Training has understandably been seen as the priority when it comes to solving long-term workforce problems in general practice. In the context of the report by our published Cogora, it has a specific definition of training.
Every healthcare professional continues ‘training’ until the day they retire. Fully qualified GPs, nurses and pharmacists need to demonstrate their continuing professional development for revalidation.
There is also the potential for some healthcare professionals to upskill, by taking on prescribing responsibilities or advanced practitioner status, for example, or preceptorship courses, which smooth the way for fully qualified staff to enter general practice, or return from career breaks. All staff do their development training in conjunction with their routine work as part of the general practice team.
However, for the purposes of this report the term ‘training’ applies to professionals who are not yet fully qualified to practise without the necessary supervision within the team.
Currently, the only healthcare professionals for whom there is a requirement – or a national programme – to spend time training in general practice in order to qualify are GPs themselves (medical students effectively need to do rotations in general practice too).
Other professionals are able to do training rotations within general practice but this is not essential for them to fully qualify, even for a career within general practice.
Practices have different financial incentives to train distinct groups of staff. This could be GPs – for whom rotations in general practice are compulsory – or other healthcare staff (including medical students), for whom general practice rotations are not compulsory.
These incentives differ based on the staffing group and, in many cases, have been distorted by the ARRS. The picture is ever-changing – the incentives are constantly changing, and there may also soon be changes to the regulations. This is likely to have significant effects on the future general practice workforce.
We will look at the situation regarding the training needs for each healthcare profession.
Medic training
By far the biggest group of trainees in general practice is doctors. Most stakeholders agree that an increased number of trainees in general practice is essential to the future of the profession. These trainees include Foundation Year (FY) doctors and GP registrars.
The Foundation Year programme usually covers the two years following medical school, where graduates rotate around various clinical settings before starting specialty training. They are not required to do rotations within general practice, but more than half do.
GP speciality training normally takes three years, and GP registrars spend a minimum of one year in general practice – but ideally 18 months, and ideally the final 12 months in general practice.
This could change. The NHS workforce report set goals to increase GP specialty training places from 4,000 to 6,000 by 2031, ensure all FY doctors do a rotation in general practice, and require GP registrars to spend the full three years in general practice.
These build on the success of Health Education England – since incorporated into NHS England – in increasing GP training places.
There may be even more demand in terms of GP training. Wes Streeting’s plans to revise the NHS workforce report will have ‘a laser focus on shifting care from hospitals and into the community’. According to the announcement from the Department of Health and Social Care: ‘The original workforce plan would increase hospital consultants by 49%, but the equivalent rise in fully qualified GPs would have been just 4% between 2021 to 2022 and 2036 to 2037.’
General practice also takes on medical students. There is no legislation stating that medical school courses need a rotation within general practice, but it is unlikely they would get approved by the GMC without it. A 2020 study suggested medical students spent a median average of 108 sessions in a general practice setting.
One of the study’s authors, Professor Hugh Alberti, Professor of general practice education at Newcastle University, says this figure will ‘no doubt’ be higher now: ‘Many traditional schools, like Newcastle, have increased our GP time since then and all the new schools have higher proportions.’ Only 13% and 14% of Oxford and Cambridge graduates respectively go into general practice, compared with 34% and 32% of graduates from University of London (excluding UCL, King’s and Imperial) and Leicester, respectively.There have been several initiatives to redress this, including new medical schools that focus on general practice and financial incentives for universities.
The NHS workforce report planned to double the number of medical school places, which will likely see more demand from medical students for placements in general practice.
This comes as a time when the UK is relying far more heavily on international medical graduates (IMGs). In 2023, for the first time, international medical graduates outnumbered UK graduates among GP trainees.
There is a question as to whether it matters that the majority of GP trainees are IMGs. RCGP chair Professor Kamila Hawthorne says the college has been campaigning to make it easier for IMGs to remain in the NHS as they are currently having to ‘jump through hoops’ in terms of visa requirements.
However, she adds: ‘We should not be reliant on doctors from overseas to ensure we have sufficient workforce – we also need to make significant efforts to train more GPs in this country and then retain them.’
Here it is worth touching on plans around staff and associate specialist doctors – predominantly sub-consultant doctors not working towards a CCT. There is also a high proportion of IMGs in this group. The GMC originally floated the idea of these doctors entering general practice to alleviate workforce issues in 2022.
