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Gold, incentives and meh

Being a portfolio GP is the only way to survive

With the rewards of a GP career being eroded by a lack of time and resources, a ‘mix-and-match’ approach is the only way forward, says Dr Laura Edwards

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Full-time general practice used to be what all young GPs aspired to. But I am now seeing more of them taking their careers into their own hands and spending at least part of the week working in other roles.

Seasoned GPs are blending roles including appraisal and CCG work, and a national survey of GP trainees last year found that 40% of trainees intended to be ‘portfolio’ at five years after qualifying.

I made a decision early in my career to be a portfolio GP: I work eight sessions a week, two of which are in a semi-urban general practice of approximately 14,000 patients, with my share of duty days. The remaining six I spend as medical director of Wessex LMCs, meeting CCG chairs, representing primary care on committees and supporting GP colleagues in disputes, performance measures or with burnout.

In the current climate, it is harder to see our positive impact on patients so our sense of purpose is diminished

But what is behind the increase in this mix-and-match approach to our professional lives? Dan H Pink’s bestselling business book Drive attributes our motivation to three concepts: autonomy – the desire to direct our own lives; mastery – the urge to get better and better at something; and purpose – the yearning to do something in the service of something larger than ourselves.

When you consider these three elements in terms of general practice, the picture looks bleak.

Many GPs will agree that part of the reason they chose the profession was the desire to help others – this is our ‘purpose’. But in the current climate, with growing mounds of paperwork and increasing preventive prescribing (where only a few patients might benefit from what we do in 10 years’ time) it is harder to see our positive impact on patients so our sense of purpose is diminished.

A recent poll has shown that gardeners are more satisfied with life than non-gardeners. Explanations for this include the act of nourishing something and seeing the fruits of your labour despite bad weather. I believe pressure has led to the erosion of both aspects in general practice. Patients struggle to get appointments, and I am aware of pressures on my patients’ lives and on appointments so I ask them to return only if my plan hasn’t worked. This is more efficient but means that I only see my failures, the seeds that didn’t grow. That’s pretty depressing.

When it comes to ‘autonomy’, our daily work is dictated by a constantly changing government agenda and an impossibly high patient demand and expectation given our current resources. There are a multitude of tick boxes that bear little relation to why the patient came to see us. We must then apply computer coding to multiple parameters and quickly write notes that must be detailed enough to rely on in court years later, with no time allocated to either task. We are human and dealing with humans: not everything fits into a 10-minute box.

The only opportunities for ‘mastery’ that I encounter are found in steering projects I cover from conception to fruition in my LMC role. But as a jobbing GP, this is severely lacking. Since 2004 there hasn’t been time allocated in our expected work plans for CPD, unlike our consultant colleagues. Professional wisdom is gained through years of experience and critical reflection on what has been done. Although we are forced to do this for appraisal and revalidation purposes, the value is not reflected in our current national contract. Patients will get better doctors if we are allowed time to think, read, reflect, discuss and innovate. But this is not viewed as a core part of our working day and so is not allotted any time, even though we see the full spectrum of disease.

The absence of these essential qualities is driving GPs to seek them elsewhere, either by reducing their sessions, leaving general practice or working in other roles, which are often no less pressured. I am lucky enough to find all three in my LMC role.

There is no doubt that this is having an effect on the GP workforce. A recent Pulse survey showed almost one in five GP partnership vacancies takes more than a year to fill. But until the working day is altered to allow autonomy, mastery and purpose to re-enter our work we will struggle to retain and recruit to what should be a privileged and highly rewarding career.

It is not exactly Field of Dreams, but the quote still applies: ‘If you build it, they will come.’

Dr Laura Edwards is a GP in Locks Heath, near Southampton and medical director of Wessex LMCs

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Readers' comments (39)

  • Spot on.

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  • An insightful article, however it does assume from the headline that "portfolio" career is not being driven by governments belief as it is easier to " performance manage" to a nonmedical agenda once the workforce is fully converted.

