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Gold, incentives and meh

Part-time revolution: How general practice is adapting as GPs reclaim control

More than two-thirds of GPs work less than full time in general practice. Carolyn Wickware asks what this means for the profession

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General practice has been undergoing a quiet revolution in recent years that has had little fanfare: it is now an overwhelmingly part-time profession.

Official figures suggest almost 70% of the workforce work less than full time in general practice – the highest proportion ever.

There are huge caveats. Many GPs counted as less-than-full-time (LTFT) workers – defined as those working less than 37.5 hours a week – do more hours in reality than other professionals working full time. And in many cases, they are doing other healthcare-related roles outside general practice.

But the figures reveal a powerful truth for the profession – that the vast majority of GPs are revolting against working 60-plus hour weeks in general practice and are voting with their feet.

Young and old GPs are turning to salaried roles with more clearly defined sessions, and in many cases to locum work, in a bid to restore flexibility and control to their working lives – control lost as a result of ministers’ continued neglect of the profession.

Hull GP Dr Zoe Norris, chair of the BMA’s GP sessional subcommittee, says it is ‘inevitable’ that LTFT working will be the future of general practice.

‘It seemed to come as a shock a few years ago when suddenly people started reducing their hours, largely because of a predominance of women, but now we’re also seeing that in our male colleagues because they want to have a life outside of medicine too.

‘That’s okay and normal. It’s the only way to make the job manageable.’

The figures bear this out. Female salaried GPs are still more likely to work less than full time – 91% do so now – but three-quarters of male salaried GPs do likewise, up from 71% in September 2015.

 

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And leaders are waking up to the fact GPs are changing, and the profession needs to find ways to adapt. The landmark partnership review – led by Wessex LMCs chief executive and GPC member Dr Nigel Watson – published its interim report last month. It advocated a move towards ‘primary care networks’ to offer more flexible working, and suggested drawing on elements of locum working.

Meanwhile, even health secretary Matt Hancock has highlighted that the flexibility of general practice is ‘attractive’ to the younger generation, while both NHS England and Health Education England have started actively promoting this aspect of the profession. This is making a difference – record numbers of medical graduates are entering GP training, it was announced last month.

Of course, ‘part time’ is a relative concept. Dr Matt Mayer, chief executive of Berkshire, Buckinghamshire and Oxfordshire LMCs, says the term is a ‘misnomer’ because GPs working three days a week are still ‘actually doing 14-hour days – that’s full time’.

Yet it is true that the increase in the LTFT figures shows that fewer GPs are now willing to work backbreaking hours in permanent salaried or partnership roles – even if the workload for those at the top end of the scale has increased.

It is unsustainable and unsafe to be doing full-time general practice

Dr Zoe Norris

 

The percentage of partners and salaried GPs working less than full time has steadily increased from 66% to 69% over the past three years. At the same time, the percentage of the GP workforce working as locums is rising, according to official data.

‘GPs are having to go “part time” in order to sustain themselves professionally and avoid burnout,’ says Dr Mayer. ‘The alternative is working five 14-hour days a week and then going off long-term sick and never coming back.’

Dr Norris agrees: ‘It is unsustainable and unsafe to be doing full-time general practice, regardless of your contractual status, and so you have to find a way for that to be sustainable. That’s usually going part time, reducing the high-pressure clinical workload and developing a portfolio career, or managing the workload by being a locum and doing a portfolio career that way.’

This is a change that has been acknowledged by the partnership review, which has come out strongly in favour of primary care networks – the large-scale organisations that will ‘involve health and social care professionals working together as a locally based, multidisciplinary teams’.

The review found 5,000 practices have already formed networks, which promise to ‘support general practice in terms of workload’, making the profession ‘more resilient and a better place to work’.

Dr Watson says the networks ‘will allow more support for individual GPs and practices and also offer opportunities for GPs to work in portfolio roles’.

Developing portfolio roles... not only improves the quality of care but GPs enjoy the variety

Dr Nigel Watson

‘A GP in my practice has an interest in diabetes. He does three days a week as a partner, a day a week doing diabetes research and a day a week doing diabetes in the community delivering care to patients,’ Dr Watson says. ‘It’s developing roles like that; it not only improves the quality of care, but he really enjoys that variety.’

