Admission and duration of GP training

Each country has its own requirements for entry into GP training with the duration of post-graduate training lasting between three and five years (Figure 1). In Germany, doctors who have completed their basic medical training and are in possession of a valid full or temporary licence to practise are entitled to apply for a position as a junior physician. Doctors who wish to become a GP apply at an institution licensed for medical training in this area of specialisation. Their GP training in a paid junior position usually starts after successful job interview with a position in inpatient care in internal medicine over a period of 36 months, followed by 24 months in general practice at an ambulatory unit under the supervision of a practise-based GP. During their five years of training, junior physicians must fulfil the requirements stipulated in the GP speciality training regulations and guidelines on the content of speciality training. Overall, post-graduate GP training takes five years to complete in Germany.

^aThere is no standardized specialty training at federal level in Germany. The Regional Medical Chambers (‘as corporations under public law’) are responsible for the specialization and advanced training of doctors. Regulations on the content and configuration of speciality training are laid out in state by-laws and the autonomous statutes of the State Chambers of Physicians. The template of the Federal Chamber of Physicians with the guidelines for the specialty training only has a recommendatory character, thus specialty training guidelines can differ in detail among the federal ‘Länder’ (Bundesärztekammer, 2014).

Figure 1. Current training pathways for GP Specialists in England, Germany, and Spain. 

In Spain entry to all postgraduate medical training is based on results in a national multiple-choice examination of clinical knowledge (known as MIR exam), combined with undergraduate qualifications. There is no formal foundation training prior to general practice training, although the sixth undergraduate year in Spain is considered equivalent to the UK's foundation year 1, as it is largely practical. This is likely to change soon, with a new specialty training law being drafted in Spain, drawing on the UK's current model with 2 years of foundation training prior to entry specialist training with a four year duration (Law SCO/1198/2005).

In England, prospective trainees are judged on the basis of an initial application form, then a multiple-choice exam, and finally an interview with a strong focus on certain competencies. The process was described as competitive but generally fair: “It is really good, I would say it is probably the most structured, most organized, most fair and most evolved application process of all the specialties and almost kind of enjoyable to do” (UK03). With the inclusion of foundation years training, it means that five years of post-graduate training are required to become a GP in the UK, although the actual ‘GP vocational training scheme is only three years. In addition, the mandatory two-year foundation training programme, which precedes the standard three years of GP vocational training, often includes four months in general practice. Four-year GP vocational training programmes are being piloted in certain parts of the UK and proposals to increase training to five years have also been explored. The possibility of extended training was perceived positively by most GPs interviewed: “I think the extension of the GP training is a good thing. I think three years is not long enough to get all of the experience that you need to in a way that you continue learning on the job, glad that it has been recognized and I certainly found that the additional year was very useful” (UK10).

Continuing professional development (CPD)

In Germany, where there is a strict division between doctors caring for inpatients in hospitals and those providing outpatient (ambulatory) care, which include GPs, a point-based CPD system is obligatory for all doctors who provide ambulatory care to patients covered by Social Health Insurance (SHI), who comprise the majority of the population. Interviewees reported being required to pursue a number of approved theoretical and practical courses, presenting evidence of participation to the regional medical chambers every five years. Those failing to do so may be punished with a reduction of reimbursement and, if they fail to show evidence of sufficient training within a further two years, their license can be withdrawn.

GP in England must complete 250hours of CPD in a 5-year period. They are appraised annually and undergo revalidation (renewal of licence to practice) every 5 years, based on a portfolio of evidence, including reflective notes on participation in CPD, audit, quality improvement activities, analysis of significant events, evidence of team working and patient feedback.

GPs in Spain related difficulties in undertaking CPD activity due to recent budget cuts, increased workload and reduced time. More newly qualified GPs also reported concerns about lack of support for professional development at their workplaces. There is little or no protected learning time, particularly for those employed on short-term contracts or locum posts. Continuous training was often referred to as a ‘personal decision’, as there is no compulsory minimum number of CPD hours in Spain. Professional societies have varied training courses, some of which are either free of charge or at a low price for their members (but membership fees apply). Pharmaceutical companies sometimes offer free courses, but most Spanish interviewees expressed unhappiness with industry involvement in the organization of training: “It is a very important thing that continuous training attendance stops being oriented by pharmaceutical industry. They eliminated most of the continuous training. There is just very little continuous professional training offered” (SP03).

