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A faulty production line

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)

  • 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'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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