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General practice is changing as doctors shift to flexible working patterns

“It’s definitely draining,” says Krishna Kasaraneni when I ask if general practice has lived up to his hopes. He still loves medicine. But, he adds, “It’s not the general practice I signed up for — not at all.”

Now a partner in a Sheffield practice, and a member of the British Medical Association’s General Practitioners Committee, 41-year-old Kasaraneni trained to become a GP in 2010. Like most trainees at the time, he planned to become a partner, and did so in 2014. He knew that partnership would be hard work but he liked the idea of helping his patients through life’s ups and downs, and knew the role would give him the freedom to shape the practice’s healthcare services around the local population. “That was the deciding factor for me,” he says.

As a trainee, Christine Clayton also took for granted that she would become a partner. “It was what we did back then,” she says. But after 16 years as a partner in a GP surgery in Surrey, Clayton resigned. She now works across various practices as a locum, and still cannot bring herself to open “the massive bag” of thank-you cards that poured in from patients when she left. But there is no way she would go back to working 12-hour days and relying on her husband to do all the parenting. “I gave so much out to the patients, I had nothing left for me or my family,” she says.

Faced with workloads that were already becoming unmanageable long before the Covid-19 pandemic, many GPs are choosing to work part-time, retire early or become locums to avoid burnout. Indeed, many part-time GPs work about 40 hours a week, which is equivalent to a full-time job, says Beccy Baird, a senior fellow at The King’s Fund, a health think-tank.

A shortage of doctors is driving the workload crisis. As people live longer, often with chronic conditions that require careful management, demands on general practice are escalating. Furthermore, GP numbers have not kept pace with demand. “At best the number of GPs is static, despite the fact that we’re training more GPs than ever,” says Baird.

Michael Holmes’ practice, which has surgeries in York and Hull, adopted a multidisciplinary approach and has made a paramedic and physiotherapist partners in the practice © Lorne Campbell/Guzelian

While experienced GPs are retiring early, salaried GPs are delaying becoming partners or not doing so at all, causing smaller practices to fold or merge with larger practices. Between 2018 and 2021 the number of GP partners in England — expressed as full-time equivalent roles — shrank by almost 12 per cent, according to NHS Digital. Every time a GP partner leaves and is not replaced, the work pressures on the practice rise. That is because the partners are the most experienced practitioners and shoulder a disproportionate share of the management workload, such as organising staffing and budgets.

Ben Molyneux has rejected 20 offers of partnership. Instead, the 37-year-old London GP has a portfolio career that allows him to control his hours and workload, while pursuing different types of work. He juggles locum sessions with an NHS clinical commissioning role and stints in an emergency department. Stepping off “the hamster wheel” of back-to-back 10-minute appointments as a salaried GP has helped him to be the “listening and attentive” doctor he wants to be, he says. It has also allowed him to develop an urgent care specialism.

While Lizzie Toberty, a 35-year-old GP in north-east England who is a member of the grassroots campaign group Doctors’ Association UK, believes in the principle of partner-led practices rooted in communities, she still declined to become a partner in her former practice. As a doctor, “you want a say in how healthcare is managed”, she explains, but she worried that when the senior partners retired no one would replace them and she could end up shouldering the entire liability. “As a partner, technically, your house is on the line and that scared me,” she says.

“Among my friends I’d say there’s probably a 50:50 mix of those that go into partnership and those, like me, who go, ‘ooh, this just feels so risky’,” she adds.

Practices are experimenting with new ways of working to help ease stretched resources. The addition of advanced nurse practitioners, paramedics and physiotherapists into teams with GPs — based in large practices or shared between practices — is one approach being tried. This multi-disciplinary team working allows GPs to focus on the sickest patients and expands the workforce, which is particularly helpful for practices in deprived and rural communities that struggle to recruit doctors.

For Michael Holmes, a GP partner at Haxby Group, a large practice with surgeries in York and Hull, “this feels like the future”. His practice embraced this way of working a decade ago and, in April this year, it made two non-GPs — a paramedic and physiotherapist — partners in the practice. “If we’re to be a multi-professional workforce, it makes sense for staff with other skill sets to be represented in the organisation’s leadership,” Holmes says.

But, he adds, his workforce is still struggling to cope with a tsunami of patient demand unleashed by the pandemic. Staff are exhausted. “The whole system is straining,” he says. And GPs are warning that as the backlog of patients waiting for surgery and scans that built in the pandemic rebounds on general practice, what was already a brain drain might become an exodus.

Shortly before Covid hit, the government announced plans to recruit an additional 6,000 GPs by 2024. In 2015 the government had already committed itself to employing 5,000 more GPs by 2020. But, without rapid workload improvements, the worry is that doctors will continue quitting faster than practices can replace them. Put simply, “GPs are working harder than ever, yet patients are still struggling with access”, and both are frustrated and upset, says Baird at The King’s Fund.

Smarter ways of working are necessary if the needs of all patients are to be met, says Iain Kennedy, a GP partner in Scotland and a BMA council member. This does not mean “face-to-face GP appointments on demand”, says Kennedy, which is the focus in England of a row between the BMA and Sajid Javid, the UK health secretary. Done properly, offering a choice of email, phone and video consultations works well for most patients, he argues. And, when combined with telephone triaging, it enables those who need to see their GP face to face to book earlier appointments, he adds. “There should be no going back to business as usual, because GP waiting lists were already too long before the pandemic.” 

For the rare times when he consults a doctor, 29-year-old Euan Strachan-Orr appreciates the convenience of health tech. Yet, as a trainee GP, he prefers “setting eyes” on patients. It helps with diagnosis, and some patients simply do not get on with or cannot use technology, he says. So while “digital consulting is here to stay”, it needs to be part of a “blended approach” that does not marginalise people who lack the tech, he says. That will require funding and practical support because, as Baird puts it, systems design is not the “primary skill” of GPs.

Combining digital healthcare with imaginative approaches to flexible working could ease the GP brain drain, says Ellen Welch, a GP from Cumbria and a member of the Doctors’ Association UK. As mother to a toddler and a 6-month-old baby, born during the pandemic, she spent her pregnancy answering out-of-hours calls from home. Since her baby’s birth she has also been working with a local surgery, logging on to her laptop to respond to non-urgent queries that patients submit to a website and making referrals for face-to-face consultations for patients who need them. She suggests such arrangements could “tap a whole new workforce” and retain the skills of GPs who leave to become parents and carers or move abroad for family reasons.

For Toberty, the uncertainties within general practice have only heightened her dilemma on whether to become a partner. To be “scapegoated” because there are not enough doctors “is incredibly damaging”, she says. “As a GP with 30 years of working ahead of me, it’s started me thinking: ‘Is this what I want to do?’”

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