‘Hidden’ no more – the real work of the ‘part-time’ GPs working full-time hours

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.

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

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

1. 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.
2. 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.
3. Workload Control in General Practice – Ensuring Patient Safety Through Demand Management. London: British Medical Association; 2018.
4. 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.
5. 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.
6. Marchand C, Peckham S. Addressing the crisis of GP recruitment and retention: a systematic review. Br J Gen Pract. 2017;67(657):e227-e37.
7. Mathew R. Rammya Mathew: Doctors shouldn’t feel guilty for working “part time”. BMJ. 2022;378:o2300

Featured photo by Jon Tyson on Unsplash