The workforce plan committed to ‘ensure that doctors other than GPs are more easily able to work in primary care’, adding that the medical workforce ‘is expected to change over the next 15 years’, with more SAS doctors and doctors in training choosing different career paths including general practice.
NHS England denied there were pilots involving SAS doctors in general practice, after GPC England chair Dr Katie Bramall-Stainer claimed they were ‘colluding in the demise of the [GP profession]’by promoting the idea of ‘primary care doctors’ in July 2024. So far there have been no further developments.
Practice nurse training
There is at least an imperative to sort out training capacity for GPs. The regulations around the time they need to spend training in general practice, plus the Government’s own targets (or revised targets with Labour’s forthcoming workforce plan), mean there will be scrutiny around this.
For practice nurse training, this imperative does not exist. The NHS workforce plan included measures to increase nurse training places from 30,000 a year in 2022 to 40,000 a year by 2028/29, and 53,500 by 2031/32, with an emphasis on community nursing. But this doesn’t seem to be in general practice, with an emphasis on health visitors and little mention of practice nurses.
Practice nurses are experiencing low morale, and many are looking to retire in the near future. To revitalise the profession, there needs to be a steady influx of practice nurses. This will be helped by nurse trainees having exposure to general practice. Such exposure will also help with their induction into general practice.
But practice nurse training faces a number of problems. The number of nurses trained in GP practices has been static for the past seven years – 181 in March 2017 and 187 in October 2024. Even including the 37 trainee nurses in PCNs, this represents barely any increase.
Trainee nurses are recruited on an ad hoc, local basis. The only requirement for nurses is they need to spend two weeks in a community setting – but not necessarily in general practice.
The incentives seem to work against placing trainee nurses in general practice. First, from the universities’ point of view, there is no obligation for nurses to spend time in general practice so it is far easier for them to place nurses in secondary care, which has the infrastructure to take on hundreds of students rather than the one or two that a GP practice can accommodate.
Second, practices have little incentive to take on nurse trainees; the clinical tariff a trainee nurse attracts is £5,519 – or around £150 a week, for what would be a two-week placement.
Asha Parmar, an ANP in North Central London, says: ‘I’ve been trying to get a GP nurse trainee for two years across two practices and have had push back on renumeration of the nurse and lack of space with little room for flexibility on working patterns.’
As one practice nurse training co-ordinator puts it: ‘What scares me as a practice nurse is whether there is a need for us at all. Is that why there is a lack of training and support provision for new practice nurses – as there isn’t a role for us in the future?’ In the battle for training capacity, nurses seem a low priority.
Pharmacist training
The number of pharmacy trainees in general practice is not counted because there are no trainee pharmacists employed in general practice. However, in December 2024, regulations were changed to allow GP practices to act as the employer for trainee pharmacists (interestingly, this was an effect of Brexit, with the European Union not permitting GP practices to be counted as an employer of trainee pharmacists).
Practices are to be given a training grant of £26,500 a year from 2025/26 to employ trainee pharmacists in their one year foundation programme. This almost exactly covers minimum wage plus National Insurance contributions. Even before this change in regulations, there were around 700 trainee pharmacists in general practice, with practices partnering with community pharmacies or hospitals.
For 2025, this will all change. All pharmacists who qualify this year will be required to have prescribing skills, which will involve 90 hours of training from a prescriber. For those pharmacists who train in secondary care settings, fulfilling this requirement will not be a problem. But it might prove a problem for pharmacists training in community settings, as there are currently not enough community pharmacists able to teach prescribing skills.
As a result, it is likely there will be more demand for training within general practice, which has the benefit of having not only pharmacist trainers, but also GPs and even ANPs, all of whom can provide training in prescribing.
It is not yet clear what the arrangements will be for this. It could mean more trainee pharmacists being employed by practices. Unlike trainee GPs, whose salaries are covered by NHS England on top of a training grant, trainee pharmacists will be on the open jobs market. Practices or PCNs that want a trainee pharmacist will be competing with community pharmacies and secondary care.
At the same time, the tariff for hospitals to take in a trainee pharmacist has decreased and is now the same as the grant given to general practice, at £26,500. But, unlike pharmacies and general practice, acute trusts won’t have scope to increase salary offerings. General practice will have the benefits of being able to offer prescribing training and, if partners and PCN clinical directors so wish, to offer topped-up salaries.
For practices and PCNs, the attraction is that the pharmacists can start consulting one-to-one with patients within about four months, according to Primary Care Pharmacy Association president Graham Stretch. They will require support within the practice but the consultations themselves will be unsupervised.
