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At the heart of general practice since 1960

What do patients really want to know about practices?

There is now a bewildering array of career options open to young doctors finishing their training ­ Dr Paula Wright sifts through some of them

Young doctors finishing their training find themselves facing a bewildering array of career options and in most places there is no formal career counselling as to how to make these choices.

VTS training is still geared up to producing the traditional 'principal'. Yet now 25-30 per cent of GPs work as sessional GPs, that is self-employed locums or freelance GPs, and employed GPs (retainers, flexible career scheme GPs, salaried GPs). Signing up for the deanery's higher professional education (HPE) programme is specially important to help you tap into local funding and provide opportunities for professional development.

GP principal

This is an exciting time to become a GP partner. Income is rising rapidly and there is greater flexibility for recruitment and investment in IT and premises. You don't always need to buy in, there is no compulsory out-of-hours work, and it is much easier to negotiate part-time hours and portfolio working.

But general practice as a self-employed partner running a small business may not be what we all aspired to. The clinical role is diluted by many other responsibilities and endless wrangles with the PCT which may grind you down before long.

The financial commitment of being a partner means it takes a long time to disentangle your finances if you want to pull out. Also if a partner goes off sick or leaves and locums cannot be found the buck stops with you.

Salaried positions

Salaried posts have been around for a few years and initially seemed to be modelled on an extended version of the new partner's mutual assessment period. This was paradoxical as many embarked on salaried posts to have a better-defined workload and less open-ended commitment and found they had the opposite.

Your workload was modelled on the partners, but you didn't have a vote and your income was lower. The result was that you would find yourself with the worst of both worlds: a modest income, no say in any decisions and yet expected take on additional work (cover absent partners) with no pay forthcoming.

Only last year has a new model contract of employment been introduced which compels GMS practices to update their employment procedures. Hours and workload are defined, and not elastic, entitlements are clearer, but unfortunately pay and pay progression (whether inflationary, seniority or QOF related) are all up to negotiation.

For more information on this option read 'Focus on salaried GPs' by the GPC on the BMA website. You need to understand the difference between GMS and PMS practices to negotiate your terms well.

Locum work

This is specially well suited if you want:

·Long holidays to travel

·Time off to study for exams

·Time to get a feel for practices in an area you are not familiar with

Beware:

·You need to be fairly confident: this is the option that offers the least support and the most isolation.

·You need to be well-organised, keeping a careful diary of bookings, and meticulous accounts of earnings and expenses.

·You need to be a confident negotiator to avoid exploitative terms of work as there are no longer any national or locally-agreed terms or fees.

·If your next step is likely to be a salaried option you need to consider how long you locum for. You will loose all your accrued entitlements to sick pay if you have break of service locuming more than 12 months. For Whitley maternity entitlements this happens after a break of only three months.

·If maintaining a good income is a top priority, you need to find out whether there is demand for locums in your area and whether there are seasonal dips in demand.

Important starting steps are:

·Joining your local sessional GP group (and attending their meetings)

·Reading all about starting locum work from websites, eg NASGP, NELG or locum123

·Insisting firmly on adequate induction information and room stocking when starting in a new practice

·Contacting you local deanery to see if there is a mailing list to join for educational events (many deaneries have GP tutors for sessional GPs)

·Not being afraid to discuss difficult cases with others partners or to ask about the existence of specific local services

Consolidating clinical skills

The pressure to do summative assessment and MRCGP all in the space of 12 months potentially squeezes out opportunities to develop real hands-on clinical skills, time management, dealing with uncertainty and so on.

If you are looking to consolidate clinical skills after finishing VTS, a good option is joining a salaried scheme with in-built educational support such as Career Start in the northern deanery. These schemes recruit a cohort annually and offer a package of salaried employment with built-in time for CPD, some of which is with your cohort. There is usually the opportunity for a sabbatical too.

Such packages were pioneers before paid time for CPD became a standard building block of the model salaried contract which must be offered by all GMS practices. Some of these schemes have let their salaries fall behind other salaried posts.