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  • Laura - the pressures of a General Practice are unsustainable. I can see this so clearly now I have resigned from my practice. 10 minute appointments are not safe and the presure not to refer, admit and limit Perscribing are frankly dangerous. My only advice is to get out of the toxic environment. Wessex insight is a really good idea for burnout GPs and the more publicity it gets the better.

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  • So, what you are really saying is, find a GP job like yours that allows you only to work one day a week seeing patients, and use the qualification to find a job filling the rest of the week at all costs that avoids seeing patients, by shuffling paper around and telling others how to do the job better.

    Now where have I read portfolios like that before? Oh yes, Dr Field and Dr Baker,

    We can't all spend just 20% of the week in clinical contact.

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  • That's what general practice is about.see patients for 3 days and then cone up with alternatives like teaching ;ccg meetings or go part time.i think this has to be there otherwise there will be burnout of the profession.who has the patience to hear the same thing 5 days a week.

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  • Something very wrong when the best way to be a GP is to er try to find things to do that don't involve 'GPing'.

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  • And herein lies one of the major reasons for the recruitment crisis we find ourselves in - if newly qualified GP's only want to see patients for 2 sessions per week then there is no future for general practice - what will these young GP's do then ??

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  • To the Author-Wow , lucky you , just 2 actual clinical sessions per week . Afraid this would be a pipe deam for most GP's. I mean someone has to see all the patients right?

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  • That's the reason the gmc and rcgp has created the bullshit procedures like revalidation.

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  • What a bloody joke GP has become.You have someone who only does 2 sessions a week who claims this makes her a better doctor because she has more time to reflect!!!!!Maybe I've been wrong all along.Mr Hunt you may a point.Perhaps you should cull general practice and have the physician assistants do it instead.

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  • A lot of GP partners have left partnership in order to make easy money I.e teaching for csa less hassle gets cpd points.no need to that paperwork ,referrals check bloods,listen to the patients financial problems,extramarital affairs: the list goes on!!!!

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  • The point is you can't do general practice (with the level of empathy currently expected) full time and remain sane. So if you are trained as a GP you have to find something else to do with the rest of your working week. I had no idea this would be the case when I did my GP training but for me it is certainly true. From experience if I try to work clinical sessions full time I turn into a emotionally dead psychopath. That would be fine if I was working in something like finance, commercial law or dare I say it politics....where it might even be a 'bonus booster' to be emotionally dead and psychopathic...but if your working as a doctor you need to be able to engage with people's emotions or you quickly get sniffed out, complained about or do something inappropriate ...like tell someone to go stick their benefit support letter up their rear end.

    People expect too much of their Drs these days...we have to be all things to all people...we aren't alowed to be human...we aren't permitted to be anything other than lovely ....we have to be caring and emphatic and cuddly and nice...to everyone ...all the time ...if we fail we run the risk of being instantly judged and labelled 'that crap Dr' with negative reviews on 'ratemydr.com' and the GMC staring down at us with menace.

    This isn't humanly possible...at least not for me...and not for you either.

    That's why GPs are choosing not to do clinical work full time. And who ever commented earlier there must be something very wrong in general practice to make this so....too right matie...the job has become a compete disaster.

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  • I actually went to look at ratemydr.com, I don't advise it on a work computer!

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  • Since when do GP's read business books?
    Control is fallacy to please self concept and narcisstic personality!

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  • @ 10.21 - very well written - I totally agree with you.

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  • Do such occasional GPs depend on other GPs being full time and thus keeping practices going and jobs available? If so, there are likely long term implications to the approach advocated here.
    I suppose someone has to be MD at LMC but three days a week in meetings??? Sooner you than me.
    One day a week in a practice of 14000 would not seem to allow for much continuity or the development of the sort of doctor-patient relationships that are one of the strengths of traditional general practice. If young doctors don't want this then fair enough but they need to be aware of the new world being created.
    Not criticising another's choices - just my thoughts

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  • As a full time GP - I can tell you that the pressure put on colleagues when you are out tending to your portfolio is enormous. It strikes me that the LMC, like the GPC and BMA is increasingly complicit (knowingly or otherwise) in the burdens that befall us. I hope you will buck the trend and be using your time at the LMC to address the problems at the source - rather than offer solutions which - for the masses - are improbable.

