Medical Education Capacity in General Practice in Scotland Working Group: interim report

3. Data and analysis

3.1 Undergraduate training capacity

There is evidence that early and positive exposure to General Practice during medical school significantly increases the likelihood of students choosing a career in General Practice (40-42). More widely, the role of General Practice in undergraduate medical education is vital to the future of healthcare delivery in Scotland. General Practice settings offer students exposure to undifferentiated patient presentations, continuity of care, and a broad understanding of health systems. GPs are uniquely positioned to help all learners, regardless of eventual specialty, develop core generalist skills essential for modern medical practice.

In 2018, the Scottish Funding Council and Scottish universities set out an aspiration to increase General Practice-based clinical teaching to 25% of the undergraduate medical curriculum. This was intended to reflect both the growing importance of General Practice in modern health systems and the need to inspire more graduates to either pursue General Practice careers or to develop necessary generalist skills in secondary care. Recommendations to deliver this aspiration were set out in a 2019 report from the Increasing Undergraduate Education in Primary Care (IUEPC) Group chaired by Professor John Gillies (43). The report set out a series of recommendations to increase undergraduate medical education in Scotland by enabling more General Practice-based teaching within primary care. A summary of progress on the recommendations from the report has been provided in Annex 1.

There has been positive and significant effort from all universities since 2018 to maximise General Practice-based content (Annex 2). Some have designed new programmes such as the Edinburgh HCP-Med for Healthcare Professionals programme, some have utilised GP out of hours services for student experience, while others have increased GP role modelling within the medical school. Whilst feedback from students has been positive, current delivery remains below the target, with some schools estimating General Practice-based clinical teaching at around 10% of the overall curriculum. In some cases, this figure is further under threat due to capacity pressures, including rising student numbers, placement constraints, competing financial demands and service demands on practices. There is an increasing conversation in respect of balancing quality of General Practice undergraduate teaching versus quantity of teaching (44).

Achieving greater levels of undergraduate teaching in General Practice remains an important ambition, even though the exact scale of the increase required continues to develop and may not align neatly with earlier targets. Recent pressures mean that some institutions are finding it difficult to build on previous progress. Increasing the quantity of General Practice based teaching cannot come at the expense of quality; both must evolve together to ensure meaningful, authentic learning. It is essential we understand the barriers affecting practices and universities such as space limitations, workload demands, financial pressures and supervisory capacity, and to address these in ways that are supportive and practical. This work should also be closely aligned with postgraduate education planning so that developments at one stage of training do not unintentionally create challenges at another. By doing so, Scotland can expand high-quality General Practice education in a way that strengthens the entire training pipeline.

3.2 Postgraduate training capacity

Foundation training

Following graduation, doctors undertake the two-year UK Foundation Programme designed to consolidate clinical skills and prepare for entry into Specialty Training. Foundation Year 1 (FY1) typically comprises a series of hospital-based rotations across core specialties. Foundation Year 2 (FY2) consists of three four-month placements, one of which may be in General Practice, depending on regional capacity and allocation.

Early exposure to General Practice remains a strategic priority for Scotland, reflecting evidence that positive experiences in General Practice during early training strongly influence future career choice. High-quality General Practice placements help trainees develop broad clinical capability, increase confidence in managing undifferentiated presentations, and equip future non-GP doctors with a deeper understanding of generalism and community-based care (21,45). The Scottish Government and NES have articulated an ambition for around 50% of FY2 doctors to undertake either General Practice or Psychiatry placements, with both community-focused specialties aligned to the national mental health and primary care reform agendas. Delivering on this ambition will require increased educational capacity within General Practice to accommodate anticipated growth in Foundation posts, driven both by previous undergraduate expansions and by additional posts already implemented (46).

Since 2021, the Scottish Government has funded 252 additional Foundation places (51 in 2021, 54 in 2022, 48 in 2024 and 99 in 2025) representing approximately a 30% increase, with a further 72 places planned for 2026. Currently, 147 GP practices host both Foundation training and GPST with a further 35 practices delivering Foundation training only. Sustaining and expanding early exposure to General Practice will be central to strengthening the General Practice workforce pipeline and attracting more doctors into General Practice careers (47,48).

General Practice Specialty Training

GPST in Scotland is a three-year programme designed to develop doctors with the broad clinical expertise, leadership, and population-focused skills required for modern General Practice (18,19,49). The programme typically comprises 18 months in hospital placements and 18 months in accredited GP training practices, providing complementary experience across acute and community settings.

