Re: Burnout is harming GPs’ health and patient care, doctors warn
Dear Editor,
The statistics speak for themselves. General practice is in a crisis of unprecedented scale, made worse by Covid-19.[1] GPs feel that workloads have become unbearable and are overwhelmed by bureaucracy. Consequently GPs are resigning/reducing their hours/retiring early. Surely at the root of GP burnout is ineffectual GP recruitment and retention. The job needs to be made more attractive and less stressful. This will need investment, thought and commitment from government.
There are 28,000 FTE GPs (60 per 10,000 patients in 2020). There were 160.8 million GP appointments (2018-19). In recent years general practice has taken over many tasks previously done in secondary care, for an ageing population, with increasingly complex needs. However primary care receives only 9% of total NHS funding. The RCGP insists this should be at least 11%.
Consider recruitment: medical student places went down and up over the last decade but general practice is not attracting them after graduation (18.7% in 2018 UKFPO figures). In 2019 the RCGP president said we needed 5000 trainees per year. But medical students see the heavy workload on attachments. They have also reported hearing in their hospital training that general practice is not intellectually challenging = 'just a GP'. The UK has traditionally relied on immigrant doctors, both EU and non-EU. Post Brexit there are difficulties with visas/point systems and no figures are available. However the impression is that many EU doctors have gone home. There is a global shortage of doctors - so the UK has to positively attract them. Also, an unprecedented number of our junior doctors apply for jobs abroad. [2]
Why are GPs so unhappy? Could it be because of the demise of 'continuity of care?'. Devolvement of chronic disease management to nurses saw some deskilling of GPs. Housecalls became less frequent. In 2004 the new GP Contract ended 24 hr responsibility (most GPs rejoiced). Access became prized over continuity of care. GPs became like taxi ranks - any patient saw any doctor (and in a large practice might never see the same doctor again). Despite having trained to provide patient-centred care, and despite continuity having better outcomes in all metrics (cost/safety/satisfaction/mortality/morbidity) its provision became virtually impossible. This Department of Health idea had two unintended consequences. First, what Balint called 'collusion of anonymity’, where no-one of the multiple providers takes overall responsibility. Second, dilution of 'doctor as a drug', where sustained interaction has a therapeutic effect. In the pandemic, consulting became remote: email, video or telephone - at one point by government diktat.
This increased the feeling of loss of control - not only in the mode of consulting (even more uncertainty!) but also over their workload. Loss of control is known to be a severe stressor and a potent cause of occupational anxiety. Moreover, short interactions with a large number of patients can be mentally exhausting and lack the connection which brings joy to what we do. It can also begin to feel unsafe. So a typical GP's day (now 10-12 hours) consists of e-consults, telephone triage/consultations, video consultations, face-to face (e.g. for examination), read/assess/action pathology results, hospital letters (not missing 'can the GP repeat these tests in 3 months?’), sign e-prescriptions, answer queries from the MDT, write referrals, attend clinical/admin meetings.
Phew! What chance of achieving any work-life balance?
GP appraisal is another stressor for many doctors. It was introduced in 2002 to promote lifelong learning and CPD, but morphed into revalidation in 2012. Many felt it was summative assessment, losing the pastoral element. Although frozen last year, it is now back, as are CQC inspections.
What can be done? It is obvious that we need a bigger primary care budget and more GPs. The job needs to be made more rewarding and enjoyable. Perhaps widening participation at medical school with more GP placements (we will need more GPs for this). Alongside increasing student numbers, education of secondary care teaching staff about the scope of General Practice might help.
For GPs: mentorship, sabbaticals, flexible working might help. Positive feedback from management / and the DH might help (what a new venture!), for it is clear GPs do not feel valued. It has been suggested that morale might be improved by a simple change of title - perhaps to 'Primary Care Consultant'. Ways need to be found to improve continuity of care which would help patient and doctor. Working in pairs of GPs?
Continual change in the way that we work is uncomfortable and stressful. I would suggest that any imposed changes need to be evidence- based, and piloted first. I say this in the shadow of the new NHS Bill.
Managing uncertainty is perhaps the defining characteristic of general practice. However, sometimes there is just too much uncertainty - and that's where we are now. Going home with a niggling feeling that perhaps among the many documents and clinical encounters, and despite one's best efforts - something might have been missed - is no way to live.
[1] Iacobucci G. Burnout is harming GPs’ health and patient care, doctors warn. BMJ 2021; 374: n1823
[2] Taylor M. Why is there a shortage of doctors in the UK? RCS Bulletin 2020; 102 (3): 78-81.