This will be financially sensible, he says, and will provide a pipeline of practice pharmacists at a time when they are in demand.
Danny Bartlett, a Royal Pharmaceutical Society England pharmacy board member, notes this implies more training capacity in general practice for pharmacists. He says this is ‘a vital moment’ when GPs and other trainers must be given ‘time and space to develop as supervisors to be able to take trainee pharmacists’.
The new regulations may lead to community pharmacies reaching agreements with local practices to provide prescribing training for a fee, benefiting all parties.
In summary, general practice is likely to see rising demand for pharmacy training – and pharmacy trainees – in the year ahead.
Other allied healthcare professionals
There are currently more than 650 nurse associate trainees in general practice. Their role involves clinical tasks including venepuncture and ECGs, taking blood pressure, temperature, respirations and pulse rate, and supporting patients who receive bad news, for example.Nursing associates need a foundation degree, typically taken over two years, which usually takes the form of an apprenticeship.
The entry requirements for the degree are pass marks in maths and English GCSE or equivalent.
PCNs and practices receive funding to employ these trainees – a training grant worth £4,000 a year (£8,000 for the two-year course), or £7,900 a year if more than 50% of their time is spent with patients with autism or learning disabilities. On top of this, their salaries are funded through the ARRS.
The aim of the role is partly to ‘allow nurses to concentrate on more intricate clinical tasks’. But as the nurse training co-ordinator put it: ‘Many practice nurses feel under pressure to train our replacements.’
For physician associates (PAs), there is again no requirement to spend time training in general practice. However, they must do 1,600 hours of clinical training, including 350 in general hospital medicine.But practices and PCNs are heavily incentivised on a local basis to take on training for PAs. For example, in the Greater Manchester Training Hub, they are offered £555 a week to take on a PA, compared with just £130.96 per week for a nurse.
Equally, there are currently no requirements for paramedics or physiotherapists to do pre-qualification training in general practice. But the professional bodies of both are expecting an increase in demand. A Chartered Society of Physiotherapy (CSP) spokesperson says: ‘To achieve CSP accreditation, students and apprentices are required to complete 1,000 hours of practice based learning as part of their degree programme. Practice-based learning must be organised to reflect the increasing presence of physiotherapy services in primary care and community settings.’
Meanwhile, the Health and Care Professions Council says: ‘We consider it best practice that pre-registration paramedic programmes include non-ambulance practice-based learning.’
There are other trainees in general practice – mainly employed by PCNs – including trainee clinical associates in psychology, talking therapy practitioners, health and wellbeing practitioners and pharmacy technicians. But these are in single figures across England. There is a larger group of apprentices (220), which confusingly includes roles such as apprentice nursing associates and apprentice registered general nurse trainees, according to NHS England. But, relatively speaking, these trainees don’t take up much training capacity. Which is lucky, because capacity is scarce.
Training Capacity
As we have seen, there are a number of different staffing groups that train within general practice. They differ in how lucrative their training is for practices, the requirements for training within general practice and how much they can contribute to the general practice team while training.
However, there is only so much resource and capacity for training. The NHS workforce plan only exacerbates the capacity issues, with Labour’s version in 2025 expected to do likewise.
Modelling by sister title Pulse in 2023 revealed the aims in the workforce report would require a doubling of training capacity for GPs alone within five years, and a trebling within a decade.
On the capacity for training, the workforce plan had this to say: ‘Management of the number, spread and quality of clinical placements is a concern across healthcare education and training, and for learners. Growth in placements has been challenging for several years, usually attributed to a lack of capacity and supervision, and this restricts the breadth of learning opportunities on offer to students.
‘We will work with stakeholders, informed by the issues we identified through a discovery exercise in 2022/23, to ensure clinical placements are designed into health and care services, and placement providers know what core standards they need to meet.’
The workforce report includes an ‘Educator Workforce Strategy’. This lays out seven priorities for supporting ‘educators’ – a term that encompasses academic clinicians and trainers: ensuring educators’ capacity is factored into workforce plans; protecting their time; introducing career frameworks; supporting their development and wellbeing; defining standards and principles; promoting equality, diversity and inclusion; and embedding evolving and innovative models of education. But details on the delivery will only be made clear in January 2025.
In the meantime, deaneries have also been tasked by NHS England with developing plans to increase training capacity.
