Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan
The King’s Fund recently conducted a survey of 318 GP trainees, and found that less than a third of them intended to work full-time (defined as eight sessions per week) upon qualifying. Most trainees felt that five to six clinical sessions was about right. The top four reasons for not wanting to work full-time related to workload issues, including the intensity of the working day, volume of administrative work, work-related stress, and long working hours.1
This mirrors previous research looking at qualified working GPs. A survey of GPs in Wessex found that 26% of GPs had reduced their working hours to help manage the increasing intensity of workload and the effects on mental health and stress.2 Is workload actually increasing? It would seem so. The BMA looked at workload control in general practice and described increasing consultation rates due to growing patient needs, complex multimorbidity, a recruitment and retention crisis, and a real-term fall in current NHS investment into general practice.3 All of this means that there is an overload of work with diminishing monetary and workforce resources to manage that work.
The average number of sessions worked in the survey sample was 6.3, but the average number of hours worked was 38.4, which would normally equate to around 8 sessions.
How this increasing workload translates into a working day effectively shows why counting whether GPs are part-time or not using the sessional system is flawed. The BMA defines a session as a 4 hours and 10 minutes period of duty, typically consisting of three hours in direct consultation with patients with time left over for other tasks. How does this translate realistically into the working day of a GP? A typical day is hard to define. Time spent on each consultation will depend on the GP, the complexity of the case and how many extra tasks are generated from each clinical contact, for instance, referrals or organising investigations. Alongside the clinical contacts and related work, are the additional test results, personal call backs, prescription requests and clinical documents to process, all of which can easily extend a four hour session to five or six hours. When sessions overrun, a six session working schedule starts equating to 36 hours a week and looks less like a ‘part-time’ job than a full-time one. The recent GP Worklife Survey unpicked the split between sessions and hours worked in more detail. The average number of sessions worked in the survey sample was 6.3, but the average number of hours worked was 38.4, which would normally equate to around 8 sessions. The Worklife survey respondents spent 40% of their time on indirect patient care (referral letters, filing test results and correspondence), administration and meetings.4 The current sessional split of 75% (three hours of a four hour session) for clinical care and 25% for administrative work doesn’t quite capture the reality of the indirect patient care workload in practice.
Is there another way to manage the increased workload of day-to-day general practice? The King’s Fund published a thought experiment about the typical day in the life of a GP, which drew on the experiences of GPs working in different practices. Alongside this typical day was a reflection on how a long twelve hour work day might have looked like in an ‘innovative practice’ with access to support from additional members of the practice team including paramedics, pharmacists and health care assistants. Some of what is in here seems a bit unrealistic (do we have time for a health walk with our patients at lunch?) but there is something to glean here about team-based working, how to utilise ARRS funded roles, effectively implement digital innovations and improve system design. It’s an interesting read in terms of thinking through the consequences of the ‘day in a life’ but working within different practice-based configurations. Whether this thought experiment can translate into real practice, well, the King’s Fund report on ‘Innovative models of general practice’ is a good read for anyone who might be interested in these kinds of solutions and includes numerous case studies describing local innovations and lessons learned.5
We cannot define 40% of our work as ‘hidden’ – it is an essential part of the job.
Going back to the King’s Fund survey, the survey found that trainees wanted to work five to six clinical sessions. Let’s consider what these ‘part-timers’ might be doing in the rest of their non-clinical sessions. Some might be academic GPs, GPs who teach undergraduate, GPs who teach GPs, GPs who appraise other GPs, GPs who work in the PCNs or ICSs, GPs who take on other specialist clinical roles, GPs who work at RCGP or even at the BJGP. The profession needs people who can commit time to contribute to these essential, whilst non-clinical activities; these roles all contribute to the profession. At an individual level, opportunities to develop portfolio careers help with recruitment and retention of GPs, as job satisfaction increases when clinicians do the work they enjoy in their non-clinical sessions.6 Aside from non-clinical professional roles, some GPs are prioritising their family, flexible working or a life-work balance.7 How can these choices be framed as ‘wrong’, especially if they are contributing to a more sustainable and stable workforce?
A final thought: one phrase I hear again and again is GPs talking about the volume of ‘hidden’ work in general practice when describing the non-clinical facing parts of the role. It doesn’t seem that ‘hidden’ to me; it’s part of our jobs and we all do it, talk about it, acknowledge it, and write about it. We cannot define 40% of our work as ‘hidden’ – it is an essential part of the job. It is time to redefine this ‘hidden’ work as essential work, or ‘non-patient facing work’. Greater public and media understanding of what kind of work GPs do in and out of their clinical sessions, and a move away from counting numbers of sessions to define what is part-time, might help change the negative narrative of the ‘part-timer’ GP.
