Introduction
General Practice at its best has always had a strong tradition of public health action and advocacy for equity. GPs such as Julian Tudor Hart have been an inspiration for several generations of GPs who have looked at the bigger picture to try and tackle the causes of the physical, mental and social troubles of their patients. Bringing general practice and public health closer together will increase the chances of both disciplines co-ordinating their work to greater effect.
For GPs this means developing additional competencies beyond core General Practice in order to become an effective part of a whole system approach. This framework is designed to support GPs, commissioners and employers to understand how to invest in these competencies for the future workforce.
The value that GPs bring to population health
The value of this role to the health care system lies in bringing the pragmatic adaptability that GPs have learned through their generalist training into the public health specialist workforce. GPs are skilled in person-centred care for individuals and families. GPs see the human consequences of the determinants of health and the effects of poverty, through hearing the stories of their patients. They may have gained a rich knowledge of their local communities. They are used to managing complexity, uncertainty, and risk. A GPwER is not simply a “mini-Consultant in Public Health”, they bring added value and a fresh perspective. A GP brings value as a change agent, as a creator and an interpreter of intelligence for action, engaging with communities on wider determinants and a driver for prevention.
The RCGP would expect that, for a GP to describe themselves as a GPwER, at least some ‘core’ general practice should be maintained, to continue to bring the GP perspective into this Extended Role.
The value to general practice of establishing formal roles in population health
Creating well-defined portfolio posts with GP and public health components would be attractive to both early and later career GPs. There may be GP recruitment and retention benefits in establishing more formal career pathways to portfolio careers in general practice and population health. Many GPs will be interested in taking on an Extended Role, and some may wish to continue developing their skills through formal Public Health training to become dual accredited in General Practice and Public Health (or consider the Dual Training scheme from the start).
Why this needs a Governance Framework
The interest in public health among GPs has increased, with a recognition of the value of public health skills in primary care. However, to take a more strategic role in population health requires skill, time, and energy. There is a lot of learning in moving from a focus on the health of individuals to that of whole populations. GPs will need to develop a greater knowledge of how the whole public sector works, and the wider and commercial determinants of health. They may be new to an in-depth understanding of how to assess and address population health needs and to commissioning services to achieve this.
GPs will need to assess and develop their knowledge and skills carefully to be able to add value to the public health workforce. The Public Health specialist workforce is highly trained. For example, consultants have completed 5 years of training, including a Masters in Public Health, and demonstrated the full range of competencies through formal assessments and examinations.
Investing in these skills in a cohort of GPs with an Extended Role in Population Health and Health Inequalities could accelerate improving population health outcomes while reducing demand. The impact is likely to be greatest in disadvantaged areas, with goals focused on reducing inequities in health.
Purpose
This framework provides guidance for GPs who identify with providing or an ambition to fulfil a role beyond that expected of every GP. A GP may already have a special interest in public health or developed an interest before becoming a GP. Alternatively, they may want to vary their career and expand their portfolio to offer these additional skills in a strategic role beyond your own clinical practice.
It does not apply to doctors who already have a dual accreditation in General Practice and Public Health or are on the Dual Training Scheme which started in 2024.
This framework is intended to provide guidance for GPs, commissioners, employers and educators about the role of a GP with an Extended Role (GPwER) in Population Health and Health Inequalities. These include all those roles where GPs are using population health competencies at a more advanced level, beyond that expected of every GP, in particular where they are aiming to reduce inequalities in health. These roles would not usually involve direct patient care, although most such GPs would continue with a clinical role which may complement this role. Most roles would include public and patient engagement.
Several variations of this role are likely to exist, each designed around local health population needs. Across the UK, there are increasing numbers of roles taken by GPs that require population health competencies. (see Appendix 3 for examples).
Employment arrangements for a GPwER in Population Health and Heath Inequalities will vary, as will role descriptions. There is limited guidance on the competencies that employers and commissioners should be seeking for these roles, and GPs are asking for guidance on how to identify and develop the right competencies. This framework does not seek to establish a rigid uniform model, rather it offers guidance around good practice in such a way that we hope is practically helpful and universally relevant.
An example of the journey from core General Practice to GP with an Extended Role
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Development/establishment of knowledge and skills Examples:
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| GPwER | |
Examples:
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We have used the following specific definitions of population health, health inequalities and public health, with further explanation in Section 2.
Population Health
We have used the Kings Fund definition of population health as:
“An approach aimed at improving the health of an entire population. It is about improving the physical and mental health outcomes and wellbeing of people within and across a defined local, regional or national population, while reducing health inequalities”.
Public Health
We have used the definition of Public Health by Sir Donald Acheson (Chief Medical Officer, 1988):
“The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society.”
Health Inequalities
We have used the NICE definition that health inequalities are:
“The differences in health across the population, and between different groups in society, that are systematic, unfair and avoidable.”
However, we note the view from the World Health Organisation and others:
“Inequity and inequality: these terms are sometimes confused, but are not interchangeable, inequity refers to unfair, avoidable differences arising from poor governance, corruption or cultural exclusion while inequality simply refers to the uneven distribution of health or health resources as a result of genetic or other factors or the lack of resources.”
Acknowledgements
We would like to thank the following for their work in support of the development of this framework: Dr Kathrin Thomas, Professor Zafar Iqbal, Dr David Chappel, Dr Clare Bambra, Dr Suchita Shah, Dr Kirsty McAvoy and Dr Ulrike Harrower.
Framework review
Date the framework was approved: July 2024
Date for next review: July 2027