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  • Portfolio GPs are lazy work-shy individuals.There are no two ways about it.

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  • may as well write 'only way to survive as a GP is not be a GP' as essentially that's what the article is saying.

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  • Being a full-time (or even 1/2-3/4 time) GP should ultimately be far more fulfilling than the "one day a week" approach if general practice is really one's career of choice. In my view (after 20+ years) the factors making it "unsustainable" are all imposed from outside. The actual job as it should be is fine but we need to restate our boundaries and define what we will and won't do and what is and isn't part of general practice to make it sustainable rather than accept its destruction. We'd also need a public awareness campaign to counteract the unrealistic and nonsensical outpourings of politicians. There's only so much we can do at practice level.

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  • Yes, I'm a tiny but suspicious of portfolio GPs also, having done a hell of a shift comprising 9 sessions for 23 years. There's nothing quite like being at the coal face seeing it all and doing a lot of continuity of care seeing families grow up - that is a genuine joy that future GPs will never experience. We had our CQC last week and I couldn't help wondering about the GP quizzing me in my room - she was almost embarrassingly ineffectual and, of course, a portfolio GP with far less experience than me. She scurried out after about 10 minutes with not much to say.
    Oh well.

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  • 2 sessions a week....then pen-pushing the rest of the time! No wonder we're in such a mess. Why bother going to medical school in the first place if you can't face seeing patients?

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  • Quite right, this article suggests that this Dr has a great interest in business and gardening!

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  • Some comments on here are filled with anger and miss the point. The article is about how difficult it is to be a GP 5 days a week and not about choosing to become a pen pusher. Laura has done the smart thing and minimised her exposure to a very toxic environment to 2 sessions a week. Instead of being angry and petty why don't you find a way to defend yourself from relentless daily attacks to your sanity. Dont just moan, take action or shut it.

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  • Disagree, you thought about gardening?

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  • Not angry or petty. Just dismayed that someone thinks one day a week GPing is the way to go. I don't think this is particularly "the smart thing" to do (anon @12.39) - just one option dependent on other GPs remaining full/fuller-time. As for being told to "shut it" if daring to point out the downsides, I reserve my right to state my opinion; you don't have to read it.

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  • "Portfolio GP" = 75% time spent doing non-GP work; paper shuffling and navel gazing.

    Surely it makes more sense to simply not train as a GP if you don't actually wish to do GP work?

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  • Portfolio careers are incentivized in a crappy capitation based system.

    These doctors would starve in a fee for service system where clinical consultations generate pay.

    The smart thing to do in the UK is be a partner and minimize patient contact.......when I was a young uk GP partner ( the junior lackey) the older fogey partners I worked with all did around 4-5 clinical sessions with the rest of the week at the deanery, or university dpt doing sweet FA. Like with most of the punters you see working clinical sessions, you have to play the system you work within. Yes some will find it abhorrent but that's just life I'm afraid.

    I used to work 9 clinical sessions and most of my partners thought I was mad. However being used to hard work has meant I am cleaning up working abroad where this type of work is rewarded . If your a hard worker and prefer clinical work and feel the system doesn't reward you , you can either put up with it or leave....... This doctor has made her choice and you are all free to make yours........ Ain't freedom a wonderful thing

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  • I think she is adapting to the situation well. Her indemnity payments will also be much better too?
    Once you are so far down the line of training as a doctor, and find yourself in a hazardous situation and cannot turn back, the smart thing to do for your sake and your familys sake is to adapt to what suits you.
    At least she is working in the job she trained in, even if it is more part time. She has not gone to Australia and not completely left the profession. So I cannot see the problem here?
    If others want to work full time for a system that will eventually knock them down and spit them out, that is completely up to them.
    Go for it girl!

