On the eve of new beginnings

Dr Shaba Nabi bows out from her time at Pulse with a reflection on how changing times have shaped her working days 

I am writing on the eve of 2014. I’ve just started as a blogger for Pulse. I am a 45-year-old GP partner in my prime, defending the independent contractor status as the most cost-effective model in the world. I have been a partner for seven years and in each I have seen my drawings tumble. I’m angry at everyone: the RCGP for its cardigans, the CCG for not appropriately funding my deprived practice and NHS England for its obsession with seven-day access. But most of all, I’m angry with my LMC and the BMA for allowing this to happen, and I can’t seem to break into this old-boy network to effect any change.  

People with influence and power tell me I don’t need more funding – all I need is to become a ‘conductor’ instead of a ‘musician’ and oversee an army of allied healthcare professionals, so I can work to the ‘top of my licence’. 

I am a GP training programme director and I wonder how I can train for this new conductor role, when I am happy playing a variety of instruments. I fear for the future when the job of a GP will become an almighty risk sink, especially when my indemnity costs are more than £1,000 per session worked. I have no choice but to reduce my clinical sessions, because the most emotionally gruelling work pays the lowest hourly rate.  

I dread my duty days when all I see is open-ended access and I might consult with 60 patients. 

I am writing on the eve of 2034, and although I’m 65 years old, I’m still working full time because of changes in pension rules. Besides, as I started my family late, I’m still supporting kids at university, who’ll leave with a £100k debt. 

I’m glad I stayed on at the practice after my partnership handed back its contract in 2017. It means I have a permanent role when most salaried GP contracts these days are fixed term. Many of the GPs I trained in the past 10 years have moved abroad or chosen alternative careers, some outside of medicine. A few have become millionaires developing AI for healthcare.  

I’m no longer sure I can call myself a GP. I’m certainly a generalist, but I haven’t seen anyone with a cough, UTI or back pain for over five years. There are five GPs in our practice, when there used to be 12. We support advanced clinical practitioners and physician associates, but as they can all prescribe and order tests, I don’t often get involved with their supervision. I occasionally get asked my opinion on whether an MRI is indicated if the physiotherapist doesn’t agree with the AI, but I rarely disagree with anyone’s concerns these days as I’m so deskilled.  

I spend the majority of my time acting as a general physician for the elderly, working hard to keep them out of hospital, as bed numbers have dropped by 30% in the past 10 years. I also work closely with specialist nurses at the interface of primary and secondary care, managing conditions such as complex heart failure and ADHD, and monitoring a wide range of medications that are no longer specialist only. I ponder wistfully on my former LMC days when I demanded an enhanced service fee for every new drug or pathway. Of course, that is now outdated, as we are all salaried GPs to community trusts.  

My income hasn’t changed in 10 years, even though inflation runs at 3%. I am fortunate to have paid off my mortgage and I’m no longer paying for childcare, but younger GPs are struggling to get on the property ladder, especially as there are so few permanent roles.  

I am sitting writing this on the eve of 2024 and I am contemplating how different my life and career will be this year. I am 55 years old and a mother of three school-aged kids, wondering how I am going to stay up late enough to pick them up from their parties.  

I guess it’s natural to reflect on your life on the eve of a new year, but most people consider all the things they aspire to do – like exercising more or writing their first book. Instead, my feelings are a sense of loss – of all the things I have loved that I will be giving up.  

After 17 years, I am giving up the leadership of my practice because it was living in my head rent free. I have no idea how I will make this transition after so long. I will continue working there but will reduce to two clinical sessions and one management session.  

After 15 years, I am giving up GP training because the pastoral role has become so challenging. This is no reflection on the amazing GPs I have trained. The problem is the hoops the college makes me jump through.  

And after 10 years I am giving up writing for Pulse because I am no longer angry enough to write a rant, as anger has been replaced with despair. And I can no longer claim to be working at the coalface.  

But I am taking on new and hopefully rewarding challenges. I will become chair of my LMC, which is my dream job. I don’t have to pretend to be interested in the ‘whole system’, as I did when I was a commissioner: I can represent general practice in an unapologetic manner. I will continue appraising and mentoring, to support those at the front line. But my days in the trenches are over. I am nowhere near retirement, so I am forced to carve out a sustainable career. I cannot drive in the fast lane for another 10 years, so I’ve decided to take the scenic routes. General practice is my life and my identity, but too high a dose is toxic. Like many of my age, I am not burned out but slowly smouldering.  

To my fellow GPs – thank you for working your butt off in the most difficult specialty, in a climate of mistrust and disdain. Thank you for the gentle care you have given me and my family in difficult times.  

And most of all, thank you for reading my blogs and your words of comfort and support over these past 10 years.  

Dr Shaba Nabi is a GP trainer in Bristol