A typical 3-year rotation within Scotland is as follows:

Elsewhere in the UK, GP training is changing toward greater time in General Practice and community-based learning. In England, most General Practice training pathways now include two years in General Practice and one year in hospital, with pilots under way testing a full three-year community-based model (50). Wales and Northern Ireland are following similar trends. Increased time spent in General Practice would only be possible with a corresponding increase in training infrastructure and capacity.

In recent years the number of GP Registrar posts has increased following the creation of 100 extra training places since 2023 (35 in 2023, 35 in 2024 and 30 in 2025). Fill rates have also improved, from 74% in 2017 to 99% in 2024 (18,19). Scotland’s GPST cohort includes a substantial proportion of International Medical Graduates (IMGs). 38% of GP Registrars in the training pipeline are IMGs (as of August 2025). IMGs provide essential capacity within the system; however, variation in time to complete training alongside variation in retention following completion of GPST can create uncertainty in available medical education capacity.

Training capacity supply: General Practice training practices and Educational Supervisors

In Scotland, General Practice placements in GPST year 1 and GPST year 3 are delivered through accredited GP training practices that provide structured supervision and a supportive multidisciplinary learning environment (49). Scotland has approximately 890 GP practices; however, current data systems do not provide a national picture of how many of these practices are involved in undergraduate and/or postgraduate medical placements.

Data from NES shows there are 393 postgraduate General Practice training practices, which equates to 44% of all GP practices (September 2025); this includes those hosting Foundation doctors and GP Registrars (32,48). Furthermore, there are 865 accredited postgraduate GP Educational Supervisors (ESs) for GPST. Practices will often have more than one ES and more than one learner at any one time.

ESs are required to complete the General Practice Trainer Entry Course (GPTEC) before being approved to supervise GPST Registrars. GP training practices undergo a comprehensive accreditation process, including a detailed submission and a quality visit, to ensure that the learning environment meets the standards of postgraduate education set by the General Medical Council (GMC) and the Royal College of General Practitioners (RCGP). Supervision of Foundation doctors follows a separate process that is quality managed through the local Health Boards.

Working patterns also influence capacity. As of August 2025, 42.6% of GP Registrars are training Less Than Full Time (LTFT), mirroring wider workforce trends. However, LTFT training extends the time individuals spend in the programme. The average time spent in General Practice training in the UK is now 3.76 years, with 59.3% of Registrars taking longer than three years due to LTFT training, career breaks or training extensions. These patterns directly shape the number of Registrars in the system at any one time, as well as the supervisory load borne by GP educators, therefore placing sustained demands on supervisory and placement capacity across practices and Boards.

GP Returner and ScotGP Retain and Sustain schemes

The ScotGP Retain and Sustain (ScotGPRS) programme is a refreshed initiative in Scotland (previously the GP Retainer Scheme) launched in 2025 by NES. It is designed to help qualified GPs who are at risk of leaving General Practice, due to caring responsibilities, health issues, retirement planning or other personal or professional constraints, remain engaged in the workforce in a flexible, supported role. It provides part-time clinical sessions (typically 2 to 4 sessions a week), structured mentoring and continued professional development support, with the aim of maintaining their skills and enabling either a return to substantive General Practice work in the future or continuing in a valued General Practice role for longer.

As of August 2025, there were 55 members working through this scheme. With the refreshed eligibility criteria, there is a likelihood of a rise in applications putting further pressure on training capacity.

The GP Returner Scheme in Scotland is a national programme run by NES that supports qualified GPs who have been out of UK General Practice and wish to return to work. It provides tailored educational placements, supervised clinical experience, and financial support while participants update their skills to meet current standards. The scheme aims to ease the transition back into practice by offering flexible arrangements, mentoring, and assessment, ensuring returning GPs regain confidence and competence to work safely and effectively within the NHS Scotland system.

For the year 2024/25, there were 25 GP returners who successfully completed the programme. The placements are usually in established postgraduate GP training sites, further contributing to the need for training capacity.

3.3 Equity of education capacity – deep end, rural and island settings

Rural and islands training capacity

Scotland’s geography presents unique challenges and opportunities for delivering medical education, particularly in rural and island areas where health service accessibility, workforce retention, and educational infrastructure are all under pressure. With around 17-20% of Scotland’s population living in remote or rural areas, ensuring equitable access to training in these settings is both a policy and workforce priority (51).

