‘Much less stressful, but I have to do out of hours again’
I moved to Canada last August and I now work in a small rural practice about four hours from the nearest big hospital, so I have had to brush up my emergency medicine skills.
The clinical scope covers everything you would expect in UK general practice, plus emergency medicine (minor injuries with the occasional significant medical emergency or trauma).
I am paid per patient I see and bill the government for the work I do. The additional paperwork burden is not arduous and having six extras at the end of the day doesn’t seem so bad any more.
As well as billing a flat fee per patient there are chronic-disease management bills that can be submitted for patients to show you have provided high-quality care over the year. These are documented like the QOF, but relate to the work of the individual GP, rather than the practice.
The other big difference is on-call work. I did very little out of hours at home, but here we are responsible for our patients 24/7. Fortunately, I am in a group practice and we share the burden. The rota works out at one in four nights on call and a similar number of weekends. Being a small rural town, it is generally not arduous although there have been nights where I have ended up accompanying a patient to hospital (definitely an exception).
Overall, I have much less work-related stress, my work-life balance is excellent and there is the option to make significantly more money if I choose to work harder.
I feel like a well respected member of the community and live in one of the most beautiful areas on the planet – something money just can’t buy.
Most difficult thing about moving
The process to get into British Columbia was long, at times frustrating and very heavy on the bureaucracy. Having to dig out reports from previous training posts was especially difficult as some were 10 years ago.
Each of the four stages I went through cost between £300 and £800. However, the British Columbia government covers the equivalent of £11,500 in moving expenses and awards a £7,500 ‘golden handshake’ for coming to practise here. I also got almost £40,000 to work in a rural area of need (three years’ minimum duration) and £2,000 to visit before moving.
The MRCGP automatically qualifies you for the Certificate from the College of Family Practice in Canada, but at some point I have to sit the Medical Council of Canada exam parts 1 and 2. I also had to prove I had a minimum amount of postgraduate training to get a provisional licence from British Columbia’s Royal College of Physicians and Surgeons.
I work four days a week. Sessions run from 9.00 to 12.00 then 13.30 to 16.30, offering 15-minute appointment slots. There are no home visits. On-call shifts generally last from 5pm to 8am, one day a week and one weekend a month.
Roughly the same as in the UK (adjusted for cost of living and exchange rate) although as GPs are self-employed, there is no NHS pension equivalent. Medical protection fees are lower.
Dr Nick Fisher is a GP in Pemberton, British Columbia, Canada
‘There’s a lot of TB and HIV to treat, but you get used to it’
I’m working in a primary care hospital in South Africa, running a rural clinic with nurse triaging once a week. I manage an inpatient ward and am on call roughly once a week for a 24-hour period and once a month over a 72-hour weekend. I’m also setting up a male-focused clinic in a local town, to increase health awareness and health-seeking behaviour. That sounds very impressive, but has so far mostly entailed having difficult conversations with a dozen Zulu men about their penises.
While the setting is different – and it is nice trading the tie for shorts and flip-flops – the bulk of the medicine is similar: lots of hypertension, diabetes and asthma. There is a lot of TB and HIV, but treating these diseases is simple once you get to grips with it.
Most difficult thing about moving
I found the loss of system capability difficult. The waiting times are longer, ambulances take longer to arrive and there are drug shortages.
You need notarised copies of your degree certificate, passport, wedding certificate and GMC registration. The process takes around six months and costs around £1,000. Africa Health Placements can facilitate the process free of charge from enquiry to placement.
Any post-internship doctor can become a private GP. There is ‘family medicine’ but it is a hospital-based specialty, with more focus on obstetrics than a UK-trained GP has.
I’m working 38.5 hours a week, plus my on-call turns. It probably works out as 40-50 hours a week: but on-calls are generally not too busy: you can usually expect four to eight hours’ sleep.
I take home the equivalent of £2,300 per month after tax. If I was working five days a week, plus on-call, this would be around £3,000 per month. Rent (including bills) is £50 a month here and many of the best things to do cost very little.
Dr Chris Lowry is a GP in Mseleni, KwaZulu Natal, South Africa
‘If it’s quiet, you don’t get paid’
Patients in Australia can go to any GP in any practice, anywhere, at any time. This means their notes are in many different surgeries and it is hard to access them. We might take long, protracted histories, then never see the patient again because they are ‘doctor-shopping’ somewhere else. My history-taking has probably improved as a result.
You get paid per patient seen so if it’s quiet, you don’t get paid. Most practices offer a minimum income guarantee for the first few months, which is usually enough time to build a list. The upside
is you control how busy you want to be. There’s more autonomy than in the UK. You practise as you would like to, without QOF boxes to tick or audits to complete.
I read about the golden handshakes being offered to tempt us back and can honestly say that it would need to be a life-changing sum of money for me even to consider it. After being a partner in a busy London practice, I feel like a weight has been lifted from my shoulders and
I can now get back to being ‘just a GP’ which is what I loved in the first place.
Most difficult thing about moving
The most difficult things were getting my head around ‘billings’ (charging per patient) and learning the nuances of the Aussie health system.