Scope of practice

1) GP practice organization and multidisciplinary teams

In Spain, most GPs are employed under salaried contract in the public health care system and work in primary health care centres. Registration with the Regional Medical Council is compulsory. Spanish interviewees described how changes in hierarchical structures (e.g. between physicians and nurses) encouraged multi-professional team working in primary care. In Spain there are also community paediatricians, dentists and midwifes, and occasionally physiotherapists, working in the same building. Most Spanish interviewees described team working as advantageous: “It is an advantage that we are unaware of, but we have it here” (SP08). However, there were concerns raised regarding coordination between primary and secondary care.

In contrast, in Germany most GPs are self-employed, working in office-based solo practices, although some work in group practices or in health centres. To be allowed to provide services billable to the SHI, based on a complicated mix of capitation and fee for service, they must be accredited by the Regional Association of SHI Physicians. All but one interviewee reported employing medical assistants (‘Arzthelferin’) who complete three years of vocational training, and whose role combines administrative and some minor clinical tasks (e.g. measuring blood pressure). The GPs described themselves as employers who delegate tasks: “I am the head of the practice and I am actually responsible for everything. But I have three employees and of course I try to delegate part of my work, everything there is to do in terms of office work. Besides my medical work I am also the employer, the boss, I am responsible for my practice, also for the management of the business” (DE05). Two German GPs described how their medical assistants undertook advanced training to extend their competencies to enable them to conduct home visits, case management, medication review and prevention activities.

This has some features similar to England, where partners in GP practices have a contract with the National Health Service (NHS) and may employ other GPs on salaries, and other health professionals such as nurses and administrative staff. Interviewees in England reported collaborating “fairly closely” with other healthcare professionals, particularly in larger general practices which usually have expanded capacity for allied healthcare workers including drug/alcohol workers, psychologists and district nurses. There are also increasing numbers of general practices where hospital specialists run outpatient clinics in the community.

2) Administrative vs. clinical duties

In all of the countries, administrative tasks are reported to occupy increasing amounts of a GP's time. In addition to the traditional administrative tasks, such as processing referrals, laboratory results, and correspondence from hospitals, English GPs seemed to have an especially heavy load, including extensive performance reporting, audits, meetings with patient groups, and engagement with the local clinical commissioning group. These GPs reported that they spent roughly equal amounts of time on administration and clinical work: “50-50 time spent between patients and managerial tasks” (UK01). The amount of administrative work may vary between partners and salaried doctors. Salaried doctors may have heavier clinical workload whereas partners may take on more of the administrative responsibilities related to the management of the practice.

German GPs also complained of a heavy administrative workload, but it was less than in England “...more than one hour per day. Six to eight hours per week, at least. You can easily count on seven hours for administrative things, this is madness” (DE03). Spanish GPs also reported spending too much time on administrative tasks and further highlighted the increasing administrative workload arising from patient's requests for certificates for incapacity/benefit claims and fitness to work assessments.

Ethical dilemmas

In each country, GPs described having to deal with ethical challenges. In Germany, a common theme was how to support end of life decisions and the possibility of having medically assisted suicide in the near future. One participant referred to the ethical challenge of caring for dying patients who are “held back [kept alive] by machines”. Another GP mentioned “an ethical issue that might arise in the future is most certainly the care and treatment of the continuously growing elderly population” (GP07), particularly “dying and medically assisted suicide to those whose situation is hopeless and who don’t want to be in this world anymore (GP07)”.

Spanish GPs expressed concern about recent changes in entitlement to care for undocumented immigrants and the impact of austerity measures on patients’ health and healthcare provision. The issues most often mentioned included the inability of patients to afford the newly introduced co-payments and their unwillingness to exclude undocumented migrants from accessing primary health care services.

In England common concerns included patient confidentiality and consent, rationing of healthcare due to scarce resources, dealing with what were seen as inappropriate requests by patients, and balancing patient needs with respect for autonomy and choice. There was general agreement that GPs in England are under pressure: “...to curtail referrals [to hospital], also not to prescribe certain drugs because they are too expensive” (UK01).

Things that need improving and future challenges

There was widespread concern in all countries that increased bureaucracy reduced the time for patient care. A Spanish GP highlighted that “Our work is based on the relationship with the patient, and the relationship has deteriorated for sure because there is no time and no energy” (SP02). In Germany, younger GPs criticised what they saw as structural failures in their training, such as lack of professional guidance and too many rotations. In both Germany and Spain, participants cited the need to improve communication across the primary secondary care interface. Spanish GPs highlighted the consequences of the austerity measures, which they saw as having little clear rationale and impacting adversely on population health and quality of care.

