Being boundaried: The costs of saying no and the costs of saying yes

Problem

Non-patient facing work makes a substantial contribution to the workload pressures of GPs. This work can be considered ‘hidden’; work that is opaque to patients and often the organisation as well. Existing evidence indicates that UK GPs have responded to workload pressures by reducing their hours or leaving the profession, exacerbating difficulties for patients in accessing GP services. Identifying the nature of behind-the-scenes work and exploring how this could be made more manageable can contribute to GP wellbeing and retention, which may in turn improve patient care and reduce health inequalities. The aims of this study were: 1) to increase understanding of the nature, extent and impact of ‘hidden’ work, and potential for change, and 2) to explore the feasibility of using qualitative methods to conduct such research in GP practices in the current landscape of stretched primary care services.

Approach

Four months of ethnographic research was conducted in two urban GP practices in England, one North and one South. Data comprised fieldnotes documenting over 100 hours of observation, semi-structured interviews with eight GPs and eight other members of practice staff and a workshop towards the end of fieldwork at each site. There are two key stages to the analysis. The first stage is based on interview and workshop data and uses the Listening Guide (Voice Centred Relational Method) to facilitate in-depth understanding of individual perspectives of ‘hidden’ work. The second stage will involve gerund (action) coding of the full data set with the aim of identifying the various ‘practices’ that create and sustain hidden work. Meanings will be explored through the lens of Practice Theory.

Findings

Preliminary findings indicate that GPs experience tensions in managing their work outside of patient consultations. Conflicts were identified between (a) providing safe, continuous, caring, care and wanting to finish at a reasonable hour, (b) wanting to be accessible to clinical queries from colleagues and trainees and getting through non-patient facing tasks without interruption, (c) wanting to meet patient’s need for timely referrals and navigating the vagaries of secondary care, (d) recognising the health impact of patient’s social care needs and questioning acceptance of work beyond their medical remit. GP discretion for how they manage behind-the-scenes tasks carries risks; saying no can threaten their identity as the kind of GP they want to be, whilst saying yes can reduce service capacity for other patients and lead to feelings of burn-out. Inconsistency of response within and amongst GPs has implications for how work within a Practice is distributed, within a context in which overwork is normalised.

Consequences

The findings generate new understanding of tensions associated with non-patient facing work. Naming these tensions can support teams in exploring how Practices may be amenable to changes in working .patterns