Five year GP training could bring partnership model back to life, says new RCGP chair
BMJ 2022; 379 doi: https://doi.org/10.1136/bmj.o2718 (Published 15 November 2022) Cite this as: BMJ 2022;379:o2718
Kamila Hawthorne’s first encounter with the Royal College of General Practitioners (RCGP) was not a positive one.
“I had done my MRCGP exams and I hated them, actually. I had the old fashioned, oral exam where I felt thoroughly patronised by the examiners. I remember stomping across Hyde Park thinking, ‘I’m never going back there again,’” she says, speaking to The BMJ before officially taking on her new role as RCGP chair on 21 November. “And now look—it’s amazing how things change.”
After receiving an RCGP research training fellowship in 1991, she decided to give the college another chance, and 30 years later she’s now more invested than ever.
“I want the college to be even more welcoming and inclusive than it currently is. We have a real diversity of members and not everybody feels that they belong,” Hawthorne says. “As a South Asian doctor—despite the British name and the British accent—I’ve come across my fair share of inequality and injustice. But I did feel it was better to work from inside rather than from outside.”
That idea led Hawthorne to stand for chair back in 2019, when she was beaten by Martin Marshall—a defeat that led to some self-doubt. She decided, however, to run again in 2022. “Over the three years, I think the whole climate has changed. The Black Lives Matter movement has made a big difference to the way people think about inclusivity and about diversity—not just for race, but other aspects of diversity as well,” she says.
Hawthorne and her family moved to the UK from Dar es Salaam, Tanzania, in 1970. She went on to study medicine at the University of Oxford and work as a GP principal in Nottingham, Manchester, and Cardiff. She now works as a salaried GP in Mountain Ash, south Wales, making her the RCGP’s first working GP in Wales to become chair, as well as the first ever South Asian woman chair.
“I don’t look Welsh and I don’t sound Welsh, but I am Welsh because I’ve been here for 27 years now. That’s the longest I’ve lived in any place in my life,” she says.
Workload and workforce
As Hawthorne takes on her new role, she is continuing work in her practice on Mondays. “Our members need to know that we are aware of what’s happening. We’re not in some ivory tower stuck in the middle of London. We know what’s going on. We feel the heat as well and we are representing them.”
Hawthorne says she sees the impact of unmanageable workload on her colleagues. “Last Monday one of my partners had 69 patients. It’s just not doable. There are big, big worries, not only for the safety of patients and having enough time to deal with them properly, but also the safety and the health of the doctors. It is a real problem.”
“The workload and workforce crisis seems to be getting worse rather than better. One person on their own can’t turn things around, but I can say a lot on behalf of our members and will have the opportunity to say things to people who have got influence and who have the power to decide to change things,” she says.
“Part time” doesn’t do us justice
Some anti-GP rhetoric in the press before and since the start of the covid-19 pandemic has centred around the idea that part time GPs are to blame for access problems.1 This is despite many part time GPs working the equivalent of what many other jobs consider full time hours.
“Things have changed dramatically since I first started as a GP. Our culture of working is very different—the hours are much longer and the intensity of work is completely different to what I remember 30 years ago,” Hawthorne says. “Most GPs are doing about three to five days a week on a regular basis—11 hour days. And many GPs are working more than that. Some of them will be doing their paperwork in the evenings and weekends and some of them will be doing other work.”
Hawthorne says the solution may be to “discard the whole classification of part time and full time GPs. They just don’t really apply anymore.” She suggests GPs should be job planned in the same way hospital doctors are.2
Could the RCGP have done more to counter anti-GP rhetoric during the pandemic? “That’s a difficult question because I think that we didn’t respond as robustly as we could have done,” she says tentatively. “It’s not just the college. GPs put a sign on our door that said, ‘Don’t come in, give us a call instead,’ whereas the pharmacy next door was open. And we could have dealt with that in a different way. The whole point was to prevent the spread of covid-19. We didn’t realise at the time what message it was giving.
“But, you know, hindsight is such an easy thing, isn’t it?”
