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Our core is killing us



Our core is killing us. I don’t mean our abdominal muscles when we have been planking too long, but our core contract. Every time I try to analyse the issues in our job, it all comes back to the fundamental issue of our core. 

Let’s start with core hours. Why are these arbitrarily set from 08.00 to 18.30 for routine care? I can’t go to my dentist or bank after 17.30 so why should I still be accepting calls an hour later? Speak to any duty GP and they will tell you of the huge sense of relief when the phones are finally switched over at half-past six and the floodgates are shut until the next morning. 

Now we are delivering extended hours in the evening and at weekends for the working population, there is even less reason to have a core contract stipulating 10.5 hours a day. Its origins may lie in the negotiation of the 2004 contract when we relinquished our responsibility for out-of-hours care, but that is now nearly 20 years ago. Gone are the days when there is a spouse at home to look after the children, and it is almost impossible for younger parents to secure wraparound childcare for 12 hours a day. 

Then there is the unlimited demand without any cap. We have normalised this to the extent that we think there is something wrong with any GP who is unable to subsume another 20 calls in addition to their full day’s workload of 30 to 35 patient contacts. Having recently watched the BBC’s adaptation of Adam Kay’s memoir This Is Going To Hurt, I’m reminded of the normalisation of our 100-hour weeks when we were juniors. We will look back one day and marvel at how we saw this number of patients in general practice and accepted it without objection. 

Our simmering complaints are being translated into RLE – retirement, locum or emigration. We are not fighting back as a profession, we are fighting for ourselves as individuals, and it’s resulting in the slow and painful death of general practice. And who can blame us? When you are close to burnout, it’s far easier to change yourself than change the entire system. 

If we have any chance of saving general practice, it is by moving away from an outdated all-you-can-eat buffet and having workload caps, like all other healthcare professionals. It seems to be hardwired into GP partners that the independent contractor status is synonymous with servicing any number of patients within core hours, regardless of their safety or our sanity. We have internalised an activity-based contract, as opposed to a time-based contract, with the delusion we are small businesses required to fulfil our core contract. The current system is setting us up for failure as we are caught between a rock and a hard place. If I am emotionally drained and exhausted after juggling 40 contacts in an 11-hour day, what do I do with the 41st call? Do I risk a contractual breach by turning them away, or do I risk my indemnity by consulting when I do not feel fit to practise? Every single day, GPs are faced with this dilemma and just carry on, praying that nothing adverse will happen. 

And every so often, something adverse does happen. And no one cares that the patient was your 41st call. No one cares about your flawed contract. No one cares you were three GPs down with Covid. All that matters is the patient in front of you and the care you delivered.

We are being judged for perfection within an imperfect system, and I’m not sure how much longer I can carry on colluding with this. 

Dr Shaba Nabi is a GP trainer in Bristol.

Read more Dr Nabi’s blogs here 

READERS' COMMENTS [5]

Vinci Ho 23 March, 2022 11:05 am

Dear Shabi, my friend
Considering my own situation right now , I see exactly where you come from , fraught with sentiments of dejection and even despair .
All I would say is , while I cannot expect other colleagues to go on with the current system ( as you pointed out correctly an imperfect system got us to fail) , I have chosen to carry on after this current recovery from burnout . Perhaps , I am stubborn. Perhaps I am a fool .
But this fight is not over until it is over . I know it sounds like cliche to many but I really mean it . The world is at a critical point of history and so are we in the realm of general practice. At 57 , considering what this career of general practice had bestowed me , I am honoured to be a witness of history , our history . Life is a cycle of peak and trough as I believe . This battle must go on whether the current signs are optimistic or pessimistic.
And for those who represent us , this is the time , the last time , you can show to all of us that you are genuinely on our side .
It is not about deserve , it is about what we believe
For me :Live by the code , die by the code .
Valar Dohaeris
Valar Morghulis

David jenkins 23 March, 2022 12:38 pm

vinci – never, ever, ever, give up !

keep pedalling – and you’ll get there in the end !

good luck with your recovery – you seem to be on the mend !

Michael Mullineux 23 March, 2022 12:43 pm

Fundamentally disagree with this. The core is not the killer, it is the signing up to deliver all the innumerable extra DES’s and LES’s, many attached to PCN membership, most unevidenced and all underfunded that is swamping many colleagues. We deliver core and a select few other LES’s that are properly resourced. We are not part of the PCN project with its administrative heavy organisation removing clinicians from providing patient care whilst delivering the latest NHSE diktat. Core is deliverable, with finite appointments serving as the filter it always has done. Further, general practice is not an emergency service, so when appointments are used up, the 41st patient really is not your problem Dr Nabi. The demand has always far exceeded any appointment availability. Sure, the demand is increased by the unfortunate progressive infantilization of our patients. But our patients are able to access multiple other resources to deal with ill health/perceived ill health. Totally agree the system is imperfect, but we have found being selective in accepting workloads, maintaining continuity, looking after our staff and colleagues and an element of fatalistic humour continue to serve as well enough.

Patrufini Duffy 23 March, 2022 2:46 pm

I agree Michael. Stop serving lobster, bottomless prosecco, lactose free milkshakes and vegan caviar at your “all you can eat buffet”. You’re only getting nailed for misaligned altruism by the narcissists. ***I have zero sympathy with practices taking extra payment for the below work and ARRS, and not picking up their phones still for 25% of patients – soon to divert their weekday slots into weekend slots and brand that as “PCN extra slots”:
– opt out of PCN
– stop providing phlebotomy
– stop your ECGs
– stop your spirometry
– stop your LARC fittings
– stop your silly ear syringing
– stop your travel consultations
– stop your covid vaccine heroics
– stop following up nonsense cases out of fear
– stop same day call backs
– stop your drug monitoring and shared cares
– stop lying to yourself
– stop the saviour mentality
– stop entertaining your e-consult demise
– stop saving referrals
– stop chasing monies and cunning schemes
– reorganise your practice priorities
– get your GPs together and make a serious plan to reduce waste.
– realise this has become a sick game of pinball, you’re at the gutter, so act accordingly

Ann Robinson 26 March, 2022 6:21 pm

Great article- completely agree-finishing at 6.30 and then staying to complete admin every day is draining and makes me unhappy