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In this issue of the journal Ding et al1 discuss the strengths and weaknesses of the salaried employment option for GPs. Also in this issue David Jewell2 comments on the lack of partnership opportunities for newly qualified GPs. From Birmingham3 we hear of plans for franchised surgeries. The fear of the approach of ‘Tesco Doc’ grows. A few years ago it looked as if the sessional GPs might take over the world.4
‘Where there is no vision the people perish’ says the psalmist. Another translation has it ‘where there is no vision the people run around aimlessly.’ The map and territory of UK general practice is currently up for grabs (and the College's Road Map is an excellent attempt for the profession to grab this territory5). With the outlook for general practice so uncertain, the question of career options for GPs becomes very difficult to guess and even harder to predict. The very eco-system within which GPs work is under threat.6
So what are the best options for individual GPs trying to make their careers through the confused and contested territory of primary care in 2008? How can they find their vision and not run around aimlessly? I am going to try and give some pointers from my own experiences both as a principal and as a salaried GP.
My friend, Adrian Kenny (GP principal in past, now sessional), describes any job as being a balance between satisfaction, salary and support.
Applying these criteria to the three main options – sessional work, salaried and principal reveals different balances for each role.
Sessional workers earn variable amounts depending on hours worked, and their business and marketing skills. Their satisfaction should be reasonable, but they lose a lot of the long-term knowledge GP principals have. Some doctors may prefer short-term encounters only with patients and find continuity a burden. Their support is variable with some simply being an extra body, and some building up good networks across multiple practices and via the excellent National Association of Sessional GPs.
GP principals in well run practices are earning well (although not quite as well as the more lurid press reports allege). Their satisfaction should be high and their support should be good, (stable team, stable patient base, friendship, and respect).
But as we all know, partnerships are very variable and some are superb associations of GPs who look after each other well and work to common aims … and some are not.
Does the salaried option offer an improvement on either of the above? From my experience, probably not. Firstly, salary is lower. Secondly, the support is very variable, and the personal discretion of the doctor is limited, which becomes frustrating. Satisfaction with the clinical work is good, but the need to accept a given employment context is frustrating. The salaried option has the benefit of ease of movement.
To sum up: there are pros and cons to all the current models of GP work patterns.
My own preference is for the good partnership. Young doctors should accept that they may have to move to find this. Also, partnerships are becoming more business orientated and if you give out the message, ‘I'm just a good clinical doctor’ the partners may happily salary you, but they won't let you anywhere near the business decisions that keep the place running. It's about owning the whole of the work of the practice.
I work best when given responsibility and autonomy. I do not fancy becoming a ‘sessional functionary robotically following guidelines’ which Raymond Tallis7 fears will become the fate of doctors. I do not think I am a good employee and if Tesco buys up my surgery I am likely to move soon after. There is something about ownership of work and systems that is vital to senior professionals performing well. We would surrender this to ignorant (of general practice) outsiders at our peril.
And although patients might get a more accessible service, I think they would get less engagement from their professional helpers. And ultimately life is about relationships, and you cannot have much of a relationship with an unengaged medical technician following a guideline. Good medicine is never ‘merely technical.’