Evidence suggests that continuity of rural exposure and locally rooted training are the strongest predictors of rural workforce retention (52,53). GPST within Scotland includes the Rural Track (RT) GP training programme centred around Scotland’s six rural general hospitals, specifically designed to encourage continuity of training in rural regions such as Oban, Fort William, Caithness, and the Health Boards of Orkney, Shetland and Western Isles (50). The following Health Boards account for the majority of rural and island General Practice training capacity: NHS Ayrshire & Arran (A&A), Borders, Dumfries & Galloway (D&G), Grampian, Highland, Orkney, Shetland, Tayside and Western Isles.

16% of GP training practices are situated in locations classified as remote or rural (Scottish Urban Rural [UR] codes 4–8). 9% of GP training practices are in “remote” and “very remote” areas primarily within the RT and Caledonian programmes. However, current methods measure GP Registrar exposure to rural and island practice by the programme they are enrolled in, not by the actual UR code of their General Practice placement, potentially overestimating rural experience.

At present, Scotland does not hold a single, comprehensive dataset that directly compares the proportion of all GP practices located in rural and island areas with the proportion of training practices, nor a precise comparison between the distribution of GP Registrars and the qualified General Practice workforce in these settings. Work is underway to improve these data sources. Nonetheless, the working group recognises a consistent concern that current training capacity in rural and island areas is under pressure to meet future population need. These areas face distinctive challenges including workload, staffing fragility and limited infrastructure, which may heighten vulnerability and constrain the sustainability of training.

Graphs 2, 3 and 4 highlight the variation in hosting both GP Registrars and Foundation doctors across different Scottish Urban Rural classifications across different boards.

Structural challenges in Rural and Island training

Several practical barriers affect the ability of rural and island practices to participate fully in postgraduate education:

Travel distance

In large rural boards such as NHS Highland, travel distances between training practices and hospital-based posts can exceed 60–90 minutes. This can lead to:

• registrars transferring out of remote placements after initial experiences,
• strain on urban practices (e.g. Inverness) when Registrars request relocation
• breakdowns in continuity within the rural training pipeline

Small practice size

Many remote General Practices offer valuable exposure to rural and island General Practice, particularly through placements for Foundation doctors, and undergraduate medical students.

One of the challenges in expanding postgraduate training in these settings is the small patient list size, which may limit exposure to the full breadth of medical conditions required for GPST. Despite this, remote practices could still play a meaningful role in GPST by acting as satellite practices linked to larger, established training practices. This is an area that is being explored.

Educational Supervision gaps

Rural and island practices may only have one ES, meaning sickness or leave can disrupt training. The NHS Shetland, Orkney, Western Isles and Highland Boards have the lowest average number of ESs per practice, raising concerns about succession planning in these rural and island locations. While the GP Trainer Entry Course (GPTEC) programme trains approximately 96 new ESs per year, targeted support is needed to increase ES numbers in rural and island locations — ideally aiming for 2 per practice.

Deep end training capacity

Scotland's health inequalities are the worst in Western Europe, with significant differences between the most and least affluent in terms of life expectancy and healthy life expectancy. General Practice can play an important role in addressing these health inequalities. GPs working in more socioeconomically deprived areas typically experience patients developing diseases at a younger age, living more of their life in poorer health, and dying younger than those living in the most affluent areas. Early onset of multiple morbidity is common, and there are higher levels of social complexity (54).

Public Health Scotland (PHS) and NES data clarifies the definition of a ‘deep end’ GP practice. It is defined as a practice where more than 44% of the population served is living in the 15% of most deprived data zones of Scotland.

Recruitment and retention of GPs to deep end settings is an important part in addressing health inequalities (55). Because patients' needs are disproportionately high and complex, having a stable, adequately supported GP workforce enables relational continuity of care. This is even more important for vulnerable populations, where trauma-informed approaches, and preventative, proactive approaches are needed.

Previous Scottish evidence suggested that newly qualified GPs were more likely to work in areas similar to their training practice. Therefore, reduced exposure and experience of learning about, or working in, areas of socioeconomic disadvantage during training could negatively impact future workforce sustainability within these areas. Reviewing this to ensure access to appropriate training and education is fundamental to better equip and prepare GP Registrars.

Of 100 practices in the most deprived areas of Scotland, 43 are GP training practices (within the limits of the available datasets), whereas of the 100 practices with the most affluent patients, 63 are training practices (56). Recent targeted schemes have aided deep end practices successfully becoming training sites, with strong support from participating doctors and positive impacts on recruitment and retention.

Although the proportion of training practices in deep end areas is broadly comparable to the national average, it remains markedly lower than in the most affluent areas. This disparity is significant, as the most deprived communities have the highest levels of need and lowest levels of GP workforces, therefore requiring a strong and sustainable future General Practice workforce (57). Practices and trainers in areas of socioeconomic deprivation also face distinct and intensified pressures, reinforcing the necessity of focused efforts to strengthen training capacity and support in these settings.