References
- Bergman K. Workload issues affecting GP trainees’ plans for their future careers: The King’s Fund; 2022 [Available from: https://www.kingsfund.org.uk/blog/2022/09/workload-issues-affecting-gp-trainees-plans-their-future-careers.
- Owen K, Hopkins T, Shortland T, Dale J. GP retention in the UK: a worsening crisis. Findings from a cross-sectional survey. BMJ Open. 2019;9(2):e026048.
- Workload Control in General Practice – Ensuring Patient Safety Through Demand Management. London: British Medical Association; 2018.
- Odebiyi BW, B.; Gibson, J.; Sutton, M.; Spooner, S.; Checkland, K. Eleventh National GP Worklife Survey 2021. Policy Research Unit in Commissioning and the Healthcare System.
- Baird BR, H.; Ross, S.; Honeyman, M.; Nosa-Ehima, M.; Sahib, B.; Omojomolo, D. Innovative models of general practice. London: The King’s Fund; 2018.
- Marchand C, Peckham S. Addressing the crisis of GP recruitment and retention: a systematic review. Br J Gen Pract. 2017;67(657):e227-e37.
- Mathew R. Rammya Mathew: Doctors shouldn’t feel guilty for working “part time”. BMJ. 2022;378:o2300
Mentions
Great article Nada. ‘Full time’ for a GP should be 6 patient facing sessions. Like for consultant there should be a ‘PA’ type model with SPAs fit CPD, teaching, research etc . Very few ‘full time’ consultants do more than 5 patient-facing sessions per week
David Mummery is a GP in West London and a research fellow at the Department of Primary Care and Public Health, Imperial College London
Everything counts , in large amounts: so said the 1983 single by Depeche Mode.2 The same could be said about the next review of the GP contract due in 2024 : for the profession of General Practice, everything counts on this contract, and how it is devised, formulated and implemented.
We have had the chaos recently of the contract imposition; we have had constant discussion and debate about workforce , workload and the possibility of industrial action; we have had GPs leaving and retiring earl , with the ever present reality of burnout for most GPs; we are repeatedly told General Practice is on its knees , and many GPs feel that on a daily basis; we have had numerous articles , workshops, mainstream media debate and other discussion about ‘ the future of General Practice’; we have a disintegrating Conservative Government and a newly re-energised Labour Party waiting in the wings to take over the reigns of Government; we have had the comedian Chris Morris , at the LMC conference giving the single best and funniest talk about General Practice in the history of the profession.3
We GPs should be listening to the Labour Party as they are the ones that are soon going to be in power. We may not agree with Keir Starmer, and Wes Streeting , and what they have recently been saying about General Practice, but we should be listening to them. Keir Starmer’s middle name by the way is Rodney; just a random factoid to try and keep you interested.
Labour is right that the GP partnership model is declining – not in all areas, but certainly in many areas of the country : in some places such as some of the coastal towns of the U.K., many practices rely almost completely on locums. An alternative ‘plan B’ has to be formulated by the BMA and profession as a whole , if the decline of the partnership model proves to be inexorable. It is irresponsible not to plan an alternative path for GPs and general practice.
What might this plan B entail?
There has been talk about GPs being employed by hospitals. This, in my opinion, is a very bad idea and will only formalise the hierarchically inferior, ‘community house officer’ role that many hospital specialists think general practice has become; general practice would lose its independence as a great medical , independent profession. So, no. No mass GP employment by hospitals. Also, secondary care, on the whole does not seem to understand general practice.
Others have talked about going the way of dentistry and essentially leaving the NHS to go private. Seriously? The most vulnerable in our population are pulling their own teeth out with pieces of string because they can’t afford to see a dentist; and free NHS dentistry seems to be unavailable in many areas. Do GPs really want such a system, where only those that have money and can afford it can access care? Is this why we became GPs? So, no. No private large scale model: if individual GPs want to do this, go and work for BUPA or HCA , but don’t impose it on the rest of us, or more importantly the most vulnerable members of the population.
Ok, so that’s no to hospital takeover and no to mass move to private General Practice. So what other models for ‘plan B’ could there be?