Dr Watson’s review suggests other ways to help the profession adapt to the growing part-time workforce, including incorporating the flexible elements of locum working into the partnership model. The interim report says this will attract some of the locum GP workforce back into substantive posts – which is essential for the future of the profession.

Dr Watson tells Pulse: ‘Younger GPs who are not becoming partners straight away and becoming locums swells the locum number but doesn’t help the long-term sustainability of general practice.’

As a result, his review team wants to increase the number of GP partners by ‘making partnerships more attractive than being a locum’ through introducing ‘greater flexibility, improved work-life balance and portfolio working opportunities for partners’ – although the interim report has few concrete proposals on how to achieve this at this stage.

But results from Pulse's first-ever locum survey lay bare the extent of the task ahead for Dr Watson – the majority of respondents say nothing would tempt them back to partnership.

Regardless of the outcome of the partnership review, the shift to LTFT working does have a potential casualty – the loss of continuity of care.

However, Dr Norris says the shift is inevitable and the loss of traditional continuity of care is the trade-off that will allow GPs to take workload ‘into our own hands’. The emphasis on continuity of care, she says, ‘kind of implies you can’t do a good job if you see someone as a one-off. That’s not the case’.

She adds that, instead of mourning continuity of care, GPs need to ‘get our heads round the fact we are working in bigger teams with different people… we need to make sure our handovers are better, that our notes are better and that we have clear plans’.

The trade-off is making the profession a more attractive proposition for medical graduates, she says. ‘One of the things we don’t sell is the flexibility and how brilliant general practice can be for doing different things and portfolio working. I think a lot of medical students and newly qualified GPs are excited by doing a mix of different things and by doing things other than nine sessions of face-to-face general practice in a partnership.’

Mr Hancock seems to acknowledge this. Speaking to Pulse at last month’s Best Practice Conference in Birmingham, he said: ‘Part-time GPs have always had an enormously important role and the flexibility that can come with being a GP is very attractive to many people.’

Dr Tom Micklewright, outgoing BMA GP trainees spokesperson, says the message is getting across, ‘not just that you can work part time but that general practice offers more flexible options’.

He says: ‘The new Health Education England recruitment video focuses on general practice that you can do in different areas, such as working in sports medicine or expedition and outdoors medicine – all potential career avenues.

‘I think the new generation of medical graduates are seeing GPs with a varied career portfolio and they’re thinking that looks like a very attractive career.’

Medical graduates are seeing GPs with a varied career portfolio and.. that looks attractive

Dr Tom Micklewright

This is a route being pursued by NHS England too. Acting director of primary care Dr Nikita Kanani says: ‘As someone who juggles being a GP with my NHS England role and a young family, it’s clear… the NHS needs to continue to embrace a range of working patterns and offer varied career options.’

And medical graduates seem to be heeding this message. Last month Mr Hancock announced 3,473 had signed up for GP training this year – a record number and the first time the 3,250 target has been exceeded – and HEE ascribes this in part to its emphasis on the flexibility of general practice.

Of course, adapting to part-time working will need extra funding for general practice – starting with cash from NHS England’s 10-year plan, set to be announced before the end of the year.

BMA GP Committee chair Dr Vautrey tells Pulse: ‘As more doctors use the flexibility that general practice can offer to develop a working pattern that suits them, we will need to train and recruit more. But by offering better working conditions and a better work-life balance we may be able to retain more GPs as well.’

But he adds: ‘It is vital the Government provides the investment to rectify the recruitment and retention crisis so GPs feel working hours are more manageable, while providing the flexibility and support for those wishing to broaden their scope.’

GPs are changing. With the right support and structures, this part-time revolution could put the profession on a positive path to the future. It is up to the Government and NHS England to ensure there are not too many casualties along the way.

