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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)

  • 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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