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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)

  • 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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