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General practice variation - GP work in Wales versus England

Leaving a post in England for one in Wales has revealed the contrasts for Professor Rodger Charlton.

Rural and urban contrasts in Wales: Cardiff Bay (top), Snowdonia (bottom left), Wales Millennium Centre, Cardiff (right) (Photographs: Istock)
Rural and urban contrasts in Wales: Cardiff Bay (top), Snowdonia (bottom left), Wales Millennium Centre, Cardiff (right) (Photographs: Istock)

Before June 2011, when I took up my professorship at Swansea University, all my work was in England. Working in Wales has made me much more aware of the widening differences in general practice in the two countries and indeed in Scotland and Northern Ireland.

GP magazine's front page on 9 December last year was headlined 'UK GP contract is close to collapse'. Commissioning is a big issue in England but not in the other three countries and the English reforms may compromise the UK-wide contract.

There are pros and cons to working in England or Wales. Here are a few of the differences you may not have considered.

In England there are few areas where GPs work in rural and remote locations. Wales is a country of great contrasts: GPs may work in a big city, such as Swansea, or a rural village in a valley or on the coast. Many patients in rural, and some in urban, Wales may prefer the consultation to be conducted in Welsh. In both countries, however, there has been a move away from solo practice.

GPs' pay
Everyone I have talked to says that GPs in Wales are paid less.

I am not sure of the evidence base, but it is a commonly held belief by GPs in England and Wales. This may have an impact on recruitment because some GPs trained in Wales feel that financially, they would be better off in England.

Given the rural nature of many Welsh practices, they are likely to have lower list sizes, resulting in a lower income. However, this may be balanced by dispensing income in some rural locations. Other components of NHS income, such as the QOF, are the same.

Just as in England, there has been a move to salaried GP posts from partnership, but in both countries, this trend has reached a plateau. 

Enhanced services
These tend to be locally controlled by PCTs in England. However, in Wales the control is not necessarily by the health boards, the Welsh equivalent of PCTs, but the Welsh government itself.

The influence of government is more directly felt in Wales and is felt much more by individual GP practices than in England.

There are no NHS prescription charges in Wales. In England, those aged over 18 years and under 60 years pay prescription charges unless they qualify for exemption.

Similarly, some large NHS hospitals in Wales do not charge for car parking, while hospital car park charges are the norm in England.

This will change for all GPs in England and Wales when revalidation starts. At present, the appraisal systems are different in England and Wales.

GP appraisal has been a contractual requirement in Wales since 2004, whereas in England, PCTs lagged behind in implementing it. For the past seven years the Wales Deanery, which co-ordinates appraisal, has maintained a robust appraisal portfolio that includes most elements of the proposed new toolkits for revalidation.

GPs in Wales therefore will have no difficulty in meeting revalidation requirements. Wales also has the Medical Appraisal and Revalidation System, a single online system to facilitate GP appraisal.

Patient consultations
The central core of general practice, the consultation, remains the same in both countries. Fluency in Welsh may be required in some parts of Wales, but in England and Wales, interpreters are required for patients from a variety of cultural groups.

Dr Julian Tudor Hart, a London born and trained GP, went on to practise for three decades in Glyncorrwg in West Glamorgan. In 1971 he published in The Lancet his observations on what he called the inverse care law: patients who have the greatest need seem to receive the poorest healthcare; this is inversely related to the population's needs. This remains one of the greatest challenges for general practice and the doctor/patient relationship.

Medical training
England has many medical schools. Currently Wales has one medical school, one dental school and one postgraduate medical education deanery.

However, like England, Wales has seen increasing demand for the creation of graduate entry medical schools. In 2004 a second medical school with a graduate entry only course was opened and is currently going through the GMC qualifying programme.

As in England, there are con- tinuing difficulties with GP recruitment and rural and deprived areas where the inverse care law may be most apparent.

  • Professor Charlton is professor of medical education at Swansea University and continues to practise as a GP in England, where he was previously associate professor of medical education at Warwick University
These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.
  • Read Dr Julian Tudor Hart's 1971 paper on the inverse care law (www.juliantudorhart.org/papers/Paper11.pdf). Make notes on its relevance for your practice population and on the pros and cons of GP commissioning in the light of his observations.
  • Study prescription charges in England and which groups are exempt. Find out how to obtain a prescription prepayment certificate and the advice patients on regular prescriptions need to get one.
  • Visit www.rcgp.org.uk; click on revalidation to see the additional requirements over and above the current appraisal system that will be applied in the four UK countries.

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