Intended for healthcare professionals

Views And Reviews Taking Stock

Rammya Mathew: Making general practice a sustainable career again

BMJ 2021; 375 doi: (Published 02 November 2021) Cite this as: BMJ 2021;375:n2626
  1. Rammya Mathew, GP
  1. London
  1. rammya.mathew{at}
    Follow Rammya on Twitter: @RammyaMathew

We’re at a crossroads in general practice. The work is relentless, and the workforce is diminishing year on year. I see colleagues all around me who were previously full of passion but are now drained and disillusioned.

The job itself is rewarding and should feel full of opportunity—yet more than a third of GPs plan to leave the profession within five years.1 Workload is partly to blame, but I also think that the professional structure in general practice needs a serious overhaul.

Partnership has traditionally been viewed as the pinnacle of a career in general practice. It brings autonomy: a sense of control over how you run your practice, see your patients, and work with your colleagues. Many GPs also strongly believe that partnership fosters a unique commitment to one’s population and provides one of the most cost effective models of primary care delivery.

But partnership also entails some unquestionable oddities. Overnight, GPs who mostly have no training beyond clinical medicine become owners of a small to medium sized business. They’re in charge of a budget, accountable for the safe running of a practice, and responsible for employing a range of staff, both clinical and non-clinical. It’s fair to say that few of us are fully prepared for this, given that we’ve spent most of our working years learning the art and science of practising medicine, not running a business or learning about human resources.

We see huge variation in how practices are run. From the maintenance of premises and how professional the website looks to how technology is used and methods of recruiting and retaining staff, I’ve witnessed a wide range of approaches. These usually reflect leadership that’s either sinking or swimming, in an ever changing and pressurised system.

Another difficulty with the partnership model is that it’s no longer financially viable to have an all partner model, which was how most practices traditionally operated. With successive years of underinvestment in general practice, the only way for partners to now make a profit is to have a lean management structure with a few profit sharing partners and many more salaried GPs on a fixed income, who have no financial stake in the practice.

How have we ended up in a situation where partners and salaried GPs are pitted against each other, with the progression of one group not in the best interests of the other? I’m sure that harmonious relationships exist in many places, but you only have to look at GP social media groups to get a sense of the tension that this professional divide creates.

Partners, salaried GPs, and locums all have their own vested interests, which is partly why we’ve failed to campaign successfully for the change needed to make general practice a sustainable and enjoyable career again. Now more than ever we need a single unified voice, but I don’t believe that we’ll achieve this without major reform that brings our profession together.


  • Competing interests: None.

  • Provenance and peer review: Commissioned; not externally peer reviewed.