4.23. We are now growing medical school places from 6,000 to 7,500 per year.

Depending on the HEE training budget to be agreed in the Spending Review, the number of medical school places could grow further. The national workforce group will examine further options, including:

• more part-time study options;
• expanding the number of accelerated degree programmes which would allow people to train in four years rather than five years to widen access;
• greater contestability in allocating the 7,500 medical training places to universities so as to drive improvements in curricula (formal and informal), and the production of medical graduates who meet the primary care and specialty needs of the NHS.

4.24. The way doctors are trained and the way they work will be a key component of the workforce implementation plan. We want to accelerate the shift from a dominance of highly specialised roles to a better balance with more generalist ones. A quarter of adults currently live with two or more long-term conditions [164], and medical training needs to support doctors to manage comorbidities, alongside single conditions. A survey of 50 smaller hospitals found only five had more than 60% ‘generalist’ doctors with no correlation between medical patient case mix and skill mix expressed as the percentage of generalist staff [165].

4.25. So we will test a wide range of new incentives to ensure the balance between specialist and generalist doctors, and the balance of specialties within medicine, better matches patient needs. We will also work to ensure specialty choices made by doctors are better aligned to geographical shortages.

4.26. The workforce implementation plan will build on the General Practice Forward View to increase the number of doctors working in general practice. While the number of new recruits has been increasing well, the number of early retirements and part-time working has more than offset this. We still believe we need a net increase of 5,000 GPs as soon as possible and are committed to this. In addition, the workforce implementation plan will continue recent provision for a range of other roles – including pharmacists, counsellors, physiotherapists, nurse practitioners – building on the success in expanding these numbers by nearly 5,000 over the past three years – and hence building the skill mix to relieve pressure on GPs. Chapter One sets out how primary care networks will be able to attract and fund additional staff to form an integral part of an expanded multidisciplinary team.

Initially, this will focus on clinical pharmacists, link workers, first contact physiotherapists and physician associates. Over time, it will be expanded to include additional groups such as community paramedics.

4.27. Additionally, newly qualified doctors and nurses entering  general practice will be offered a two-year fellowship, a scheme suggested by the GP partnership review [166].  This would offer a secure contract of employment alongside a portfolio role tailored, where possible, to the aims of the individual and the needs of the local primary care system. This will enable newly qualified nurses to consider primary care as a first destination role. There is also evidence that such approaches will, for example, increase the number of GP registrars taking up substantive roles in primary care.

4.28. The government has also committed to a new state-backed GP indemnity scheme from April 2019, as part of a five-year funding and reform package. The purpose of the indemnity reform is to address concerns about rising NHS indemnity costs, in a cost neutral way, as well as extending the scope of coverage to support the expanded multidisciplinary teams described above.

4.29. Working with the British Medical Association, the medical Royal Colleges, the General Medical Council and providers, we will also address:

• how the wider NHS can support the implementation of HEE’s work to improve the working lives of doctors in training, including providing adequate time for supervision, accelerating implementation of ‘step out and step in’ training programmes and further work to enable trainees to switch specialties without re-starting training;
• how to accelerate the development of credentialing, which has been piloted by HEE, to enable doctors to broaden the scope of their practice, both during and after training;
• how to reform and re-open the Associate Specialist grade as an attractive career option in line with the HEE led strategy for Specialist and Associate Specialist doctors;
• the acceleration of work to ensure doctors are trained with the generalist skills needed to meet the needs of an ageing population, alongside the development of specialist knowledge and skills;
• the development of incentives to ensure that the specialty choices of trainees meet the needs of patients by matching specialty and geographical needs, especially in primary care, community care and mental health services;
• the consideration of any further proposals from the work on reforming medical education which will support the delivery of the Long Term Plan.

References

164. Stafford, M., Steventon, A., Thorlby, , Fisher,  R., Turton,  C. & Deeny,  S. (2018) Understanding the health     care needs of people with multiple health conditions. The Health Foundation. Available from: https://www.health.org.uk/publications/understanding-the-health-care-needs-of-people-with-multiple-health- conditions

165. Imison, C. & Vaughan, L. (2018) Acute medical care in England: Findings from a survey of smaller acute hospitals. Available from: https://www.nuffieldtrust.org.uk/files/2018-09/1536830967_medical-generalism- interim-report-slide-deck-final.pdf

166. Department for Health and Social Care (2018) GP partnership review: key lines of enquiry, call for evidence. Available from: https://www.gov.uk/government/publications/gp-partnership-review-key-lines-of-enquiry-call- for-evidence