There aren’t enough GPs because they’ve made the job rubbish

This is the elephant in the room for GP recruitment and retention. Over the last 10 years the job of being a GP has been systematically trashed by successive governments and by the press. The warnings that doctors would leave General Practice have been ignored and now the chickens are coming home to roost with access to actually seeing a GP being near impossible in some areas. The question is: What do we do about it? What actually works

What we don’t need are unevidenced retention “initiatives”
The idea that golden hellos and golden handcuffs or more training or more personal support will solve the problem is laughable. When you strip them down, these are all ways to try and manipulate doctors to go into or stay in General Practice when they don’t want to. Simply making all GP jobs salaried won’t fix the problem – there are already enough difficulties recruiting Salaried GPs. Unless you solve the underlying problems with the job, people won’t want to do it.

Seeing patients is not the problem
Before all this started we had a long history of enjoyable fulfilling careers looking after our patients and running our practices. We were busy and worked long hours but there was no shortage of doctors wanting to be GP partners – even when we had to provide out of hours care for our patients too. So if the patients are not the problem, what is?

It is easy to be simplistic
The BMA might say “more money”, “less work”, “better conditions”. While it is true that you need enough money, survivable workload and reasonable conditions, these are not enough to make a great job. We are people, not robots, and we need more than this.

Is it the risks of ownership which are putting people off?
The business risk of being left last (wo)man standing is actually caused by being unable find people who want to join you in doing the job. General Practice is not an inherently risky business since people have to have a GMS contract to compete with an existing practice and they can’t poach patients by undercutting on price because the service is free. Owning your building gets you an asset which is appreciating and a guaranteed market rent. Again, assuming there are people who want to be GPs, it will be easy to sell it on when you retire.

What does the research say makes a fulfilling work life?
At this point we should look to the business world where they have been looking at how to make great careers with a lot more dedication than we have in the NHS. Autonomy, Mastery, Purpose (1). Just Cause, Trusting Teams, Worthy Rivals, Flexibility, Courage (2). Safety, Shared Vulnerability, Team Purpose (3). Growth mindset (4). There is too much to go through all of these in detail so I’ll just start with the first three (although I strongly recommend you look at all of them).

Autonomy
It turns out that having a say in how you do your job makes a huge difference to whether you enjoy it. And it significantly improves your performance. This shouldn’t be a surprise – people have been known to go to war to keep their autonomy. So the NHS needs to stop micromanaging doctors. QOF and the target driven culture should go. There should be no constraints on how we spend the funds coming into practices as long as we are maximising effective care.

Mastery
Having a job which encourages you to grow and become the best you can be is intrinsically rewarding. We have the RCGP to thank for championing the Expert Generalist and laying the foundations of evidence based General Practice. Partnerships can give you a safe environment to practice in where you hold each other to high standards and receive thoughtful feedback to consistently get better. Replacing doctors with paramedics or HCAs or pharmacists or smartphone apps dumbs down the care patients get to the lowest common denominator. And it deprives GPs of the patient contact that was why most of us went into medicine.

Purpose
We all want to spend our lives doing things that are intrinsically meaningful and important to us. Life’s too short to waste it on what doesn’t matter. At its heart, the purpose of General Practice is to help people in our community live longer and have more fun. Continuity and knowing the patients individually increases this sense of purpose and adds meaning because you care about the people personally.

OK so not all GP jobs are rubbish
We can all find examples of practices that are thriving. But they are now the exception, not the rule. Even my happy little practice near Cambridge, with three enthusiastic partners and an enviable work life, has been unable to recruit a fourth to replace me. Of the doctors who finished the Cambridge GP training scheme last year, up to one third are not working in NHS General Practice.

It doesn’t help healthy practices if the rest of the herd are sick. We need to look at how we can help support and develop practices so that GP jobs become enjoyable, fulfilling and sought after.

(1) Drive – Daniel Pink
(2) The Infinite Game – Simon Sinek
(3) The Culture Code – Daniel Coyle
(4) Mindset – Carol Dweck