Enriching Careers in General Practice: Morale in general practice: is change the problem or the solutionBMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6920.32 (Published 01 January 1994) Cite this as: BMJ 1994;308:32
Despite the pervading gloom about morale in general practice it can still offer a rewarding career. This article, which is the first in a series examining ways to improve general practitioners' job satisfaction, weighs the evidence for low morale in the profession and examines the factors that cause most dissatisfaction. The main causes of discontent seem to be increased paperwork and out of hours work, and many blame the 1990 contract for their problems. Dissatisfaction was growing before the contract was introduced, however, and some doctors believe that it has had positive effects. Further change seems inevitable if general practice is to offer a stimulating career for life.
The problem of morale among general practitioners in Britain has been building for many years. Low morale is often attributed to the imposition of the 1990 contract and health service reforms1 2 and the 1980s have been canonised as a golden age. Yet there was evidence in the 1980s of uncertainty and isolation,3 dissatisfaction with the lack of a career structure,4 stress,5 and a perception of being overworked.6 Burn out was defined and adopted,7 and the “heartsink” patient was classified.8 The neglect of doctors' families has long been acknowledged,9,10 and so has the difference in status of general practitioners and hospital consultants.11 Contractual changes, whether perceived as good or bad, may not deserve the emphasis that they have received in recent years.
* This is the first in a series of articles examining ways to increase fulfilment from a career in general practice.
In the past six months I have interviewed 36 general practitioners, three former general practitioners, and six people with other roles in planning or coordinating primary care. I also administered a pilot questionnaire on job satisfaction, sources of satisfaction and dissatisfaction, special roles within and outside the practice, and whether the practice was budget holding to 19 general practitioners attending a postgraduate meeting on extended study leave and 27 attending a conference on rebuilding morale run by the Bedfordshire and Hertfordshire faculty of the Royal College of General Practitioners. This series of articles is based on their views, together with my experience of five years in general practice and a survey of published work. The first article looks at the extent of the problem of morale. Over the next few weeks I will examine personal development, practice development, a formal progressive career structure, a renegotiated contract, and future roles of general practitioners.
Contradictions of morale
A contradiction exists between the enviable job security and prosperity of general practitioners and their lack of incentives and planned opportunities for career progression.12 One commentator in the mid 1980s described general practitioners as “resentful prisoners.” 13 This was at a time when over 40% of medical graduates said that general practice was their career of choice and over 80% of general practitioners were doing the job they wanted to do and enjoyed it.14
General practice attracted the brightest medical students in the 1980s.15 They followed an innovative generation that had developed group practices, built primary health care teams, established vocational training, promoted health, and still enjoyed an independence that hospital consultants had already lost. Much of the optimism was attributed to the family doctor charter of 1966,16 which made these innovations financially viable. Nevertheless there was little improvement in doctors' morale between 1964 and 1977 (box).17,18
Despite the gloom currently expressed by some, other general practitioners are optimistic. Fired up rather than burnt out, they believe that general practitioners have been given enormous power in the health service and they are ready to grasp endless opportunities.
How bad is morale?
Reading the newspapers for general practitioners leaves you with little doubt that morale is low. Recent articles have covered the dissolution of inner city practices because of stress,19 a general practitioner too busy to take part in a survey on workload,20 a crisis in recruitment,21 and the formation of a task group by the General Medical Services Committee to investigate the problem of low morale.22 At least two courses accredited for the postgraduate education allowance this autumn focused on morale and how to improve it. And Shropshire Family Health Services Authority plans to run workshops on stress management for its general practitioners in response to a survey carried out by the Shropshire medical audit advisory group.23
Recruitment patterns also suggest that morale is low. Fewer doctors are applying for vocational training. The average number of applications for each post fell from 8.2 in 1989 to 2.6 in 1992,24 and in Scotland 13% of trainee posts are vacant.25 A survey of general practitioners completing their training in the South West region showed that they are hesitating before joining practices, and qualitative data suggest that patients' demands and expectations, workload, and the 24 hour commitment may be responsible (Rachel Rowsell, personal communication).