 

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  • Additional reporting: Beth Gault

 

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Readers' comments (19)

  • AlanAlmond

    Better to find a job you can do full time, enjoy and earn good money than one you can only manage part time and financially just about get by. It sounds good having all that time out but seriously isn’t it a bit of a waste? I work part time because I have to. If I worked full time I’d go nuts...seriously. That’s the primary reason I work part time. I fill my time with other stuff but I don’t get paid for doing it. What an utter waste that all these useful, motivated intelligent people aren’t going to work..in a field that desperately needs them, because the job is so insanely intense doing it more than a few days a week breaks your sole. It’s that that needs to be fixed. As others have already said David Banner has it down in a nut shell. That a job is so crap it can only be done part time, cant really be spun as a “good thing”

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  • doctordog.

    The job is what you make it.
    For me it’s all about the money.
    I would work more if the chancellor isn’t getting nearly all of it.
    One day extra at work per week would earn me £11.00 after tax.

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  • AlanAlmond

    doctordog “the job is what you make it”

    Totally agree, that is surely way so many people are making it a part time locum job

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  • yep going part time was the weakest option, but the only way to remain sane. Too late now, nobody really did anything be it at the top (where nothing would have ever been done anyway) or at our level.

    Its all over dont see a way out. Government will continue regardless ( as we have all collectively been too weak and continue to be so as witnessed by this reports headline)and the brainwashing of new recruits is just their latest plan.

    Dont care anymore. I will be out of it soon anyway, good riddance, I am just gonna enjoy the rest of my life and yes i will continue to work, but as a volunteer abroad, in countries where people are most likely genuinely very sick and dying!!! Nobody really cares about them either. What a fffed up world this has become, and we all know that.

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  • Must have been quite a job to sort the statistics, seeing as a 'Full-Time' GP is officially classified as doing 26 hours per week, rather less than 37.5!, but may actually be doing 52.5 while the doors are open, and taking paperwork and admin home for the nights/weekends.

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  • Agree David Banner. So many GPs escaping into part time says something profound about the job. Recruitment & retention to GP partnership is an issue because hours remain excessive and the contract still is open-ended. A new contract needs to tackle both these issues, with core hours 9am – 5pm and core duties. Yes, 9 to 5, just as everyone else thinks we work, and as most others work in the health service. Any duties outwith core, namely delegated from secondary care, need to be priced and charged for via an Enhanced Service – they will soon stop once funds begin to shift from hospitals – so either we get better resourced or the workload reduces; and anyone wishing to provide early or late surgeries could of course be rewarded via an Extended Hours Enhanced Service. Yes, the family friendly work-life balance younger doctors want – provide it or see general practice disappear. We also need to look at home visits being GP-initiated and not prompted by everyone else as they currently are. The new Scottish contract has failed to tackle these issues and instead hopes to obtain help for other professions over the next three years – too late to halt the crisis of failing practices – and still the qualifying GPSTs don’t want partnerships. The only respite has seen a planned buy back of premises. At least the 2004 contract ended out of hours commitment and priced it accordingly – and also priced QOF to boost income – although not perfect, these at least were solid deliverables. Other health professions limit their workload but the core task of being a GP partner remains one of doing everything no one else in the NHS fancies doing. And by the way, wasn’t David Banner the Incredible Hulk?

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  • I agree with David Banner. How can withdrawing from this situation be said to be taking back control? This is a retreat, albeit a justified one in the face of crippling work and pressure. The only way for those stuck in the middle, is to try and adapt e.g. by changing service delivery and skill mix. We are having to dismantle GP as it has been and forge something new- but in the process we are losing something precious. What other choice do we have other than to give up. Every man for himself indeed.

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  • Entropy is costly. Enjoy.

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  • Some may say "Your part time flexibility is my early mornings, late evenings and working through the holidays"

    I'd say "I'm off, been there done that and never got the thanks!"

    Do we really want to be managed from above? Well the answer at the coal face is "No - I'll work when and where I want as a locum" - Until those taking the risk and ultimately the responsibility for premises, staff contracts, GMS Contracts etc. are rewarded MUCH better than locum or salaried jobs then the temptation will be to take the money and the flexibility.

    At the end of the day we can't all have ultimate flexibility and remain 'equal' - Some are indeed more equal than others. Big Brother will take over the farm and GPs will be offered take it or leave it contracts....unless SOME GPs take back control and are rewarded for doing so, not just money.....maybe they too would like some flexibility!!

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