Family-friendly policies for general practice
Dr Clarissa Fabre, president of the Medical Women’s Federation, gives her advice on managing the financial and professional risks for GPs who want to start a family, and on providing the optimal environment for career development.
It is often said to medical students and junior doctors that general practice is an ideal career choice for a woman – it is easy to work part-time and to fit family around career. This statement is true – but irritating. Both men and women should choose general practice because they wantto be general practitioners, not because they are advised by their seniors that it is an ‘easy option'.
Having children is the biggest career hurdle that women face in most professions. However, one should bear in mind that intense family responsibilities occupy a relatively short period of a woman's career, and increasingly, husbands are contributing. Around 40% of women doctors are married to doctors, and male colleagues, especially the younger ones, are generally very sympathetic.
Our responsibility is to ensure that all medical careers (both in general practice and hospitals) are as family-friendly as possible. What is important in general practice is that the workload impact of maternity leave on the other doctors in the practice is minimised, and the financial impact is removed altogether. Many women have their children while in their registrar years. At this time, the workload disturbance to a practice is minimal, and there are no financial penalties to the practice. However, pregnancy and maternity leave for salaried GPs and GP partners needs consideration.
Approval for a fourth year of training has just been granted. In some ways, this would be beneficial to women doctors. The MRCGP would still be awarded at the end of Year 3. However the problem of funding has yet to be solved. Year 4 trainees could find themselves filling positions based primarily on workforce or commissioning priorities, and they would earn substantially less than in their current first year as a qualified GP. There is the possible creation of a new ‘sub-grade GP' who would be used to plug the gaps.
Workplace-Based Assessments (WPBAs) and part-time training
At present, a half-time GPtrainee has to do the same number of WPBAs as a full-time trainee in each six-month period. This results in the half-time trainee doing double the number of WPBAs overall. Most of the ‘trainee year' is taken up with assessments rather than learning what general practice is really about. The Medical Women's Federation raised this anomaly at their recent meeting with the GMC, who have discussed the matter with the Academy of Medical Royal Colleges. We are confident that the Royal College of General Practitioners will agree with our position on part-time training and the number of WPBAs required, which is in fact in line with most of the other Royal Colleges.
The shortage of partnership opportunities
Salaried doctors and locums now comprise around 40% of the GP workforce, and a disproportionately large number of these (70%) are women. The main reason for the increase in the number of salaried GPs is the change in the way GPs are paid, as part of the new contract in 2004. There is now no separation between staff costs, practice expenses and GP pay, and no financial incentive to take on a partner. Put bluntly, in the vast majority of practices, it is financially advantageous to existing partners to replace a retiring partner with a salaried GP (or a nurse).
In the BMA Sessional GP Working Group Report, published May 2010, 76% of salaried GPs said they would like to become partners. More than 80% of those looking for partnerships said there were no opportunities available in their area. Many felt stuck in ‘dead-end' jobs with no hope of progress. Lack of contact with peers, exclusion from information cascades, low self-esteem and low status were common problems. Some 48% of salaried GPs did not have a contract which conformed to the BMA national model salaried GP contract, or had no contract at all.
I am often told that becoming a salaried GP can be a positive career choice. That is true. But often, it is the only career choice, to the detriment of the individual doctor's career and earning capacity, and to the detriment of general practice. In my view, becoming a partner at some stage in one's career is the ideal goal.
In the new world of Clinical Commissioning Groups, we hear about small groups of ‘entrepreneurial' GPs running several practices, staffed entirely by salaried doctors. These ‘leaders' often do very little clinical work themselves. Is this the structure we want for the future of UK general practice?
The perils of career breaks
Taking a long break from general practice in the UK now carries substantial risks, with the emphasis on patient safety and revalidation. After a break of more than two years (for example for childcare reasons, working abroad, or following a partner overseas), GPs lose their place on the Performers' list, and GP trainees need to restart their training programme. After five years away from UK practice, the doctor needs to do an MCQ, Simulated Surgery, the AKT and six months' retraining. This is irrespective of any clinical work the doctor might have done while away from UK practice.
The ‘Returner Scheme', funded by the Department of Health from 2002, facilitated re-entry. However, this virtually disappeared in 2006, and similar schemes in general practice are now funded (or not) at the discretion of local deaneries. I have heard of several doctors who have been unable to return to medicine in the UK because of frustrating bureaucracy, excessive hurdles, and the impossibility of finding a GP placement. Under National Minimum Wage Regulations 1999, GP returners should receive a salary.
Career breaks require careful advanced planning. The rules for career breaks need to be examined carefully and made more flexible, and the paths for re-entry clarified and facilitated. It is bizarre that a UK trained principal in general practice can find it difficult to get back into medicine, while overseas junior doctors, often with poorer undergraduate training, can more easily fit into the system.
Flexible Parental Leave
In 2009 the Equality and Human Rights Commission embraced the concept of parental leave in the ‘Fathers, Family and Work Report'. In Germany, parents receive 67% of their salary for up to 12 months, or up to 14 months if at least two months of the ‘pause' is taken by the father. In Denmark, men were slow to take up the offer of parental leave until they were offered full pay.
Flexible Parental Leave may be introduced in the UK from 2015. Four weeks of parental leave and pay would be exclusive to each parent in the first year, with 30 weeks of additional parental leave and pay available to either parent (17 weeks of which would be paid). With the current system, women are seen as potentially unattractive GP partners and employees, because of the possibility that they make take maternity leave. To make childcare a parental concern rather than an exclusively maternal problem removes some of the pressure on women in this regard.
Parenthood, locums and funding
It is essential that a GP partner's maternity leave is cost-neutral (as well as workload neutral) to the remaining partners. Otherwise, young women doctors will be regarded as a potential liability in the practice. Maternity locum payments in general practice are at present left to the discretion of individual PCTs. With the disappearance of PCTs, it appears the responsibility for these payments will fall to the National Commissioning Board. We must ensure that the payments do not disappear completely, and that they are uniformly implemented at a national level.
Women GP partners who have children must bear some of the costs of locums required during maternity leave, to cover their absence. This is entirely reasonable and inevitable, for the simple reason that they will normally continue to draw their full share of practice profits during maternity leave. The over-riding principle should be that a pregnant GP is no worse off than a pregnant hospital doctor (8 weeks full pay and 18 weeks half pay). The maternity rights of salaried GPs are outlined in their individual contracts (if they have one) or are at the discretion of their employer (whether that be a GP practice or a private company, but again their position should be no worse than a hospital doctor.
Professional leadership roles for women GPs
With the large number of women entering general practice, it is important that women are prepared to put themselves forward for leadership positions - whether that be as partners in general practice, or CCG leads, or by participation in local or national medical politics. Women are often reluctant to put themselves forward, but once encouraged to do so, often perform extremely well. The Medical Women's Federation places a high priority on encouraging women to undertake these leadership roles.
Pulse will be running a seminar on skills for practice finance on May 18. Click here to find out more.
Dr Clarissa Fabre is the president of the Medical Women's Federation, sits on the BMA General Practitioners' Committee, and is a GP in Buxted, East Sussex
BMA. Sessional GP Working Group Report. 2010. http://tinyurl.com/d5r69xe
HM Government. National Minimum Wage regulations. 1999. http://www.legislation.gov.uk/uksi/1999/584/contents/made