Recently, the GP I have been seeing through the “first available doctor” phone system seemed, on the surface, disinterested and emotionally cut off. This was not my usual experience, and I wondered what could have caused such a shift in approach and outward appearance. Patients want to be seen as people, heard, treated with respect, and receive treatment that is tailored to their particular needs – and I was sure that my GP didn’t go into medicine wanting to work in this way.
Until recently, I hadn’t considered that my GP might be experiencing unprecedented pressure. Our research, which has just been published in the British Journal of General Practice, suggests that GPs have hunkered down and gone into a kind of “atomised” isolation.
With the new GP Contract in 2004, General Practice entered an era in which practices thrived. Incomes for GPs were comparable to those of similarly qualified hospital doctors, practices had the funding they needed to provide a good service to their patients, and young GPs were queuing up to take on partnership roles in practices.
But the devil is always in the detail. The contract also ushered in a new era where the autonomy, status and income enjoyed by GPs was chipped away at over the next decade. Jeremy Hunt has stated that this was “penance” for the 2004 contract.
Our study suggests that the cycle of performance management and monitoring of consultations (where GPs have to jump through “hoops” for scarcer and scarcer public sector resources) makes it ever more difficult for GPs to do what most came into medicine to do – care for patients.
One GP said: “It's becoming very Big Brother… especially general practice, about what we have to do in order to earn money and look after people…Obviously guidelines and protocols are really useful and we need those, especially as things become more complex. But that's squeezing out just the relational aspect of general practice, which is a lot of the time what people need and where help and healing really happens…”
In addition, the management of complex health conditions in general practice has increased due to an ageing population, and because conditions once treated in hospitals are now dealt with in primary care to save money. GPs have a growing responsibility to deliver the same quality of care but with effectively fewer resources. There is increased patient demand for appointments and all the while GPs must attempt to safely see one patient every 10 minutes, and somehow follow-up all the paperwork, phone calls and after care that those consultations generate. One GP summed this up as, “Oh dear, is this going to be a two wee day or a one wee day?”
What struck me about the interviews we conducted was how GPs generally go into the job wanting to be good doctors, to make a difference to people. As one of them put it, “We all love our job, we work for the patients, that’s why we do [it]”
Despite this love, GPs are becoming reclusive. More than ever we expect care that is patient centred, but practitioners are becoming distanced from colleagues, patients and loved ones. One GP said they used to be much more sociable, but “[now] I shut my [surgery] door and I can possibly be in there for about 11 hours without much opportunity to talk to anybody.” The headwinds in the NHS actually encourage a particular way of working, and a kind of atomisation happens – an isolation that is the logical outcome of the current system.
Others noted how their work had become a source of conflict at home, with long work hours behind arguments. One commented that: “There was one particular day…[when] I really felt that something had broken for me… I came home and I just went upstairs… I just went into a kind of stupor… with so many people and so many emotions you just haven’t got the time to process anything.”
Of course, it’s not all doom and gloom. Some GPs still thrive, and many are getting better at finding ways to deal with job stresses. For example, one said that mindfulness really helped them get through the day. But many GPs said the current situation is just not sustainable for them, and they are looking to leave, or to reduce the impact that the intensification of GP work has had on their lives. One said: “Amongst my cohort… half of us are thinking of just working part-time.”
The medical profession is committed to providing excellence, with good doctors working on the front line – but the changes in the NHS are making that less possible. For many GPs it comes down to a simple choice: my sanity and/or my partner/marriage (and children) or continuing in an unsustainable profession.
Those of us in work have faced intensification of work life, pressure to do overtime, reduced security, increased competition for scarce resources, and pressures to survive on our own entrepreneurial acumen. GPs should not be immune to what other workers are facing. But as we have discovered, the sorts of changes described by GPs have cut them off from their natural support systems. And as with commercial airline pilots, I would argue that it is vital that GPs get the right balance of work, life and rest – our lives might depend on it. It’s time to rethinking general practice.
Damien Ridge is Professor of Health Studies at the University of Westminster
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