Building a career portfolio in general practiceBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7065.2 (Published 02 November 1996) Cite this as: BMJ 1996;313:S2-7065
The new developments in service definition make a portfolio career inevitable, argues Berkshire GP Helen Crawley
Seven years ago my husband read Charles Handy's book, The Age of Unreason, (1) and spoke enviously of my “portfolio lifestyle.” As a pregnant part time general practitioner just completing a research project my portfolio was well balanced (see box 1). Whether they realise it or not, general practitioners are already experienced at juggling career portfolios and developing study portfolios. This trend will continue as the core services a GP must provide are negotiated and defined by the General Medical Services Committee (GMSC). As Carl Gray described on these pages some weeks ago some hospital doctors are already planning their careers in portfolio terms. (2)
Box 1: Handy's five portfolio categories (1+2+3=career portfolio)
Wage or salary work- money paid for time given (what employees earn)
Fee work-payment for results delivered (what professionals charge)
Gift work-work done for free outside the home eg for charities, friends or in the community
Homework-care of the home and family
As self employed independent contractors, principals in general practice receive remuneration through a complex system of fees and allowances. They receive fixed allowances and capitation based payments for treating NHS patients (in a sense equivalent to Handy's salary work) and fees for some NHS and private work (Handy's fee work). In addition they receive an allowance for spending sufficient time on study courses (Handy's study work). I will look at these three areas of professional, income generating work before looking at trends in the other two areas of a well rounded GP's portfolio-home work and gift work.
There are three main areas from which general practitioners derive income: (1) core work provided by every GP, (2) core work provided by every practice but not every doctor, and (3) non-core work, which includes NHS and private work. The GMSC has recently sent an implementation document on core services to all GPs. Interestingly, the way in which core services and non-core services are remunerated falls approximately into Charles Handy's categories of salary work and fee work. Charles Handy noted that “fee work is increasing as jobs move outside the organisation.” As doctors define what is central to their core work as NHS general practitioners, more services will have to be negotiated as fee work.
The GMSC has defined the core services of every GP as “to make an initial decision about the immense range of problems presented by, or on behalf of those who are or believe themselves to be ill, to provide continuing care, and to refer when necessary.” (3) Currently, this includes 24 hour responsibility for patients. The basic allowances and capitation fees which GPs receive can be seen as a basic salary for providing this care and ensuring the smooth running of the practice.
In addition fees are payable for new registration cheeks and health promotion, which the GMSC defines as core services provided by every GP. In practice some of this workload is shared with practice nurses. Fees are payable for core services which every practice is expected to provide, although not necessarily every partner. These item of service fees and target payments are for work done or goals met (see Charles Handy's definition of fee work). They include payment for immunisations, cervical cytology, contraception, child health surveillance, and maternity services excluding intrapartum care. Much of this work is delegated to employees such as practice nurses, although overall responsibility rests with the doctor. Some practices also choose to offer minor surgery, intrapartum care, or vocational training within the current core contract.
By looking at a GP's workload in this way, several trends become apparent both in the development of GP services and the progression of an individual GP's career.
Firstly, the complicated way in which modern GPs juggle their career portfolio goes hand in hand with the fragmentation of primary care. Gone are the days when the singlehanded GP managed the total care of his patients from cradle to grave, with a little help from his receptionist and the district nurse. Even the smallest primary care team will now include practice nurses seeing patients at the surgery, health visitors helping to undertake child health surveillance, and practice staff assisting with preventative care. Many singlehanded principals share out of hours care with other doctors. As core services become defined singlehanded GPs will have to decide which non-core services they have the time and training to provide.
Box 2: Non core services
Examples of services which many general practitioners or their employees currently provide for their patients usually without specific remuneration
post-operative care including home care following day ease procedures, removal of sutures and dealing with dressings
care of minor injuries
prescribing and administering in areas of specialist knowledge e.g. oestrogen and Zoladex implants
shared care with other providers e.g. drug abusers, dialysis patients, monitoring of rheumatology patients protocols which demand general practitioner activity prior to referral
care of highly dependent patients in the community
manipulation of musculoskeletal disorders
treating patients with acupuncture or hypnotherapy providing transport for specimens
commissioning and purchasing including advice to purchasers
Examples of NHS services for which general practitioners may currently receive remuneration
providing education and training e.g. as a general practitioner tutor, course organiser or teacher of medical students
Medical audit advisory group work
attending case conferences
sessional work in hospitals
performing specialist procedures such as endoscopy and vasectomy
Examples of non-NHS work for which remuneration has been negotiated either nationally or locally
membership of boards, panels and committees
part time police surgeon or prison medical officer duties
ife assurance reports and medicals
private certificates, sports medicals, drivers' medicals and medico-legal reports
occupational health work
general practitioner services to private patients
lecturing and writing on medical topics
In a group practice more services may be provided on site but patients are likely to find their care divided between their usual GP, another partner providing more specialist services, doctors from outside providing additional skills, and fellow professionals such as practice nurses, nurse practitioners, and counsellors. Within the practice they may also encounter a general practice registrar and locums who are covering for their own general practitioner while he or she engages in non-core activities. Their desire to see their own general practitioner may thus be thwarted.(4)
Secondly, general practitioners develop their career portfolios by selecting areas of non-core work in which they have a particular interest or skill. New partners tend to perform the core work of general practice-they see a lot of patients and may help with other core services such as practice management and child health surveillance. Sooner or later the new general practitioner will tend to develop non-core interests, perhaps undertaking a clinical session at the local hospital, becoming involved in local politics, course organising or commissioning, developing an interest in occupational health, or starting to provide lengthy courses of psychosexual counselling for patients. Some of this work may be poorly paid or unremunerated-that is, gift work (at least under the current GP contract), and will require understanding from the doctor's partners. Some of this work will be well paid. For the individual general practitioner the level of remuneration may not be the primary concern. Non-core work provides new challenges and interests and helps prevent burn out.
For some general practitioners the pressures on time involved in undertaking non-core work lead to increased stress and decreased career satisfaction. Other GPs are able to employ locums or assistants who provide the protected time necessary to undertake non-core tasks. Thus full time general practitioners with outside interests are often available less than full time. Sometimes GPs find their non-core work so interesting or attractive that they join the increasing numbers of part time principals (see box 3).
Box 3: Contracted commitment of general practitioners in England (5)
Finally, by looking at exactly what a GP should do as part of core services, it can be seen that there are two ways of limiting workload. GPs could be paid fees for undertaking non-core work. Increased provision of non-core services could then be met by decreasing list size or employing assistants. Alternatively, the precise working hours of a GP could be negotiated in a salaried service.
Some demographic trends become apparent. Working part time is becoming increasingly popular (see box 3). For many GPs this is because their paid portfolio has enlarged to include non-core work or even non-medical projects, but the largest group of part timers is found among women between 25 and 45 years of age, presumably because of domestic commitments. As more women enter medical schools and general practice more principals will be needed to provide the same number of whole time equivalents.
General practice is a rewarding, interesting, and satisfying career. It offers the opportunity to provide general care to patients over a continuity of time. In addition it is possible to develop a career portfolio suited to the individual doctor. There are opportunities to specialise in a wide range of clinical and non-clinical areas and to develop or change interests. Should outside activities become time consuming it is relatively easy to work part time. As more GPs realise the flexible potential of their portfolio lifestyle they will spend less time performing core work. The twin nettles of increasing part time partnerships and the decreased practice availability of full time GPs who are undertaking non-core work must be grasped in order to avert a serious workforce crisis.