The RCGP is pushing hard for five-year training for general practice.
The college's determination is buttressed by the Tooke report which insisted on the two extra years to prepare GPs for more care moving into the community, multiple morbidities and an ageing population.
But how easily will the RCGP achieve its aim?
Early talks with the DoH set August 2011 as the start date. Dr Bill Reith, who chairs the college's postgraduate training board, says 2012 or 2013 is now more likely.
The college is refining a cost: benefit analysis for the DoH, which criticised its interim case last autumn for giving too little financial information.
Since then, the financial landscape of the country has changed, Dr Reith admits. Is five-year training still affordable? He remains 'reasonably confident' that it is.
Five-year training could boost qualification rates. Since the MRCGP became the exit test for trainees, increasing numbers of would-be GPs have failed the exam, even after multiple resits.
Most failures can be explained by candidates entering vocational training without going through national selection. But the two extra years will help more doctors pass by adding confidence, the college argues.
The RCGP is upbeat but there are significant threats to five-year training. One is this year's 33 per cent drop in applicants to train as GPs, leaving some practices without a trainee for the first time ever (GP, 10 July).
Dr Reith believes the 2009 drop is a blip that will correct once increased medical school intake translates into increased foundation doctors.
But F2 doctors are increasingly unlikely to get a taster of general practice. In 2006 the DoH in England set a target of 55 per cent of F2 doctors doing a general practice rotation. This target marked a retreat from a 2005 target of 80 per cent.
Today the percentage is dropping as the number of foundation doctors grows, says Dr Reith. In Northern Ireland, Wales and Scotland only around a quarter of F2 doctors do a GP rotation.
'This is a concern. We know that once foundation doctors have seen what general practice is like, they increasingly realise that work is being transferred into the community,' he says.
This has the potential to leave general practice short on applicants even with three-year entry.
Fears over pay
GP asked its GP35 panel of 35 GPs under 35 what it thought. One in four said that five-year training would have put them off becoming a GP.
The GPC's trainees subcommittee is worried that pay in years four and five will not match the pay of a qualified GP.
It is also concerned about the 'lack of a fully planned structure for the extra two years'. It is worried that 'trainees will be allocated to unsupervised posts that are not of educational value'.
Dr Reith points out that more time in a practice will allow trainees to handle patients with chronic conditions better. It will allow time to learn skills like clinical leadership. Also the RCGP curriculum was designed for delivery over five years, not three.
Dr Shimnaz Nazee, a GP in Swansea and member of the GP35 panel, adds: 'GPs need strong leadership skills, the mental capacity to cope with the unexpected, the business acumen to run an effective service and provide proper guidance and training for staff.'
There is also concern that the treasured but already taut 1:1 trainer: trainee link will snap under five-year training. Trainees subcommittee chairman Katie MacLaren is 'incredibly disappointed'.
An extra 6,000 trainees would put trainers under huge pressure, she says. A massive shift in the ratio of trained doctors to trainees from today's levels of 15:1 to 4:1 is predicted.
There is a risk, too, that an increasingly competent, confident and growing trainee workforce will blight openings for newly-trained GPs. Practices staffed up with trainees will be less likely to take on salaried doctors. Dr Reith admits that this is a possibility. But the college is not likely to be dissuaded.
|GP35 panel's views|
I hope the trainees do not end up substituting European Working Time Directive gaps in the hospitals when really they ought to be in primary care for longer.
If general practice is what you want to do, whether it takes three years or five years it is worth doing the training.
Most GP registrars are not capable or cannot handle the pressure of working as a partner straight after registrar year and I guess five years' training is ideal to help trainees gain the leadership, the clinical skills needed to run/provide quality and safe services.