Integrated GP Fellowship: Developing Specialism in primary care and Generalism in secondary care

Dr Elin Griffiths and Dr John Rees

Programme Directors for Carmarthen GP Speciality Training

Hywel Dda University Health Board


It is recognised that recruitment and retention is difficult throughout the UK but is critical in Health Boards covering large rural areas. The foundation and concept of the project idea was to encourage recently qualified GPs to stay or come to Hywel Dda UHB and become Integrated Fellows, working in both primary and secondary care during their fellowship year.

This would inevitably mean a greater integration of primary and secondary care resulting in:

  • Improved communication between both specialities

  • Fellows remaining working in the hospital and GP posts at the end of their fellowship in permanent posts

  • Improved recruitment and retention

Project Aims

A number of GP practices in Carmarthenshire are vulnerable: unable to find replacement partners for retired colleagues and unable to recruit salaried doctors to work in their practices. Continued difficulty will inevitably result in the practices “handing back” control of the practices to the Health Board. This is known to be financially inefficient health care, no long-term ownership of the practice with consequential less optimal patient care. Successful fellows were placed in practices that needed support to ensure sustainability of the GP practice.

In addition, and following discussion with Health Board managers, fellows were placed in secondary care placements where they had special interests but also in specialties of need, requiring medical support, but often depended on locum cover.

At the end of the fellowship year, fellows would remain as partners / salaried GPs in their original practice. Fellows would also remain as associate specialists or GPs with a specialist interest (GPSI) in their secondary care placement.

A unique aspect of the fellowship is that the fellows are mentored by two experienced clinicians providing support. Finally, the fellows are encouraged and financially supported to obtain a postgraduate qualification in their chosen secondary care speciality e.g., diabetes, dermatology or emergency care.


The need to convince major stakeholders (Health Board) of the value of the project and make it sustainable.

A 'dog with a bone' attitude would not have been successful as persuasive exemplars, but persistent gentle persuasion and the ability for 'water to fall off the duck’s back' seemed more successful.

Good communication was fundamental, being civil to all stakeholders (of which there were many) growing in number frequently, was essential. Convincing clinicians of the benefit of fellows to their individual teams was crucial. Face to face meetings to develop trust between different factions made the exemplar sometimes challenging but always fun.

Key Outcomes

Two Integrated fellows have nearly completed the Bevan innovation. One has just started.

  • Our first fellow has recently completed her diabetic post graduate qualification and hopes to stay in Hywel Dda as a salaried doctor in a local practice and continue to play a role in the diabetic department after returning from maternity leave.

  • Our second fellow has been instrumental in working with the Welsh Ambulance Services NHS Trust to decrease conveyancing rates of ambulances sent to hospital A&E, ensuring that patients are best served for treatment closer at home.

  • Our recent exemplar has a special interest in dermatology and plans are in place to set up a local dermatology network, due to the scarcity of dermatology services in the local community.

We believe that all three fellowships follow the principle of prudent health care, ensuring patients are treated close to home and in their community. We are confident that the diabetic and dermatology fellowship will be further developed: that the fellows will visit primary care centres allowing secondary care to concentrate on complex type 1 diabetic patients and enable malignant skin lesions to be seen as a priority in hospitals.

Next Steps

We hope the Health Board will make the Integrated Care GP Fellow Scheme part of their programme for the transformation of clinical services within Hywel Dda. The movement of appropriate care out into the community, closer to the patient, is an area the GP fellows can thrive in. We would like it to be an integral part of the portfolio of posts advertised by health boards.

Workforce planning is an imperative part of providing the population with the NHS it deserves. Consequently, having the right care closer to home, reducing inappropriate variation, using the doctors skills efficiently and crucially, putting the patient at the centre of their care.

Our Exemplar Experience

Supportive and professionally stimulating, is how we would describe the Bevan Exemplar experience. Keeping onward momentum and enthusiasm can be a challenge, especially during a pandemic! Being a Bevan Exemplar also gave us a timeline which was essential.

Bevan Exemplar Showcase 2021