Pitfalls:

·How much choice do you get over which practice you are placed in, or are you just an employed floating locum?

·Are the practices attractive to work in or is this a covert mechanism for solving recruitment problems to practices that can't recruit'. There is no amount of CPD that will compensate for working in an undesirable environment.

·Is allocation to practices based on your preference and merit (is it fair to part-timers)?

·Are there strings attached to doing the sabbatical?

Starting a family

If you are planning to start a family you may be thinking about:

·Wanting some longer-term job security

·A defined fixed commitment rather than the open-ended entrapments of partnership

·Part-time working

·What maternity entitlements you will get.

If income is an issue, then part-time partnership may combine stability with a reasonable income. The detail will be in the partnership agreement as to whether you may find yourself upsetting your work-life balance every time a partner goes on long-term sick, maternity leave or simply leaves and there are no locums to cover.

The buck stops with you as a partner but not as a salaried GP, retainer or FCS doctor where your job plan and contract determine what your commitment to the practice is, and this cannot be changed by your employer without your agreement.

·Get the BMA to check the terms of either your partnership agreement or your salaried contract.

Make sure that:

·You will be employed on the GMS model salaried contract.

·You agree with your employer what your date for continuous NHS service will be. This will usually be the date when you started work as a house officer unless you have had a long career break.

The retainer scheme was introduced at a time when there were strong financial disincentives against practices employing GPs. The scheme offered an incentive for practices to take on GPs employed on a part-time basis with a commitment to mentoring and paid educational time.

PMS practices and nGMS have both removed these disincentives and thus salaried opportunities have grown. However, GPs wishing to work very limited hours may still find the only option they have is the retainer and FCS scheme.

As a starting point here you should:

·Contact the local deanery and find out whether there is a list of practices interesting in taking on a retainer or FCS doctor. The northern deanery has a database of 60 such practices.

·Read as much about these schemes as possible: your deanery may have compiled existing guidance into a handbook. If not the Department of Health has guidance on its website about both of these schemes, and so does the BMA website (some of it in a members-only section). The GPC's focus on salaried GPs is a key document to read.

·Approach practices positively with your CV. Leave sensitive topics such as pay and hours until each side has a basic feel for whether there is a match. Be clear about timescales by which certain decisions can be reached.

Portfolio working

If you want to have a portfolio career it used to be the case that it was best to become established as a principal first and then build from there. These days things are different.

You can become a trainer as a salaried GP or partner after three years. There are now freelance GPs in post as course organisers, GP tutors, associate directors, appraisers, undergraduate student tutor, in PCT roles etc.

Networking is key to developing these roles as only in this way will you find out where the career openings are in your area. It always helps if you are not the first to challenge the system and your local sessional GP groups will have examples of pioneers in these roles.

All VTS schemes should offer a session on career options and approaching the local sessional GP group is likely to yield a valuable resource. In time, formal career counselling should be developed for this valuable section of the workforce.

Paula Wright is a freelance GP

Sources of information

·www.bma.org.uk (GP part): Focus on salaried GPs

·NASGP.org.uk

·NATpact.org.uk

·Whitley maternity right. Full section 6 on maternity: www.dh.gov.uk/PublicationsAndStatistics/Letters

AndCirculars/AdvancedLetters/AdvancedLettersArticle/

fs/en?CONTENT_ID=4004316&chk=0sSGrV

·Amendments about extension from 18w to 26 weeks:

www.dh.gov.uk/PublicationsAndStatistics/Letters

AndCirculars/AdvancedLetters/AdvancedLettersArticle/

fs/en?CONTENT_ID=4062467&chk=VXK42j

·FCS scheme

www.dh.gov.uk/PolicyAndGuidance/HumanResourcesAndTraining/MoreStaff/FlexibleCareerScheme/fs/en

·GPwSI

www.natpact.nhs.uk/cms/352.php

www.natpact.nhs.uk/cms/165.php

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