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  • Well I’m one of those useless uber-part-time GPs who only does two clinical sessions per week. I totally agree with those who claim I’m taking the piss, because I am taking the piss.
    I didn’t start it however. I didn’t unilaterally downgrade the pension. It wasn’t my fault that I was forced to do three times the workload, over my 12 hour day, than would have been safe and manageable. I didn’t make it impossible to have any kind of break; introduce lots of silly unnecessary tasks like QOF and DES; or ask secondary care to dump as much work as they could on me.
    I also didn’t come up with extended hours, or the idea that patients could make on-line complaints, mentioning my name, whilst remaining anonymous themselves.
    I spent 20 years as a partner doing the job properly. The buck really did stop with me. I knew my patients well, and became fond of many of them. I enjoyed my job, had a break at lunchtime, and felt I was appreciated and rewarded for my efforts. Then things got more and more stressful, I found myself working faster and later, and it stopped being enjoyable.
    The last straw was the pension change. I realised that by picking up some private work, and going salaried rather than partner (avoiding the 30% pension deduction), I could cut my sessions down to just two per week.
    The sessions are still about as pleasant as eating a pile of dung, but only a small pile, rather than the huge steaming pile that would otherwise be the case.
    Now the buck most definitely does not stop with me. There is virtually no continuity of care, no commitment, no personal relationship. I feel sorry for my patients, and my colleagues, because it’s not their fault either. But as I said, I didn’t start it…

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  • I agree with the preventive prescribing bit. It's tedious and the NNT figures are alarming and based on biased drug company data. How match of Primary Care is based on what patients like rather than what they need?

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  • If everyone takes her advice there won't be enough folio work to share out..maybe part time work in a garden centre watching the lovely little seeds mature would appeal?

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  • @5-18 - know exactly where you're coming from. I work in Australia now, and if you go to meetings and don't see tHe patients you don't earn an income because the consultations generate the billings. Even senior partners actively try to minimise the time spent away from income-generating clinical work.

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  • Show me the way to be a GP in the UK 5 days a week that doesn't involve risk of suicide and I'll come back from portfolio working. 10 years as a partner, watching 3 partners burn out and one suicide, I got out too to survive. Only with hindsight is it possible to see that being a partner doing 9 sessions is impossible for most humans. I too take the p*ss now, but I'm so glad to be alive that the guilt trip no longer pushes my buttons. I wanted to be a GP from primary school. The job is not what I trained to do but without emigrating there's no other way to do it satisfactorily. Now I'm using the principle that anything I enjoy that pays the bills that doesn't involve seeing patients at 10 min intervals, esp if it's not NHS work, is one step closer to a career change. It's about survival. You are not alone if you're feeling inadequate as a GP; the system is broken, not you. Get out alive, please. You've paid your dues and you owe it to your family. The cavalry are not coming - look at Cameron's 7 day announcement.

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  • 'Anonymous | Sessional/Locum GP01 Oct 2015 12:46pm

    Portfolio GPs are lazy work-shy individuals.There are no two ways about it.'

    Hilarious ...you're Victor Meldrew right?
    Actually this proves a point ...whoever wrote this works full time for sure...totally. So at ease wth colleagues, work and full of the joy of living. Xx

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  • The author is merely shining a light on the reality of the pressure cooker environment of daily practice that we all suffer. Given she works tirelessly for her colleagues and thrives in her LMC work, her practices are reaping the benefits. This in turn means she can persist with her practice work. I believe she is also a mother to a young child, so before we all berate her for her paucity of clinical sessions, let's just remember she is committing 8 sessions a week to general practice in whatever shape or form that may be. Just because we're envious doesn't mean the author is wrong - quite the opposite, in fact!

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  • @ GP Partner 10.55pm: whilst your sentiments are touching and well meant, I would disagree that it benefits other practices. It solely benefits the author, and more grease to her elbow. But I find it grating that those, who know full well that their choices have a detrimentally effect on others in regard to clinical workload, seem to either ignore or pretend they don't understand the impact of their actions. If you're going to stitch others up to look after your own self interests, at least have the bXlls to admit it - its not a crime!!

    DGPP (3.75yrs)

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