Following graduation all doctors now need to complete two years of foundation training, rotating every four months through different specialties, usually including General Practice. Thereafter doctors can apply for specialty training. Currently entrance to General Practice training is competitive as many see it as an attractive specialty.

General Practitioner (GP) specialty training at present is three years long. It consists of an 18 month rotation in approved hospital posts and 18 months in a GP training practice. It is now obligatory for new GPs to become members of the Royal College of General Practitioners (RCGP). This is done by sitting a multiple choice question exam (AKT - applied knowledge test), a simulated surgery assessment of clinical skills (CSA - clinical skills assessment) and a continuous work based assessment (WPBA - work place based assessment) of performance throughout the final year.

www.rcgp-curriculum.org.uk/gp_training_information/gp_training_map.aspx

www.rcgp-curriculum.org.uk/nmrcgp.aspx

Once qualified a GP must have yearly 'appraisals'. This involves demonstrating to another qualified GP that they are maintaining their clinical skills and knowledge up to date. Over the coming years, in order to practise, a GP will have to have a licence that will be renewed every five years, this is called 'revalidation'.

All doctors' practise is regulated by the General Medical Council (GMC). The British Medical Association (BMA) is the independent trade union and professional association for all doctors and medical students. The Royal College of General Practitioners (RCGP) acts as the 'voice' of general practitioners on education, training and standards issues. The RCGP sets the exam in order to become an RCGP member during the final year of training.

The administrative system of the National Health Service (NHS) is currently based on a hierarchical structure. A general practice receives payment for the services it provides from what are known as Primary Care Trusts (PCTs). These are partnerships covering an average population of 300 000 people. PCTs are managed by larger Strategic Health Authorities (SHAs), who in turn are managed by the Department of Health (DoH) that responds to Government. The health care system is paid out of central taxation and NHS medical services are free at the point of delivery, apart from a fixed payment per item on a prescription. At present this is £7.10, however many patients are exempt from this charge.

There are significant changes expected in the coming years following the publication of the White Paper 'Equity and Excellence: Liberating the NHS' in July 2010 by the DoH. This paper proposes abolishing PCTs and SHAs and transferring 80% of the total NHS budget directly to GPs. GPs would then be responsible for commissioning services. 

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353

GPs have a role in the assessment of their patients' need in their particular area, and are able to influence the commissioning, that is the contracts for provision of medical care for their patients. There are various ways to work as a GP. Those who run GP practices are called GP partners or principles. Other GPs are salaried practitioners who may be employed with a contract by GP partners and occasionally by PCTs or Health Authorities. There are also GP Locums who offer their services to cover clinical sessions when the doctor who regularly works there is absent.

GP partners receive payment from the PCT based on the number and age of patients they have, the services they offer, and if they meet certain quality markers. They work as a business partnership and are essentially self-employed. They usually employ a practice manager to help run the practice, as from the money they receive from the PCT they need to cover most of the practice expenditures, from salaries to the cost of equipment and the running of the building. Salaried GPs do not have the business and managerial responsibilities of a GP partner and usually have a fixed salary. GP Locums invoice their employer and usually are paid by the hour or per clinical session without a contract.

Published NHS figures from 2007 suggest there are 6.5 GPs per 10,000 patients and 8261 GP practices in England. There has been a trend away from single-handed and small partnerships towards multi-partner practices with an increase in 6 and 7 GP partner sized practices.

The usual opening hours of a GP practice is from 8am - 6.30pm. However, recently GPs have begun to also offer extended hours during weekday mornings, evenings and Saturday mornings. The out-of-hours work is now mostly done by means of a co-operative of local GPs sharing responsibility, who often employ GP Locums to do the work. NHS figures in 2007 show GP partners regarded as full-time worked an average 44.4 hours per week in 2006/7. The average length of surgery consultations with GP partners has increased from 8.4 minutes in 1992/3 to11.7 minutes in 2006/7. The vast majority of consultations are undertaken either in surgery or by telephone, with perhaps one or two home visits per day mainly to the elderly. It is estimated that one in four consultations have a psychological element, thus mental health is a large component of the GP's workload.

All residents in the UK are expected to register with a local GP practice. Patients have the freedom to choose any GP practice available in the area they live. Once registered most patients stay with their GP practice, only changing if they move from the area. Patients can attend a hospital Accident and Emergency Department for a genuine problem, however they are referred back to the GP if it is not an emergency. There are now also around 90 NHS walk-in centres in England where patients do not have to be registered. These deal with minor illnesses and injuries. However, routine access to the secondary health system is through the GP. As well as acting as a 'Gatekeeper', the GP is responsible for the day to day care of their patients and the co-cordination of the care between different specialties.

National Exchange Coordinator for the UK

Dr Madeleine Attridge (madeleine.jic@gmail.com)