Rapid Response:
Re: Burnout is harming GPs’ health and patient care, doctors warn
Dear Editor,
The statistics speak for themselves. General practice is in a crisis of unprecedented scale, made worse by Covid-19.[1] GPs feel that workloads have become unbearable and are overwhelmed by bureaucracy. Consequently GPs are resigning/reducing their hours/retiring early. Surely at the root of GP burnout is ineffectual GP recruitment and retention. The job needs to be made more attractive and less stressful. This will need investment, thought and commitment from government.
There are 28,000 FTE GPs (60 per 10,000 patients in 2020). There were 160.8 million GP appointments (2018-19). In recent years general practice has taken over many tasks previously done in secondary care, for an ageing population, with increasingly complex needs. However primary care receives only 9% of total NHS funding. The RCGP insists this should be at least 11%.
Consider recruitment: medical student places went down and up over the last decade but general practice is not attracting them after graduation (18.7% in 2018 UKFPO figures). In 2019 the RCGP president said we needed 5000 trainees per year. But medical students see the heavy workload on attachments. They have also reported hearing in their hospital training that general practice is not intellectually challenging = 'just a GP'. The UK has traditionally relied on immigrant doctors, both EU and non-EU. Post Brexit there are difficulties with visas/point systems and no figures are available. However the impression is that many EU doctors have gone home. There is a global shortage of doctors - so the UK has to positively attract them. Also, an unprecedented number of our junior doctors apply for jobs abroad. [2]
Why are GPs so unhappy? Could it be because of the demise of 'continuity of care?'. Devolvement of chronic disease management to nurses saw some deskilling of GPs. Housecalls became less frequent. In 2004 the new GP Contract ended 24 hr responsibility (most GPs rejoiced). Access became prized over continuity of care. GPs became like taxi ranks - any patient saw any doctor (and in a large practice might never see the same doctor again). Despite having trained to provide patient-centred care, and despite continuity having better outcomes in all metrics (cost/safety/satisfaction/mortality/morbidity) its provision became virtually impossible. This Department of Health idea had two unintended consequences. First, what Balint called 'collusion of anonymity’, where no-one of the multiple providers takes overall responsibility. Second, dilution of 'doctor as a drug', where sustained interaction has a therapeutic effect. In the pandemic, consulting became remote: email, video or telephone - at one point by government diktat.
This increased the feeling of loss of control - not only in the mode of consulting (even more uncertainty!) but also over their workload. Loss of control is known to be a severe stressor and a potent cause of occupational anxiety. Moreover, short interactions with a large number of patients can be mentally exhausting and lack the connection which brings joy to what we do. It can also begin to feel unsafe. So a typical GP's day (now 10-12 hours) consists of e-consults, telephone triage/consultations, video consultations, face-to face (e.g. for examination), read/assess/action pathology results, hospital letters (not missing 'can the GP repeat these tests in 3 months?’), sign e-prescriptions, answer queries from the MDT, write referrals, attend clinical/admin meetings.
Phew! What chance of achieving any work-life balance?
GP appraisal is another stressor for many doctors. It was introduced in 2002 to promote lifelong learning and CPD, but morphed into revalidation in 2012. Many felt it was summative assessment, losing the pastoral element. Although frozen last year, it is now back, as are CQC inspections.
What can be done? It is obvious that we need a bigger primary care budget and more GPs. The job needs to be made more rewarding and enjoyable. Perhaps widening participation at medical school with more GP placements (we will need more GPs for this). Alongside increasing student numbers, education of secondary care teaching staff about the scope of General Practice might help.
For GPs: mentorship, sabbaticals, flexible working might help. Positive feedback from management / and the DH might help (what a new venture!), for it is clear GPs do not feel valued. It has been suggested that morale might be improved by a simple change of title - perhaps to 'Primary Care Consultant'. Ways need to be found to improve continuity of care which would help patient and doctor. Working in pairs of GPs?
Continual change in the way that we work is uncomfortable and stressful. I would suggest that any imposed changes need to be evidence- based, and piloted first. I say this in the shadow of the new NHS Bill.
Managing uncertainty is perhaps the defining characteristic of general practice. However, sometimes there is just too much uncertainty - and that's where we are now. Going home with a niggling feeling that perhaps among the many documents and clinical encounters, and despite one's best efforts - something might have been missed - is no way to live.
[1] Iacobucci G. Burnout is harming GPs’ health and patient care, doctors warn. BMJ 2021; 374: n1823
[2] Taylor M. Why is there a shortage of doctors in the UK? RCS Bulletin 2020; 102 (3): 78-81.
Competing interests: No competing interests