General practice training programmes in Britain run for three years and consist of two years in approved hospital posts and one year in general practice as a general practitioner registrar. Although the general practice phase is envied across the world, it can be said to have failed overall because it has not succeeded in attracting enough recruits and has inadequately prepared those who do enrol to become principals in the rapidly changing NHS. The reasons behind this failure are complex, but they include the short length of general practice training compared with specialist training and the poor educational quality of some of the senior house officer posts used in the hospital component of training programmes.

The regulations that govern general practitioner training allow a variation on the above training programme, ¹ permitting up to two years as a general practitioner registrar and a minimum of one year in hospital posts. ² Despite this, only a few training schemes have been able to include such longer periods in general practice, such as in the armed forces and some innovative schemes funded under the London Implementation Zone Initiative. ³ Since April 2000, however, when funding for general practitioner training was transferred to the Medical and Dental Education Levy, ⁴ the directors of postgraduate general practice education have, with their course organisers and trainers, been able to develop more flexible and innovative programmes that are better tailored to the needs of doctors training to become general practitioners. These new opportunities reflect the aspirations outlined in the NHS Plan for England, which also highlighted the need for modernising the senior house officer grade, ⁵ and the consultation document A Health Service of All The Talents. ⁶

The new training placements are prov-ing to be popular with applicants. We focus here on women’s health placements in primary care, why they are necessary, and what they have to offer.

Women’s health placements

A national survey in 1990 found that 89% of trainees had acquired experience in obstetrics and gynaecology, ⁷ and in 1991 obstetrics and gynaecology was the specialty most frequently undertaken by doctors training to be general practitioners. ⁸ Current data held by the Joint Committee on Postgraduate Training for General Practice (JCPTGP) indicate that in 1999 there were 2002 applications for a JCPTGP certificate, 75% of which included obstetrics and gynaecology (personal communication, JCPTGP 2000).

The desire to complete a senior house officer post in obstetrics and gynaecology results from many factors including the inadequacy of undergraduate education in the specialty, the perceived prevalence of problems associated with obstetrics and gynaecology in everyday general practice, and also the requirement of six months’ training to join the health authority’s obstetric list. The latter is perceived by many to be a prerequisite for finding a suitable partnership in general practice.

However, the relevance to the obstetric list and its qualifying criteria provided by the senior house officer posts is questionable. ⁹ There is persistent dissatisfaction with the quality of training and educational content of many of the senior house officer posts in the speciality. ¹⁰ The main reason appears to relate to the ever-increasing tension between service and education. Many senior house officer posts carry a disproportionate amount of workload, leaving little space for protected time for education and training. In addition, changes in obstetric practice have meant that the senior house officers have practically no involvement in the labour ward other than clerking duties. As a result, the learning experience rarely relates to the needs of future general practitioners. While the review of the senior house officer grade should lead to a radical change in the role of the senior house officer in all specialties, there is increasing pressure to address the problems of the seniorhouse officer posts in obstetrics and gynaecology. This is partly due to the problems highlighted above but also as a consequence of the over production of juniors with a certificate and completion of specialist training, which has necessitated a cut in the number of senior house officer posts in Britain.

It was against this background that deaneries began to experiment with general practice based women’s health posts. In 1995, the first women’s health post was piloted as part of the Airedale Training Programme in Yorkshire. In 1999 the West Midlands followed this lead by cutting a large number of obstetric and gynaecology senior house officer posts from popular general practitioner schemes. It was possible for other deaneries to develop their own women’s health placements when the funding flexibilities became available in 2000.

The Airedale women’s health post

This is a 12-month post based in a training practice which combines hospital based obstetrics and gynaecology with that in general practice. There are daily antenatal clinics in a practice which has responsibility for around 220 confinements per year in addition to well-woman and cytology clinics. The general practitioner registrar gains further experience in community based clinics such as postnatal, sexually transmitted disease, family planning, and well-woman clinics. The general practitioner registrar also works in a hospital setting benefiting from specialist clinics and ward rounds, and by being on call approximately once a week in either the practice, or the hospital. The curriculum is based on the joint Royal College of General Practice and Royal College of Obstetrics and Gynaecology statement, is recognised for DRCOG, and satisfies the criteria of eligibility to join the Obstetric List. Regular evaluation of the post has demonstrated that the experience gained is relevant, useful, and enjoyable.

The experience in the West Midlands

In the West Midlands specific placements have been established in Stafford, Worcester, Birmingham, Hereford, and Warwickshire. There are also opportunities for individual general practitioner registrars to extend their training by six months with a focus on women’s health issues in other areas. The educational experience is different in each location depending on the expertise and interests of the local general practitioner trainers and consultants.

In Stafford, a close relationship with the hospital unit has resulted in a placement whose educational experience is similar to that in Airedale but concentrated into six months instead of a year. The post is integrated into the existing three year training programme, replacing the senior house officer obstetrics and gynaecology post which stopped in 1999. Although based in a training practice, the general practitioner registrar is also linked to a hospital midwife to gain experience in hospital clinics and normal and difficult deliveries in the labour ward.

Community women’s health posts devised in Worcester, Warwickshire, and Hereford enable the learner to work in departments of genitourinary medicine and community family clinics. In Birmingham, there is an opportunity for the GP registrars to further their knowledge and skills in women’s health, sexual health, family planning, and HIV prevention, after completing a regular senior house officer post in obstetrics and gynaecology.

The future of women’s health training for general practitioners

The success of these placements leads us to recommend that they should be used as templates for future developments in general practice training programmes. There will need to be more advanced training opportunities for doctors who wish to practise intrapartum care, but, for the majority, these new learning opportunities should lead to better equipped and better motivated general practitioners in the future.