Hawthorne now wants to engage with the public more, to enable them to understand what GPs do and what their days look like. “When patients come to what looks like a half empty waiting room, they think we’re not seeing that many people. But we are. We’re seeing them virtually as well as face to face and dealing with all the paperwork and the pathology reports and the letters and everything else that has to be done.”
The partnership model is not dead
Another workforce problem that predates the pandemic by some measure is the steady decline in GPs wanting to become GP partners.3 This decline, coupled with recent talk of making most GPs salaried and contracted by NHS trusts or large scale primary care operators,4 has made the future of the partnership model uncertain.
“Quite a lot of young GPs are afraid of taking on a partnership because of the additional responsibility and the worry that they may be left as a ‘last man standing’ in the practice if everybody else leaves,” Hawthorne says. “We’ve got to turn that around.”
She suggests providing an optional two year extension to GP training—from three to five years—could help solve this.
“It seems there are a lot of young doctors coming into general practice who are not quite ready for the responsibilities of working independently and of running a practice. And I’d be very keen on a three plus two model, where we have a clinical fellowship after you’ve done your MRCGP exams,” Hawthorne says. “Then you can start concentrating on being that GP that you’ve always wanted to be and putting what you’ve learnt into practice in a sheltered and protected environment.”
She says a good partnership is “both cost effective and efficient and provides a level of care for patients that’s really unequalled.” It can also give GPs an opportunity to innovate and improve the way they work for themselves and their patients—something they would not normally get in a salaried position, Hawthorne argues.
“A lot of people have gone into general practice because that’s what they were looking for, they were looking for that opportunity, they want to be in control of how they provide services to patients,” she says, adding that while the “salaried option seems to work better” in some parts of the country, she hopes the partnership model survives.
Climate crisis and health inequalities
Alongside workforce and workload, Hawthorne says health inequalities and the climate crisis are her priorities. “I was dismayed by what was coming out of Liz Truss’s government in terms of inequalities,” she says. “It is still early days for this new government and they’re still finding their feet. Time will tell.”
She says the previous “levelling up” under the Conservative government5 saw an “awful lot of talk” without much funding. “Our role as a royal college—our role in general practice—is to keep reminding them of it, in the nicest possible way. If they are saying that their aim is to protect the most vulnerable in society, then we need to keep encouraging them to do that.”
Turning to climate change, Hawthorne says she has seen how enthused GPs have become about making healthcare sustainable. She plans to work closely with the college’s new special interest group on the matter, which is currently being set up.
“It’s everybody’s business. And if we’re not careful, we’re going to head for catastrophe,” Hawthorne says. “It’s interesting seeing what’s going on at COP27 in Egypt and worries that the 1.5°C target may not be reachable anymore. It is scary. We have a lot to do.”
Getting to know Kamila
First job?
I worked in a bakery when I was 15. I lived in south east London and I worked in Slatter’s bakery. Ken Slatter was famous because he appeared on Bruce Forsyth’s Generation Game icing cakes.6 My second job was selling girls’ school uniforms in Harrods. It was more fun than it sounds.
Dream job as a child?
An astronomer. It was the time—in the sixties and seventies—when lots of us youngsters were completely captivated by the moon landing, perhaps going to Mars, thinking about space and what was going on out there. It just blew your mind.
Most embarrassing moment?
I was in medical school and it was paediatric surgery week, but I hadn’t realised it was also 1 April. I was really keen to impress the paediatric surgeon, so when he asked who would like to assist in an operation I jumped up and volunteered. He said, “Okay, well go and have a shower then. This is paediatric surgery. You’ve got to be cleaner than for adult patients.” So off I went to shower. I hadn’t brought a towel so I had to use paper towels and when I finally got back, rather damp, about half an hour later, he said, “April fools!” Of course, the operation was already done and I felt such an idiot. It just shows sometimes you can be too keen.
Favourite part of being a GP?
It’s that doctor-patient relationship. The very first time a patient came back to me—to see me as opposed to seeing anybody else—when I was a trainee, I was so pleased. I nearly got up and gave her a hug. Whenever you go through something important with a patient, a little bit of you becomes a little bit of them and a little bit of them becomes a little bit of you. And wherever you meet them again, there’s that connection. I think it’s so special.