Assuming the partnership model is doomed ( which due to unlimited joint and several liabilities in an ever dwindling number of GP partners it is very likely to be: liabilities especially relating to estates will become an increasing problem), what is the best ( or least worst) option for this ‘plan B’ as we go forward: we have already discounted two options .
A third ‘plan B’ option is the rise of the GP super-practices : a corporate model with layers of GP executives and directors and managers etc, performing large scale industrial general practice and ‘patient farming’ of many tens and hundreds of thousands of patients. It is a corporate, capitalist system, aiming for profit for the companies and partnerships involved and likely to want to run the organisation on the cheapest staff possible to maintain and boost profits. We have seen this model spring up across the U.K. in various places, and in some cases the owners are now US health companies. Continuity of care is poor , as generally are patient ratings and feedback and If shareholder owned, then they are beholden to their shareholders. These organisations are generally more keen to employ cheaper staff such as ANPs and physician associates, rather than the more highly-trained GPs who have a much wider and greater clinical experience. This model is not good for GPs or the profession of General Practice or patients: poor ratings, poor continuity of care, exploitation of employees, lack of support for GPs and aiming for profits at all costs could be the norm. No thanks. So that’s another no.
Ok! Plan B mark four – let’s think about this. We need to re-vitalise and re-invigorate General Practice; clinical work must be core and the high risk personally to GPs of doing clinical, patient- facing must be recognised and acknowledged. Payment for GPs has to in some way be linked to clinical work done and thereby clinical risk exposure for all GPs – it isn’t currently in the partnership system. Toxic hierarchies that can exist, have to be abolished in Primary care and flat hierarchies encouraged; one group of GPs should not be the bosses and paymasters to another group and profession should stop being fragmented and divided into : partner, salaried, locum , sessional, portfolio etc. GPs need to be drawn back in from the large locum pool and encouraged to work in teams and groups. Other work such as CPD, teaching , research etc needs to be a visible (and therefore paid) part of a GPs job-plan as it is for a consultant; working 5 or 6 clinical sessions a week should be classed as ‘full time’ and not ‘part time’ as it is by the mainstream media.
So what we need is the invention of a ‘new category’ of General Practitioner. Let’s be old fashioned and just call this new category a ‘GP’ but with no other qualifying features. This new GP will be employed by local authorities or possibly the ICS. This new GP will still be ‘ independent’: the independence of General Practice is not logically linked with the partnership model: in any new system the BMA and LMC must remain as representative and negotiating bodies and funding and form of this must be included in any hard negotiated deal. A good salary must be negotiated; there must be safe workload caps and alert systems ; there must be consultant like job contracts with a PA and SPA type system for job planning, and the SPA time for the CPD, research , teaching , management , special interests etc must be ‘ built’ into the model with for instance 2 SPAs if 5 or more clinical PAs are worked and 1 SPA if less than 5; there must be occupational health for all GPs; the unlimited joint and several liabilities of the partnership model must go. Toxic hierarchies must also go and healthy flat hierarchies of working must be encouraged. Care for patients must remain free at the point of access. This model may be highly appealing to the large number of GPs in the locum pool;4 it may be appealing to some partners and many existing salaried GPs; it will increase the number of ‘patient- facing’ GPs ; it will restore the sense of vocation of General Practice and help it remain the greatest medical profession of all.
As in Charles Lamb’s quote , let us remain a profession who metaphorically ‘lends’ rather than ‘borrows’ like the corporate vultures do: let’s steer well clear if that dangerous road. We and our families are all patients: we need to devise a model that we can proudly say to them we work in, with the best interests of our patients at heart. It should be fun and fulfilling and exciting, patient- facing and sometimes dangerous; not the will-sapping digital dullness that we seem to be living though now.
We can do this. Let’s be proud to call ourselves just general practitioners and make a new system together that will make us, our families, our patients and future generations proud: also, let us once again say with pride, ‘I am a GP’.
References
‘Everything Counts’ song and video, by Depeche Mode, 1983,
[accessed 6/6/23]
Chris Morris, 2023 BMA LMC Conference Speech,
[accessed 6/6/23]
Khan N, https://bjgplife.com/hidden-no-more-the-real-work-of-the-part-time-gps-working-full-time-hours/ [accessed 6/6/23]
Khan N, https://bjgplife.com/the-hidden-shelves-locum-and-academic-gps/ [accessed 6/6/23]
Featured image: Giant Jenga: a metaphor for primary care funding, by Andrew Papanikitas, 2023