In a survey of 640 British medical graduates Isobel Allen found that almost half of the doctors who qualified in 1981 had regretted their decision to become doctors at some time, compared with only a sixth of graduates from 1966.14 Principals in general practice were the most contented group. In 1990 a survey of 1263 general practitioners who had finished vocational training in 1981, 1985, and 1988 found that only 51% were satisfied or very satisfied with their jobs and status26 compared with 84% in 1986.14 One fifth were dissatisfied.26 I asked general practitioners at two recent postgraduate meetings in Hertfordshire about satisfaction. Only 16 out of 46 respondents said that they were satisfied or very satisfied with their jobs, and 15 expressed dissatisfaction. The three commonest reasons for discontent were paperwork, night and weekend work, and interactions with administrators.
In 1987, Cooper et al sent 4000 doctors a questionnaire on job stress, demographic factors, and personality.27 Among the 1817 who responded job demands and patients' expectations, interference with family life, constant interruptions at work and home, and practice administration predicted job dissatisfaction and lack of mental wellbeing. A further random sample surveyed in 1990 (917 out of 1500 replied), shortly after the new contract came into force, scored significantly higher for anxiety, and depression and lower for job satisfaction.1
In early 1992 the General Medical Services Committee balloted all general practitioners in the United Kingdom with a 12 page questionnaire on the current state of general practice and the changes they would like to see in the future. Over 25 000 were returned, with a response rate of over 72% among principals.28 Four fifths of respondents agreed with the statements that “the role of general practice within the NHS is undervalued” and “too much is being asked of general practice at the present time.” The same proportion thought that it should be possible to opt out of 24 hour commitment to their patients. Nearly 40% wanted to opt out of this responsibility, and a further third wanted to but thought it was impossible.
General practitioners: bloody but unbowed
The general practitioners I talked to were still enthusiastic about some aspects of their work but some are battle scarred. Roger Neighbour, a general practitioner, trainer, and author of The Inner Consultation,*RF 27a* said that he felt demoralised for a couple of years after the 1990 contract but has adapted to adversity. He resented working harder for no obvious benefit and felt bruised by the way the contract had been introduced: “It was bodged job. People responded in two main ways: they became vociferous activists and mobilised the energy of the GMSC or they withdrew and let the world go by. But you can't stay down forever.”
General practitioners I talked to in Sheffield expressed frustration at the rising expectations of patients encouraged by the patient's charter.29 As well as coping with the extra problems caused by a reduction in social services provision and rising unemployment the general practitioners face increasingly strident and inappropriate demands from their patients. Nevertheless, they recognise that the contract was a stimulus for greater organisation. Bryan Hopwood, a general practitioner in Burngreave, Sheffield, said: I feel a lot more mercenary. I resent the increased work, the frozen pay, doing good work for nothing. I will retire as soon as I can, and everyone I know is saying the same. We've always been a friendly, relaxed practice, and never had any complaints, but since last year we've had three threatened legal actions and two complaints; verbal abuse, especially of the female partners; and broken windows about every four months. His mood rose as we talked about his partnership and staff relationships: “Trying to work this system if your partnership is in dispute must be a nightmare.”
John Tomlinson, a general practitioner from Alton in Hampshire with 31 years' experience, was dismayed by the new contract. He believes that it divided general practitioners and their patients into haves and have nots, turned efficient family practitioner committees into leviathan family health services authorities, and made money the focus of everything. He has always aimed at “providing the best standard of care possible, with equality of access for all patients.”
In nearby Romsey, Peter White has built up his practice over the past 12 years, been a trainer and undergraduate teacher, and is now a general practice tutor. His morale is improving, having been low for a couple of years. “My career has lacked conscious planning. I have found myself doing jobs that needed training I never received just because I didn't say no. General practitioners bolt on bits to their career, but it might be better if progression was built in and changing practice was not viewed so negatively. It should be possible for a general practitioner to do research without leaving practice, but protected time costs money and good will, and that isn't always available. The money needed for practice innovations causes conflict between partners and people get hurt. We aren't trained to manage change.”
Clive Richards, formerly a general practitioner in Avon, knows of very few general practitioners who are continually enriched by their work but acknowledges that many survive and make the job work for them. His research into the health of doctors predated the new contract,30 and he believes that blaming the government is a red herring. “Doctors feel special,” he said. “They think that they can do without sleep, don't need support, and can survive a career that doesn't change from entry to retirement. They ignore the evidence of dissatisfaction, alcohol and drug misuse, suicide, and marital disharmony among doctors. The profession does not care for its cares: doctors are trained to ridicule weakness - to deny their own and their colleagues' feelings.” He believes that a career in the front line needs to be punctuated with other activities.