Cogora, our publishing company which carried out this research, asked the seven deaneries across England what they were doing to address capacity issues. There were a few common strands. All the deaneries who answered pointed to the Blended Learning Programme, introduced during Covid and now adopted nationwide. This involves trainees combining technological and digital approaches to learning with practice-based training. In its report on blended learning, Health Education England makes a point of highlighting how it helps with capacity: ‘Technology offers opportunities to support clinical placements and increasing the available capacity using techniques such as virtual ward rounds and the provision of remote supervision and mentoring.’
Deaneries pointed to their accreditation of practices and PCNs as Unified Learning Environments (ULEs), enabling them to take on medical students or trainee doctors and healthcare professionals in a more streamlined fashion. Opening this up to PCNs has increased capacity, the East of England Deanery said.
The Greater Manchester Training Hub has set up accredited ULEs for GP practices, PCNs and federations, allowing them to take on any trainees, attracting a tariff as a result.
There are other innovations taking place elsewhere. The RCN’s Kim Ball highlights a GP nurse training scheme at the Staffordshire Training Hub. The Staffordshire GPN Foundation School, launched in September 2023, states: ‘The variability, instability, and optional nature of general practice nursing training have long been issues due to the lack of a structured pathway, unlike the established GP training programme for doctors.’ The school says it was launched in recognition of ‘the need for change’ and modelled after the GP training scheme.
But practices and PCNs are still having to prioritise, given the limited capacity. There is only so much physical space for each staffing group. Trainees may not always require their own space, but they certainly will if they are to contribute to service delivery and patient care alongside their training placements.
A key problem is the number of trainers and their available time. GP, nursing and pharmacy trainees all need to be supervised by their senior equivalents. These same trainers will also be overseeing other allied healthcare professionals.
The data are patchy in relation to the number of professionals providing training within general practice. According to the GMC, there are 7,940 GP trainers in England. The Nursing and Midwifery Council says there are 1,346 nurses on its register with a general practice nursing SPQ qualification who can provide training, but it does not have figures on how many are actually doing so.
The General Pharmaceutical Council says there are roughly 3,500 designated supervisors for trainee pharmacists, but cannot specify how many work in general practice. NHS England’s Educator Workforce Strategy found there were problems with service pressures eroding the time available for training, as well as an ageing educator workforce.
The surveys conducted by sister title Nursing in Practice provides a bit more cheer on this. As one nurse respondent put it, training can be ‘one of the most rewarding parts of my work’.
Of the 830 GPs who responded to sister title Pulse’s survey, 23% were trainers and 16% were considering becoming a trainer. It found that the average age of trainers was 49, compared with 52 for non-trainers, while the average age of those considering becoming a trainer was 45.
Meanwhile, the average time they wanted to remain as a trainer was seven years. For the 198 nurse trainers who answered the Nursing in Practice survey, this figure was 5.7 years.
More trainers are needed, however. As RCGP chair Professor Hawthorne put it when addressing the Health and Social Care Committee hearing in December 2024: ‘More and more people need to be trained in generalism, and the best place to do that is in general practice. And that’s not just medical students and GP trainees. It’s nursing students, it’s physician associates, it’s clinical pharmacists.
‘The whole raft of the team needs to come out into general practice, and we don’t have the room to train them properly, nor do we have the trainers.’
While the lack of capacity remains, practices need to prioritise. There are many non-financial benefits in taking on trainees of all types. But, with an ongoing funding squeeze, practices and PCNs are having to give greater weight to the financial aspects –whether that be preferring certain staffing groups because of the funding they attract, or avoiding other groups because of adverse cost-benefit analyses. Such choices do not necessarily translate to the longer-term benefits to the workforce; for example, there are now greater financial incentives to train PAs and nursing associates than there are to take on practice nurses or medical students.
This is an example of the GP contract being fundamentally broken, with incentives poorly aligned with long-term needs.
The BMA and NHS England are currently discussing an overhaul of the contract, with a new version expected to be implemented in 2028. Training, and how it integrates with overall health of general practice, must be a key factor in to this.
This chapter is based on a major new white paper from the publishers of Healthcare Leader, Cogora, on the changing general practice workforce in England, in conjunction with the Rebuild General Practice campaign group. Alongside our sister titles – Pulse, Pulse PCN, Management in Practice, Nursing in Practice and The Pharmacist – we have surveyed around 2,500 general practice professionals, interviewed more than 100 frontline practitioners, analysed hundreds of data for every practice in England and brought together all the editorial expertise within our titles.
Download our General Practice Workforce White Paper here.
