The future of general practice: the views of GP trainees

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The number of doctors entering GP training is higher than ever, yet the overall number of full-time equivalent GPs keeps decreasing. This is one of the reasons that patients report increasing dissatisfaction with their ability to access general practice, although they are satisfied with their care once they are seen.

All the political parties have pledged to significantly increase the workforce in general practice to help improve access. In order to understand more about future GPs and their career intentions, we repeated a survey we ran in 2016 and 2018, receiving 840 responses from trainees across England. We found the following.

  • Only 27 per cent of trainees intend to work full time in general practice one year after qualifying and only 5 per cent after 10 years (down from 31 per cent and 10 per cent in 2016). 
  • The intensity of the working day remains the commonest reason for choosing part-time or portfolio work (69 per cent), although family commitments (66 per cent) and interest in other work like emergency medicine or palliative care  (50 per cent) were also important factors Other NHS clinical work or medical education continue as the commonest choices to combine with general practice as a portfolio career.
  • Only 41 per cent of respondents are considering GP partnership at 10 years, down from 45 per cent in 2016; the most common reasons for this are the financial implications (58 per cent) and the lack of training in business matters (47 per cent). 

Flexibility makes for an attractive career

In the 2016 survey, trainees reported they were considering portfolio working at a later stage in their career, but this year we saw an increase in the number of trainees considering it one and five years after qualifying (24 and 51 per cent, up from 18 and 44 per cent in 2016).

As a current GP trainee splitting time between clinical work and a post at The King’s Fund, I find this work-life variation brings an enjoyable balance to the working week, helping me to reduce stress and broaden my skills and knowledge and I would like to continue this pattern throughout my career. Similarly, many of the respondents also hope to pursue other clinical or non-clinical interests alongside general practice, with interests ranging from expedition medicine to medico-legal work.

This opportunity to broaden their skills by working in other areas is one of the things that attracts trainees to general practice. Almost 22 per cent of the respondents had already done other specialty training like medicine or surgery before coming to general practice. Health Education England’s focus on promoting general practice as a flexible training option, providing opportunities to delay starting training and facilitating transfer from other specialties appears to be having a positive effect. 

Concerns about an unmanageable workload

Despite this desire for a more flexible career, the intensity of the working day remains the leading factor in not wishing to undertake full-time GP work, with 69 per cent respondents citing this. Many referred to the risk to their own health: 

Patient volume and work intensity makes a nine-session week look intolerable in terms of risk of burn-out and maintaining a decent standard of care.

The days are too long to even exercise – there’s no 'balance' or promoting health when you can’t even achieve health yourself.

We asked respondents what was driving this intensity, and the commonest factor was a lack of staff, cited by 24 per cent of respondents, with increasing patient complexity, partly due to an ageing population and wider availability of medications and treatment options, leading them to believe that future workload is likely to be unmanageable. Many respondents highlighted increasing expectations:

Higher expectations from the public and the media for GPs to simultaneously find all the cancers, cure all the infections and also to save money by never referring to hospital and a perceived lack of self-care within the population.

Decreasing threshold for patients to present to their doctor with symptoms or problems – partly driven by a 'just in case' mindset and partly because of an over expectation of what modern medicine can offer in terms of diagnostics or resolution.

The fact that so few trainees feel that full-time clinical work is a manageable or realistic prospect. This has clear implications for future workforce planning and needs to be taken into account. As one respondent put it:

Hopefully patients will still be at the heart of general practice and will be what GPs find rewarding in their jobs. Often I hear that GPs still love seeing their patients, but it’s all the associated stress of being a GP in the NHS that gets them down. I hope that doctors’ welfare will become more of a priority and that systems will be in place to enable doctors to enjoy their job again eg, having longer with the patient to allow them to feel like they are doing a ‘good job’ rather than a ‘good enough’ job.

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Comments

Helen McArdle

Position
practice manager,
Organisation
general practice
Comment date
29 February 2020

Hello, I work in a GP practice as a practice manager looking after 4686 patients. I have been reading he forward plan which has high expectations, but maybe manageable. But my question to you is..... where is the support for practice managers and elevating our workload. I work approximately 65hrs a week. Im contracted to 37.5 and do the rest of the hours in my own time. Where is our help, who looks after us? inevitably the forward plan talks of care plans, bigger teams, better access ie: virtual waiting rooms. Who will be organising all this work for this to happen? practice managers of course. Who will be discussing and involving the wider team, engaging staff, organising clinics, recruiting staff, HR work, distributing workload. So along with our normal working day which includes, keeping moral at a high, claims, buildings manager, IT manager, overseeing QOF and quality framework, training new staff, updating policies and procedures, carrying out audits, ensuring all mandatory training is up to date, trying to organise staff to attend training, looking after ST3's, completing year end toolkits, holding PPG meetings, organising all the flu clinics, ensuring all the correct read codes are being used throughout the whole team as to not to impact on claims, ordering of stock, locating best prices of stock, being extremely supportive to a new social prescriber recently in post who has had no induction at all with our PCN...oh and as I was doing last week, changing batteries in our fire alarms, cleaning up dog dirt in our waiting room and then trying to explain to a patient that ripping a tile off the bathroom wall is unacceptable.

Im just listing a few things I have to look after.....so I ask again...where I our support, and support to help retain my staff?

Gordon Irons

Position
Member PPG,
Organisation
Queens Park Medical Centre, Stockton-on-Tees
Comment date
03 September 2020

I'm surprised nobody has responded to your submission of 29th February, Helen, even though the intervening period has been engulfed with lockdown's and other various crises - maybe GP trainees are not fully attuned to the pressurised environment within which Practice Managers operate.

I am a member of a PPG attached to a Practice which has a client list of almost 20,000. If your Practice has a similar clientele to ours you will find that many people, even those associated with the health service don't really appreciate the scope of your responsibilities or the influence you can bring to bear.

The burden of Practice Management has been exacerbated by the introduction of Primary Care Networks, something which seems straightforward in concept, but is incredibly complex, with attendant organisational and performance monitoring responsibilities attached as though they were mere boxes to be ticked. One wonders whether Practice Managers are actually the best qualified to be Clinical Directors.

The outcome of this new supervisory layer within General Practice implies adjustments that may end up profoundly changing a mode of health service which seemed a short while ago to be ingrained in society. At the end of an what will surely be a series of policy changes we end up with large-scale "Roundhouse" format General Practices, incorporating extended facilities, those most affected by these changes could actually be GP's themselves.

You will also be aware that apart from the usual reference to appointment delays, most of the PPG meetings are taken up with questions affecting administrative matters - no wonder many GP's shun PPG gatherings unless they have a measure of control of the agenda. Even matters concerning Carers, Diabetes Groups, Social Care and various volunteer supports end up falling under the Practice Manager's remit.

One of our constant problems is how to encourage membership of the younger generation; much of our membership is elderly, who have a limited range of interests and a reluctance to embrace rapidly growing digital technology. In a desperate measure one of our members recently half-seriously suggested using an incentive as enticement to the young; offering annual full blood tests so that the young could monitor their well-being and enable certain health symptoms to be tracked. This she argued could incorporate generic references and aid data collection techniques to be developed.

Last, but not least, if Practices are going to have to compete for clientele, they must develop a level of communication that ranks with modern levels, including enterprising newsletters. Do you have any creative PPG members in your organisation who can take on this task and turn your Practice into a leading health player?

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