A number of English GPs were also concerned about the Quality and Outcomes Framework (QOF).³⁰ QOF is a payment scheme designed, in theory, to reward high quality care, with payments for performance against a package of quality indicators, such as control of certain chronic conditions and implementing preventative measures, but also some managerial measures. Although the scheme is voluntary, in practice almost every GP signs up to it as provides up to 30% of the practice's income. GPs argued that, although the rationale behind “balancing the perceived health needs of one individual against those for a whole population and the resources”(UK10) may seem obvious, “Referral behavior is very complex and it's very difficult to judge in practice on how they perform just by looking at how much they refer” (UK01), leading to concerns about whether it is leading to rationing of necessary care “GPs are being paid not to do things that they think may be appropriate. So… being paid to reduce your referrals to hospital is not accepTable” (UK09).

Strength and limitations

Strengths of this paper include its comparative research on a sample of European GPs, exploring several aspects of their training and practice. Furthermore, participants included a varied group of doctors, working in different primary health care settings, at different levels of seniority. We were able to undertake an in-depth analysis of their experiences and expertise on a series of topics, some of which were quite sensitive, such as the ethical dilemmas faced in their day-to-day practice. However, as the interviews were conducted in different languages and translated for the analysis there was a risk of missing details and contextual information, although where possible statements were verified through desk research.

An additional strength of the paper is that it provides the current state of affairs of GP training and scope of practice among European countries.

There is widespread agreement on the importance of engaging in continuing professional development, and mechanisms to do so were present in all countries although to varying degrees. It is considered “voluntary”, with no minimum number of credits in Spain but is compulsory in England and Germany. In addition, the UK and Germany have revalidation systems in place, although the former goes beyond that in any other European country.⁹ The more holistic assessment of clinical competencies and personal attributes used in England was seen as fair and effective, consistent with previous studies.^31-33 In Spain the government approved a law that envisages the introduction of mandatory CPD and revalidation at regular intervals,³⁴ although this has not yet been put in place, hindered in part by a lack of funding consequent on austerity measures.

The differences that have been described in this paper relate to the different ways the health care system is organized and funded in each country, as well as how GPs’ responsibilities and roles are defined. Key differences included whether GPs work in multidisciplinary teams or singlehandedly; and the varying time devoted to administrative and clinical activities. However, our interviewees also shared common concerns and challenges such as the need to adapt services to an ageing population (with increasing challenging multi-morbidity and thus polypharmacy), the need to improve coordination between primary and secondary care, the lack of time for patients and the ethical dilemmas that arise in their daily practice.

One clear difference related to how the financial crisis is affecting GPs’ ability to provide services. Whilst few German GPs spontaneously mentioned the issue, English GPs raised concerns about budgetary pressures, within which they included the QOF, even though this is formally seen as a means to improve quality, whilst Spanish GPs emphasised new co-payments and denial of access to healthcare by migrants ³⁵. The latter issue may become a greater concern in England following the passage of legislation similar to that in Spain.³⁶

It is important to note that the interviews were conducted before the UK voted to leave the European Union. This paper, therefore, adds to the evidence of the extreme complexity that the UK will face in disentangling itself from the existing arrangements. Health professional mobility will be a particularly challenging issue, given that many of those who voted to leave sought to prevent free movement of people, yet the National Health Service in the UK depends substantially on health professionals from other Member States. Moreover, this is happening a time when it is facing other major problems as a consequence of the referendum vote, such as increased costs of pharmaceuticals resulting from the large decline in the value of sterling.

It remains to be seen how the UK will address this issue, given the difficulty reconciling the wide range of views within the government at Westminster as well as the very different views in two of the nations of the UK, Scotland and Northern Ireland, which voted to remain. Thus, it is not yet clear that it will be possible to achieve a national consensus, let alone one that will be agreed by the remaining 27 member states. Many of them will also be affected by whatever the UK decides, given its status as one of the preferred destination countries among GPs across the EU. It is, however, clear that this vote has created enormous uncertainty, with very damaging consequences already emerging for British research. It will be important for the British authorities to provide some clarity as soon as possible to minimise the damage but, given their internal disagreements, this will be extremely challenging.

Ethical issues discussed by participants reflected distinct issues in the three countries at the time of the interviews. The combined findings are in line with a comparative literature on ethical difficulties among physicians across Europe.^{26 37}

These differences have practical implications. As noted in the literature,³⁸ GPs who are interested in moving to another country should be provided with information on the new health care system in which they will be practising and this should include ethical and professional regulatory frameworks.

Although mobility of both health professionals and patients has increased, comparative research on the scope of practice of health professionals has so far been limited. There is a clear need for a much better understanding of the scope of general practice across Europe. Regardless of differences in primary care systems and cultural and historical context, GPs in each country face common challenges such as lack of time for patients, financial constraints, difficulties in coordination of services, working in multidisciplinary teams, as well as the issues arising with an ageing population. Finally, it is important to note that the differences identified in this paper have strong historical roots, grounded on the different national experiences.