Coping with General Practice: a mixed methods study

Background:

This study focuses upon understanding the perceived pressures that General Practitioners (GPs) working in the National Health Service (NHS) in England face and the strategies which individuals use to cope with and manage these.

There are increasing demands upon health care provision in the NHS. These relate in part to the increasing healthcare needs of an ageing population and are compounded by the emergence of new treatments and technologies. Additionally, there have been significant contractual, organisational, administrative, and regulatory changes for General Practice to accommodate at a time of financial constraint. These pressures have been recognised in reports by the Kings Fund (Baird et al., 2016) and more recently the Health Foundation (Fisher et al., 2020).

There is a consistent pattern of increasing workload felt at the individual level occurring at the same time as both significant demographic changes in the GP workforce and increasing difficulties with recruitment and retention. GPs describe significant work stress, and research has described some of the individual and workplace attributes that may moderate this.

GP wellbeing is recognised as important internationally. For the individual doctor, workplace stress and burnout contribute to ill health and lack of career engagement. These impact patient care, jeopardising its quality and safety (Hodkinson et al., 2022; Gunja et al., 2022).

Although previous studies have considered those who have left the workforce, this study aims to identify and explore aetiological factors in GP stress amongst those currently in the workplace. Understanding these should assist in designing approaches to address the issues before doctors leave the workforce.

Methods:

A sequential mixed methods design underpinned by critical realism allowed for in-depth exploration of how GPs practicing in England perceive their working life.

Initial qualitative interviews with GPs, considered how individual doctors framed their understanding of their working lives. The theory generated in the first phase was refined using a cross-sectional survey approach to analyse data collected from a broader range of GPs. In the final phase, theory gleaned in the first two phases was consolidated in a series of stakeholder interviews. This used the principle of retroduction to identify possible underpinning mechanisms for GP workplace stress.

Findings:

The initial interview phase identified themes relating to how GPs perceive and manage their working lives. External factors (including health policy, increasing role complexity and wider changes in society), contribute to a perception of uncertainty in the professional role of the GP. There is variation in the individual characteristics of the GP and their working environment which affects how the individual responds to these challenges.

Further exploration in the questionnaire demonstrated significant levels of distress in the GP workforce as determined using standard measures for moral distress, perceived stress, burnout, and morale. The nature and degree of these were related to both personal characteristics and professional workplace factors (including job demands and job control).

The stakeholder interview phase confirmed the findings in the initial phase and identified possible explanatory factors, including hierarchy, power relationships and race.

Discussion:

This study explored GPs' perceptions of their working lives and identified individual and workplace factors associated with distress. At an individual level, constraints on moral agency and the work of emotional labour engender internal conflict. These constructs have been examined, considering links to underpinning models of stress (such as allostatic load). The findings are consistent with Karasek's (1979) Demand-Control model of job stress such that the highest levels of stress are seen in those who perceive their jobs to have high levels of demand with low levels of control.

Adopting a critical realist approach enabled consideration of the generative mechanisms which offer plausible explanations for the empirical findings. These include wider social structures (such as gender and race) as well as the specific social structures of the NHS and the medical profession. The complex intersection of these impacts upon the agency of the individual GP.

Recommendations:

This study has corroborated the findings of multiple studies demonstrating deterioration in GP wellbeing. Additionally, it has recognised possible courses of action to improve workforce wellbeing. At a local level, this could include review of practice support structures, review of administrative workload, and reduction in the allostatic burden resulting from multiple interruptions and decision density. Job planning should recognise the need for balance between work and other commitments.

At a wider system level is a mismatch in understanding the expectations of the GP role between GPs and other stakeholders which must be addressed in future contract discussions. Where there is policy change impacting upon GPs, there needs to be clear and direct communication of this, allowing adequate time for implementation and evaluation of change. There are significant structural inequalities in medicine which must be addressed.