Setting up group supervision in general practiceBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g131 (Published 14 January 2014) Cite this as: BMJ 2014;348:g131
General practitioners are experiencing increasing levels of stress as a result of rising work pressure. David Porteous and Simon Atkins describe how and why they introduced group supervision in their practice to help them manage challenging aspects of their roles
Recent reports about stress levels among doctors make sobering reading. In May 2013, a survey of young doctors reported that 44% were experiencing rising stress and deteriorating work-life balance.1 In August 2013, a Department of Health survey reported that stress levels among general practitioners (GPs) were at a 15 year high, with one in 10 doctors saying they were planning to quit in the next five years.2
None of this is surprising, given the increased pressure that general practice is under. GPs’ workload has risen, and they face more complaints,3 as well as the constant threat of unannounced visits from the Care Quality Commission and the relentless cycle of ill informed political interference. With this rising demand and our profession’s poor record of looking after itself,4 it is no wonder that there is such evidence of burnout. With no respite on the horizon, it is understandable why so many colleagues are leaving general practice.
Quitting is not the only option for dealing with the situation, however. Doctors have much to learn from other professions working at the sharp end of human suffering. For counsellors, psychotherapists, and social workers, individual supervision and support are mandatory to enable them to deal with difficult caseloads.5 GPs also hear stories of trauma, loss, and abuse every day in an environment that’s been described by psychoanalyst Mannie Sher as containing “the noxious substances of pain, anxiety and stress.”6 In their gatekeeping role for the NHS, GPs have the added responsibility of carrying high levels of risk. Yet supervision for GPs is not even recommended, let alone mandatory.
Supervision in our practice
The GPs in our practice decided that, to protect ourselves from burnout and to continue to provide a high level of service to our patients, some form of supervision was essential. One possible solution would have been to join an established Balint group with other local doctors to look at some of these issues.7 This is a valuable approach, but we wanted to try to do something ourselves. We wanted to build on the trusting relationships we had already developed within our team and make discussions specifically relevant to our practice.
We already had a head start with this. As a group of partners we have been together for more than 12 years, throughout which we have met daily over coffee to offer mutual support, discuss troubling cases, and, importantly, to share a laugh or two. This forum has been invaluable in our working lives, but it is informal and highly interruptible and doctors are often too busy to join in. Ideally, we wanted to develop a way to build on the success of these shared times by having a regular meeting, but in protected time so all could attend.
After discussion we agreed on a model of group supervision with an experienced non-medical psychotherapist as our supervisor. We decided to have one hour sessions from 8 30 am to 9 30 am every fortnight, alternating between Tuesday and Wednesday mornings so that doctors working on different days could attend at least once a month. Our normal two and a half hour morning surgeries were reduced to two hours, and we paid for a locum session to make up the shortfall in appointments.
The group was to be for partners, salaried GPs, and registrars. We approached several supervisors and were able to find one locally who had worked with similar clinical teams in the past.
Each session costs £65 for the supervisor and £250 for the locum, giving an annual bill of around £6300 for 20 sessions over the course of the year. We considered trying to secure funding for the sessions from local commissioners but decided it would be better for us to continue to fund the sessions ourselves. We wanted to avoid the risk that external funding might come with an external agenda for our meetings and with an expectation of measuring prescribed outcomes.
Our supervision group has now been running since the beginning of 2013 and the sessions have always been fully attended by all available doctors. We have covered everything from difficult patients and problems with other NHS colleagues to complaints and failing practice systems. All the feedback on the sessions has been positive.
We have analysed these issues from multiple angles, allowing our supervisor to help us consider some of the unconscious elements at play, in both our patients and ourselves. By doing so, we have gained new perspectives on how to deal with some tricky and emotionally draining issues.
We have been able to unpick the reasons why particular patients make our hearts sink every time they consult us. By considering individual patients’ perspectives, we have been able to appreciate how our responses might inadequately acknowledge their distress and so unwittingly contribute to frequent and prolonged consultations.
Becoming confident with setting boundaries in our work is also regularly raised during the group’s sessions. These discussions have helped us deal with patients in distress. This can be challenging in the limited time of the usual GP appointment, especially when other, equally deserving, patients are being kept waiting in reception. Increased confidence in setting boundaries can also give structure to the care of people who have never had safe boundaries in their lives and who are unconsciously crying out for them.
Working together with reception staff
Our discussions also revealed a possible reason why reception staff occasionally booked patients in for follow-up appointments with a different doctor. We realised this could be because we had never explained to our reception staff the importance of follow-up appointments when it comes to continuity of care.
Our supervisor also wondered if people’s insistence on having an appointment “now” might be one reason for a patient not being booked with the correct doctor. To improve understanding of these issues, we developed a programme in which non-clinical staff observed GPs’ interactions during appointments, and doctors reciprocated by observing the pressure that receptionists were put under by patients.
As a result of our meetings, we no longer become frustrated, angry, or stressed when things don’t seem to be working out for a patient, colleague, or system. Instead, we ask what might be causing the problem. The answer to this question is usually revealing and gives us an opportunity to try something different to move the problem on.
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare: None.