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Being a portfolio GP is the only way to survive

Dr laura edwards 3000x2000px

Full-time general practice used to be what all young GPs aspired to. But I am now seeing more of them taking their careers into their own hands and spending at least part of the week working in other roles.

Seasoned GPs are blending roles including appraisal and CCG work, and a national survey of GP trainees last year found that 40% of trainees intended to be ‘portfolio’ at five years after qualifying.

I made a decision early in my career to be a portfolio GP: I work eight sessions a week, two of which are in a semi-urban general practice of approximately 14,000 patients, with my share of duty days. The remaining six I spend as medical director of Wessex LMCs, meeting CCG chairs, representing primary care on committees and supporting GP colleagues in disputes, performance measures or with burnout.

In the current climate, it is harder to see our positive impact on patients so our sense of purpose is diminished

But what is behind the increase in this mix-and-match approach to our professional lives? Dan H Pink’s bestselling business book Drive attributes our motivation to three concepts: autonomy – the desire to direct our own lives; mastery – the urge to get better and better at something; and purpose – the yearning to do something in the service of something larger than ourselves.

When you consider these three elements in terms of general practice, the picture looks bleak.

Many GPs will agree that part of the reason they chose the profession was the desire to help others – this is our ‘purpose’. But in the current climate, with growing mounds of paperwork and increasing preventive prescribing (where only a few patients might benefit from what we do in 10 years’ time) it is harder to see our positive impact on patients so our sense of purpose is diminished.

A recent poll has shown that gardeners are more satisfied with life than non-gardeners. Explanations for this include the act of nourishing something and seeing the fruits of your labour despite bad weather. I believe pressure has led to the erosion of both aspects in general practice. Patients struggle to get appointments, and I am aware of pressures on my patients’ lives and on appointments so I ask them to return only if my plan hasn’t worked. This is more efficient but means that I only see my failures, the seeds that didn’t grow. That’s pretty depressing.

When it comes to ‘autonomy’, our daily work is dictated by a constantly changing government agenda and an impossibly high patient demand and expectation given our current resources. There are a multitude of tick boxes that bear little relation to why the patient came to see us. We must then apply computer coding to multiple parameters and quickly write notes that must be detailed enough to rely on in court years later, with no time allocated to either task. We are human and dealing with humans: not everything fits into a 10-minute box.

The only opportunities for ‘mastery’ that I encounter are found in steering projects I cover from conception to fruition in my LMC role. But as a jobbing GP, this is severely lacking. Since 2004 there hasn’t been time allocated in our expected work plans for CPD, unlike our consultant colleagues. Professional wisdom is gained through years of experience and critical reflection on what has been done. Although we are forced to do this for appraisal and revalidation purposes, the value is not reflected in our current national contract. Patients will get better doctors if we are allowed time to think, read, reflect, discuss and innovate. But this is not viewed as a core part of our working day and so is not allotted any time, even though we see the full spectrum of disease.

The absence of these essential qualities is driving GPs to seek them elsewhere, either by reducing their sessions, leaving general practice or working in other roles, which are often no less pressured. I am lucky enough to find all three in my LMC role.

There is no doubt that this is having an effect on the GP workforce. A recent Pulse survey showed almost one in five GP partnership vacancies takes more than a year to fill. But until the working day is altered to allow autonomy, mastery and purpose to re-enter our work we will struggle to retain and recruit to what should be a privileged and highly rewarding career.

It is not exactly Field of Dreams, but the quote still applies: ‘If you build it, they will come.’

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