Tackling common problems for new GPs

Struggling with a heavy workload

Each of the partners keeps on giving me extra work to do and I don’t feel I can say no. How should I handle this situation?

You will probably want to do everything you are asked, but it is vital that you do not become overwhelmed, especially if you are being dumped on. Minor niggles must be brought up and discussed early, before resentment builds up.

I would recommend that any new GP asks to have a designated partner as a mentor. There is so much to learn about where things are kept and how the practice operates as well as dealing with the medicine. You may find that all tasks take longer than expected, just through being unfamiliar with the processes. Your mentor should be the first port of call if you are struggling, because your colleagues are unlikely to have the time to make your life comfortable, let alone to do their own work. Ideally the issues you are having with your responsibilities should be brought up at a practice meeting, however daunting this seems.

Any salaried GP contract should specify exactly what you are expected to do. Having specific finishing times is impractical, given varying consulting speeds, but it would be worth clarifying whether you are expected to do, for example, QOF work.

As a new partner, however, it is more difficult to specify your hours, because as we all know, workload has mushroomed.

Develop a rapport with all your colleagues, including the practice manager, so that you feel comfortable raising concerns early. Most partnerships want you to settle in happily since recruitment is at a crisis point. It is in everyone’s interest to ensure that you are happy and plan to stay.

Dr Fiona Cornish is a GP in Cambridge

This problem may simply be  down to poor co-ordination and communication from the partners, who might need to speak to each other before giving you extra work. Speak to the practice manager or senior partner to see if they can help co-ordinate your workload better.

If you’re a salaried GP, then all extra roles should be written into your job description and you should be able to complete the tasks within your contracted hours.

If you’re a locum, any extra work should be written into your contract and you can charge accordingly. If you’re a partner in a practice, it can be much more difficult. Talk it through with your partners to reach a consensus about the way forward. Most partnerships give incoming partners a reduced workload for the first few months until they’re settled.

Don’t fall into the trap of working harder and for longer. Speak to colleagues (a new practitioners’ group or First5 CPD group can provide a valuable sounding board), a BMA employment adviser or your LMC. Ultimately, if the practice won’t negotiate with you and doesn’t listen to your concerns, you may need to look for alternative employment elsewhere.

Dr Phil Williams is national lead of the RCGP’s network for newly qualified GPs, First5

Confused about which path to take

I can’t decide whether to be a salaried GP, a locum GP or a partner. How can I make up my mind?

You are fortunate enough to be completing your training in a seller’s market. You should be able to negotiate a job that is right for you and so long as you work hard and efficiently, many practices will be keen for you to join them.

Although locum work is flexible, it can also be seasonal. Demand is high around Christmas and in the summer holidays, but less so during November and February.

Sessional work can also be quite solitary, with a high proportion of on-call days and little continuity. Although earnings can be high, as a self-employed professional you will usually have no holiday or sickness pay and the lack of regular peer group support may put some people off.

Entering a partnership straight out of training is certainly an option, but some new partners do find that the registrar post has not prepared them for 12-hour days of intense work. But completers who have previous medical or life experience, or financial obligations, may find partnership is the quickest route to a good income.

For many, a salaried post will be the right compromise between job security, continuity of care and freedom from the management and business side of general practice. As it is so hard to recruit partners now, many practices are offering salaried-plus posts with a view to partnership at a later stage if you settle in well.

Dr Harry Yoxall is medical secretary of Somerset LMC

There is not a straightforward like-for-like comparison to be made between these roles.

Set out your personal priorities, and once you have established these, conduct your own research on the differences between the way these roles are remunerated.

If you are a salaried GP your financial arrangements don’t change at all from being a registrar. You can go on paying your tax in the form of PAYE and national insurance, and your superannuation contributions are deducted by your employer.

Locums are self-employed, and responsible to HMRC for their own tax, national insurance and superannuation liabilities. But locums can earn more than salaried GPs because they can work more flexibly. Also, more of your expenses are tax deductable as a locum – work-related travel expenses being a good example.

There is nothing to stop you being salaried for part of the week – say, doing six sessions – and also being self-employed for the rest of the time doing locum or out-of-hours work.

When joining a partnership as a GP principal you are self-employed, again responsible for your own tax returns. However, if you are joining a well-run, profitable practice you could be taking a stake in something that’s growing and already successful at the start of your career – but you will still need to take advice from an accountant before committing.

Bear in mind that practices differ widely. Some are successful, clinically excellent and well run; others fall short of these standards.

There may be a requirement to borrow money to pay your share of the working capital of the practice or ownership of the surgery premises. In a situation like this, interest on that loan would be an allowable expense for tax purposes.

Peter Waller is head of tax at BW Medical Accountants

Risks of taking over another partner’s list

I’ve just joined a practice and taken over the personal patient list of a retired partner. I need to update the prescriptions to current guideline standards, but what are the medicolegal risks? How can I avoid complaints?

I would suggest that in your first few consultations with new patients you need to work on introducing yourself and developing that bond of trust.

Deal with their agendas first to show that you care. You will need to make a professional judgment on each patient and the risk they face on their current medication regime. If you change the medication too early, without their acceptance and trust, they may not take the medication anyway – drugs left inside packets definitely don’t work.

Guidance will often state that patients who are stable on existing regimes don’t need to change their current habits so avoid any unnecessary battles. Changing drugs can mean new side-effects and unfortunately, since you are the new doctor, the patient is likely to lay the blame at your door.

Choose your timing – once you have developed a bond of trust, offer a medication review or mention that there may be something better now in light of the latest research or guidance. Believe in yourself and build up a support network around you to talk through any difficult cases.

Dr Laura Edwards is a GP in Locks Heath, near Southampton, and medical director of Wessex LMCs

Patients may be worried about seeing a new doctor so you will need to allow for anxiety and potential mistrust at the start of your relationship. Good communication in each first consultation is key so ensure that you have read the patient’s medical history and can reassure them of your abilities.

If you notice that a treatment regime deviates from current clinical guidelines you must flag this with the patient. Broach these discussions sensitively and in person rather than make a change they will discover only when they collect their prescription.

Be careful not to be seen to criticise care that was given previously, and if a change in treatment is agreed give a clear explanation of why you’re changing it, and the risks and benefits of doing so (as outlined in GMC guidance).  

If a patient refuses to accept the new treatment, explore why. Unless there is imminent risk of harm for continuing the present regime, ask the patient to make a follow-up appointment to discuss and decide whether to change their treatment.

A considered, collaborative approach will reduce the risk of the patient feeling pressurised or wanting to make a complaint.

You cannot be forced into prescribing medications that you do not believe are in the patient’s interest or that deviate from accepted practice without justification, so consider the risks and benefits of stopping the medication without replacement versus continuing and monitoring the regime. Discuss it with senior colleagues – the local prescribing lead and secondary care teams should be able to answer any questions you might have.

The final decision and reasons behind it should be clearly documented in the patient’s medical records.

Dr Pallavi Bradshaw is a medicolegal adviser at the Medical Protection Society