likely to come asking you for help, especially when the exam date is looming. If your GP is a trainer then it might not be a bad idea to discuss training requirements with him or her in advance, and perhaps prepare some handouts, or allocate a time when the registrar can come and sit in with you – otherwise you might find yourself being pestered at an awkward moment.
RCGP – Curriculum and Assessment Site
Lulu (self-publishing site)
Dr Hairy’s Guide to the GP Curriculum
By Dr David Hindmarsh and Julian Le Saux
Available from: http://stores.lulu.com/drhairysguide