Abstract
Gone are the days of nine sessional GPs working 35 years until retirement. The number of GPs leaving the profession within the first 5 years of qualification is at an all-time high. GP suicides are all too common and more doctors are choosing to work part time. Burnout, wellbeing and attrition from the profession are all hot topics at the moment, and rightly so. What is the point of trying to fill the deficit of GPs by training more doctors, if we cannot hold onto those we already have?
When GPs are asked why they choose locum posts the common themes are flexibility, increased control of workload, and the perception that such posts are less risky than partnership (Department of Health and Social Care, 2019). However, for practices, locums are expensive with rates continuing to rise in most parts of the United Kingdom (Bower, 2019). Locum GPs do not offer the same continuity of care for patients compared with permanent salaried doctors and partners.
So, is a portfolio GP career a solution to this problem? Such a career encourages commitment, reliability and continuity for practice and patients, but allows the individual flexibility, control, and variety of work and workload.
Portfolio careers are not new or ground-breaking. They allow practicing GPs the opportunity to explore variation and different avenues of work, including teaching, leadership roles, management and journalism. The list really can be endless. I myself work four sessions at the practice where I trained, undertaking two sessions of research and spending two mornings per week teaching students at the local medical school – all under the umbrella of the same employer. Portfolio careers are typically self-constructed, but could GP practices, Primary Care Networks (PCNs) and Clinical Commissioning Groups (CCGs) do more to encourage and promote this career option?
Clinicians working as GPs in their base practices could, with time and encouragement, explore other career opportunities. Normalising the provision of help with structuring a portfolio career could allow more GPs to grow and develop clinical, managerial and teaching skills. It could provide other avenues for learning, which could then be brought back to the surgery to enhance patient care. This would facilitate the development of well-rounded, multi-interest GPs and potential future leaders. It would allow variation in workload and bring different areas of expertise into practices. It could also improve the sense of control of working life and might even improve wellbeing.
Such help could improve continuity of care for patients, often diminished by the ever-growing number of locums. Surely it is better to employ two permanent part-time doctors long-term with varied interests, rather than a succession of full-time locums likely to leave whenever the grass looks greener elsewhere? Incentivising the varied work plan of a portfolio career in addition to commitment to the workforce and the practice team must be a positive thing? Research has shown that continuity of care decreases mortality and use of hospital-based services while also increasing uptake of health promotion, patient satisfaction and adherence to medical advice (Pereira Gray et al., 2018).
GP partners are essentially following portfolio careers. They are expected to lead a team and run a business. These demands, speaking from experience, can put newly qualified GPs off applying for partnerships. Why not formalise these leadership and management roles and the associated training within portfolio careers? Why not encourage development of future leaders of primary care proactively rather than have newly qualified GPs working in more limited salaried roles waiting for the older generation to vacate their partnerships?
Who funds all this I hear you cry? My practice has been able to encourage my career development through offering me a post-certificate of completion of training (Post-CCT) research fellowship role with partial funding from Health Education England (HEE). The return on investment comes from commitment, patient continuity and the ability to evaluate innovation within the practice. At the same time, the cost of this arrangement is comparable to or less expensive than employing locums. The NHS long-term plan has made creating and encouraging these fellowship roles one of the goals for primary care (NHS, 2019). The Kings Fund also recommends that training in leadership and management should be made available to these portfolio GPs and funded by the NHS Leadership Academy and HEE (The King’s Fund, 2016). Portfolio GPs could be based within PCNs and funded by PCNs thus improving the local network (NHS, 2019). The funding for additional roles could also come from elsewhere, such as from universities or the private sector.
As well as these increasingly popular post-CCT fellowships formalising the portfolio route, the option of manufacturing your own portfolio career remains, pulling on strengths and special interests. Many GPs work part-time in a practice and then undertake work in other areas, including sports medicine, the prison service, research, medical education, leadership (such as with the local medical committee or CCG), travel medicine, and journalism. Alternatively, work as a GP with a special interest in other specialities such as emergency medicine, sexual health, dermatology or cardiology is possible. Most HEE and CCG websites have information about local post-CCT fellowship opportunities. If you want to undertake special interest work in this way, a good starting place is your local hospital trust.
Some argue that encouraging portfolio careers, with GPs working four to six sessions within their practices, is not solving the issue of dwindling GP numbers. However, if improved job satisfaction can stop 40% of GPs dropping out of general practice 5 years after CCT (Lind and Wickware, 2018), delay the retirement of experienced GPs and stop the ever-increasing burnout rates, this would surely help primary care? It might even encourage doctors to take up general practice, enticing them away from other specialities. These careers are already starting to gain popularity. In 2017, a nationwide survey showed that 15% of GP trainees chose general practice with the option of a portfolio career (Kaffash, 2017).
However, the portfolio career is not for everyone. It is easy to overcommit and accept every opportunity when starting out, leaving you thinly spread and not performing optimally in each role. This can lead to loss of interest in your primary role. Time management and organisational skills are key elements to a portfolio career. At times, you may have competing priorities, or find work from one role impacting on the time allocated to another. This is both the benefit and curse of a portfolio career. Furthermore, training for the additional roles can be costly and time- consuming. Income can be variable depending on the opportunities available, although the formal post-CCT route negates this issue by offering a regular fixed income.
Regardless of whether a portfolio career is the answer, the current system seems to have significant vulnerabilities (Marchand and Peckham, 2017). Many GPs now feel that a full-time GP role is not sustainable or desirable. So, why not be proactive and look to diversify with your own flexible, varied portfolio career? Hopefully portfolio careers will strengthen long term commitment to primary care.