I became a permanent resident before I arrived, although you can also come on a business visa, which is easier.
The MRCGP was all I needed, as it is recognised as equivalent to Fellowship of the Royal Australian College of General Practitioners. You also need to obtain a mentor on arrival and complete a few online training courses.
I work 40 hours a week in four 10-hour days, followed by a three-day weekend. If you work more you earn more.
Wages are equivalent to what I was earning in the UK as a highly stressed partner, working 47 hours a week.
Dr Chris Davis is a GP in Sydney, Australia
‘I earn half as much, but stress levels are very much lower’
General practice in France can be a lonely business as most GPs are singlehanded practitioners. You are self-employed, as in the UK, but there is no government support, as yet, for employing receptionists, a medical secretary, a practice nurse or the various other team members you’d have in UK general practice. I’m 60 and there’s no way I could afford to set up as a ‘médecin libéral’ (equivalent to a GP partner) now. When I do locum GP work in Razes, the rural town where I live, I find this difficult at times.
We’re also paid per attendee, not per session, which is time-consuming when appointments run over. For example, last week I saw 18 patients in one surgery and had to travel five miles for a home visit. I started at 2pm and didn’t finish until 8pm.
But there are compensations. The absence of targets and government pressure to achieve them removes stress from the consultation. The consultation is once again enjoyable in the way it was when I first started as a GP 30 years ago. And GPs here are not burdened with gatekeeping so there is no restriction on referrals. You give the patient a letter but they choose their specialist and set up an appointment.
However, as in the UK, the French government is introducing measures to extend the GP role although there is strong resistance from the country’s GPs, who are not nearly as well paid as those in the UK.
Most difficult things about moving
Wading through the bureaucracy of getting registered as a GP, and fear that my French wouldn’t be up to scratch despite taking a course in medical French and joining the Anglo-French Medical Society which runs the courses.
Also, my MRCGP means nothing here as there is no equivalent, although my impression is that training requirements for GPs in the UK continue to be of a higher order than in France.
None – UK citizens have the right to work in any country in the European Economic Area without a permit.
I had to go through a lengthy and costly process to get my certificates translated by an accredited translator. Then I had to have them accepted by the Ordre des Médecins (the French equivalent of the GMC). GP specialist training has been established in the UK for more than 30 years but only recently introduced in France, with the European law of 2005 making this a requirement. The French administration found it hard to understand that I could have completed this training a good 10 years before that.
I work five half-days at the hospital (with no on-call) and the occasional half-day as a GP. A half-day GP locum session can run from 8am to 2pm and a half-day at the hospital is never more than four hours.
I earn about half of what I was earning in the UK for similar hours, but without the managerial responsibility and the extra hours of meetings required as a GP partner. Stress levels are much lower.
Dr Margaret Cant is a GP in Limoges, France
‘A clinical session is long, but I see only a dozen patients’
You get more time with patients as a GP in New Zealand. Fifteen-minute consultations are the norm, which seems luxurious by UK standards. That equates to around 12 patients a session.
While clinical sessions are relatively long (three to four hours), there are very few home visits, and it is easier to get away on time. I am home for dinner with my children every night, instead of running in at bedtime to kiss them good night (if I’m lucky). Plus, having seen only 20-odd patients, my brain isn’t completely fried.
And there’s no QOF. Although New Zealand seems intent on trying to import most of the worst ideas from the NHS and there are more performance indicators of late, there is nothing like the same level of intrusive regulation. The QOF was one of the reasons I left the UK.
Most difficult thing about moving
The payment systems take some getting used to. Accident Compensation Corporation is the government-run no-fault compensation system for accidents and injuries. It imposes a high administrative burden on GPs, but it is a good system that pays for (private) treatment for injuries and also means doctors can’t be sued – keeping medical defence costs down to the equivalent of £1,000 per year. The range of pharmaceuticals available is much more restricted than in the UK, so you have to develop a new mental formulary.
It was (and probably still is) relatively easy for UK-trained GPs to get either a work or residence-class visa. There’s predictably a lot of paperwork, plus police checks and medicals. For a family of five, as we are, this took a while and was relatively expensive, but was easy enough to navigate without having to pay for an immigration adviser as well.
UK-trained GPs with the MRCGP have a period of ‘provisional general’ registration, which entails an element of supervision for the first year but they can otherwise practise as a GP. After that, you can practise without supervision, but there is compulsory annual re-certification and the GP is required to maintain a ‘collegial relationship’ with another GP. Full ‘vocational registration’ is available after an assessment process with the Royal New Zealand College of General Practitioners.
General practice is pretty much nine to five here (often with a 15-minute tea break mid-session and an hour or two at lunch). Partners work longer hours with all the usual additional small business-type responsibilities, but they will not generally be working full-time clinical sessions at the same time.
For a locum GP in my region, the going sessional rate is only the equivalent of around £250 to £280 plus goods and services tax. However, the cost of living is more expensive here than in the UK. I found it was necessary to work nine or 10 sessions a week. I now work full time in military medicine, which pays slightly more than a comparable salaried post in the UK.
Dr Greg Brown is a GP in Wellington, New Zealand