It would be necessary to assess infrastructure, teaching capacity, and research in more socioeconomically deprived areas, in order to deliver a high social return on investment in terms of improved equity and population health.

3.4 Enablers and barriers to medical education delivery

Unlike the model in secondary care, there is no requirement for GP practices to provide undergraduate or postgraduate training. Understanding what enables or limits a practice’s decision to participate is therefore essential to sustaining and expanding medical education capacity.

Three strands of work help to understand this: the 2018 survey created by the Increasing Undergraduate Education in Primary Care (IUEPC) Group, the 2022 Scottish Government’s GP teaching capacity survey, and the Scottish Government’s Future Medical Workforce project.

There are consistent themes across this data, alongside the literature; therefore the working group has opted to prioritise articulating the solutions in the next phase of work, rather than further surveys to re-describe the challenges. A short summary of enablers and barriers follows (39,45,58).

Enablers

• Protected time for teaching, particularly against a backdrop of increasing clinical workloads and complexity. Support for trainers and educators to have their role more effectively resourced (with protected time) was highlighted through the Future Medical Workforce project as a consideration for workforce planning and important for building doctors’ confidence and competence (through training) in order to sustain fulfilling medical careers.
• Practices suggested that longer lead times for organising placements and clear advance communication would help in planning and resource allocation.
• Many GPs describe personal enjoyment and fulfilment from teaching, watching students develop their confidence and competence. Therefore, trainer roles can offer an opportunity to find greater fulfilment and balance. Engaging in teaching is also seen as stimulating for staff, helping to keep their clinical knowledge current and improving the practice's skills mix.
• Flexibility in placement length and teaching hours was also noted as an enabler. Shorter placements, such as four-week blocks, can be easier for practices to manage around staff leave, vacancies and expected rises in clinical workload. However, it is also important to consider impacts on trainees (and trainers). The Future Medical Workforce project highlighted the benefits of rotational training (such as variety) but also the risks of shorter placements (in terms of negatively impacting a sense of belonging in a team, establishing trusting mentorship, and development of clinical confidence).

Barriers

• Time was the most frequently cited barrier in the 2018 and 2022 surveys. A significant clinical workload leaves little capacity for teaching. GPs report a tension between providing clinical services and the time required to support teaching properly.
• Insufficient financial compensation for teaching can be a barrier with many practices identifying the funding as crucial income stream and the main motivator for participation. Specifically, there is a need for funding that allows for locum cover to manage the clinical workload.
• Lack of available rooms within practice premises.
• Administrative burden of documentation for accreditation and overall training portfolios.
• Staff shortages were detailed as a barrier with practices lacking sufficient staff to cover clinical duties during teaching.

A significant proportion of accredited GP training practices also contribute to the education of a wider range of learners across the medical profession and MDT. Different training grades also bring different levels of educational funding, which practices must weigh up alongside other considerations when deciding which placements they can accommodate. These considerations include learner numbers, placement length, the learner’s contribution to service delivery and supervision requirements. Furthermore, individual learner competence and confidence vary, influencing the level of supervision required. This variation makes it difficult to predict with precision the number of supervisors, practices, or total hours of supervision required at any given time, and the overall impact on practice workload. Further details of the expectations, supervision requirements and funding arrangements for each medical training grade in General Practice are found in Annex 3.

3.5 Data requirements for capacity planning

Understanding medical education capacity requires insight into both the drivers of training demands and the supply of training capacity. To support effective planning, it is important that we can understand:

• number of undergraduate student placements required (by understanding curriculum content and timing)
• Foundation placements required and their rotations
• GPST rotations
• training practices and their geographical & socioeconomical distribution
• supervisor capacity, both undergraduate and postgraduate

The data sources available provide a rich picture of activity at each stage of training. There would be some advantage in linking some of these sources of data and having greater clarity on reporting cycles. In particular it would be helpful to consider the data available to (59-61):

• understand how particular teaching models, such as longitudinal placements, rural immersion or deep end experiences, impact capacity and whether they correlate with later career choice or retention
• model future placement needs across the undergraduate to postgraduate continuum, linked to future service need
• understand anticipated supervision and space requirements
• understand where capacity is tightest across the pipeline
• assess how undergraduate and Foundation Programme exposure influences General Practice recruitment
• evaluate whether interventions, educational, workforce or financial, are shifting outcomes