How good is morale?
Many people agree that time away from the practice helps to retain sanity, but an accusation levelled at enthusiastic academics and committee people is that they spend little time in their practices and have retreated from the harsh reality of general practice.
Geoffrey Marsh, Stockton general practitioner and unashamed apologist of larger lists, upturns the argument: I go crazy when I hear people express the idea that general practice is something to escape from. Are committees really more fun than than real work. They're sterile compared with consulting and looking after people. Denis Pereira Gray, professor of general practice at Exeter university, shares his optimism but agrees with the impression that general practitioners with outside commitments are happier. “Outside jobs or study give a chance to look from a different perspective, broaden the horizon. Without them a doctor's outlook may be too limited for the complexity of the job.”
* Was there ever a golden age of general practice?
Another optimist is Mike Pringle, professor of general practice in Nottingham and a job sharing partner in Collingham. He believes that general practitioners have done rather well in the past few years compared with hospital consultants and other professions. “Although almost pathological anger was expressed when the contract began, many practices have made positive changes as a result. I feel that general practice is in a renaissance. We have been given the remit of resource distribution through fundholding and have the opportunity to hire staff creatively with minimal supervision. But general practice is dogged with a deep suspicion of elitism, a feeling that no general practitioner should set him or herself up as an example to others.”
Mike Pringle's comparison with other professions is supported by a survey in Staffordshire that compared 704 general practitioners with 588 teachers (response rates 82% and 87% respectively) matched for age and sex and found that teachers reported more anxiety and depression, were more likely to smoke and drink more than 22 units of alcohol a week, and had more sickness absence.31 Neither professional group had changed since 1989. The same cohort of general practitioners was also asked about work patterns in 1989 and 1991. They reported spending more evenings on paperwork, feeling more tired, and doing less work outside the practice in 1991 than in 1989.32
Causes of low morale
Problems with morale did not begin with the 1990 contract, but they do seem to have become worse. Psychiatric morbidity in Britain rose by at least 8% between 1977 and 1985, possibly because of the threat of unemployment and the recession,33 and this may have affected the way patients and doctors behave towards each other. The volume of work, particularly out of hours and paperwork for which there is no obvious good reason, is a problem. Some general practitioners resent the idea of consumerism in medicine and believe it erodes the trust essential in the doctor-patient relationship,34 although there is little sign that patients have changed their behaviour.35 Fear of complaints and physical violence is increasing.36
There is no career structure to provide goals for general practitioners,12 and the goals they make for themselves may be thwarted by lack of time and money.32 Paradoxically, as they look for stimulation, many general practitioners fear further change. Doctors lost control in the negotiations of the health service reforms. Few felt that they owned the contract that was imposed,2 and for some the contract has been assimilated through a process of grieving the loss of the autonomy.
Change and morale
These articles are not primarily about the 1990 contract, although it has been mentioned many times already. It is a convenient focus for the woes of general practitioners, but many of the woes existed before the contract. Denis Pereira Gray thinks that general practitioners tend to undervalue themselves. His perception is that “the better organised practices were less threatened by the contractual changes. It was the badly organised ones that had to divert all their attention to contractual requirements.”
If morale is bad, a change of attitude or circumstances is needed to make it better. We cannot return to a golden age. We, our patients, and the world have changed. The contract's requirement for medical audit implies change, and audit may give general practitioners the opportunity to regain professional pride and political influence. Change should not be feared, not least because more is inevitable.
Survey and follow up: comparing general practitioners in 1964 (n=422) and 1977 (n=365)
Enjoyment-A similar number said that they enjoyed their work
Overwork - More complained of overwork in 1977, although they had more staff and visited fewer patients at home
Consultations - Both surveys estimated that a third of consultations were trivial, inappropriate, or unnecessary. This was more likely if doctors lacked access to hospital beds, did fewer procedures, and used deputising services and less likely if a trainer or member of the Royal College of General Practitioners
Clerical and administrative work - More than a third of doctors were still frustrated by paperwork in 1977
Personal time - Complaints about late calls, lack of leisure, and feeling tied fell by two thirds in 1977