Coping with General Practice: A mixed methods study

Problem

The expert generalist role is required to help meet the breadth of clinical challenges posed, whilst health policy is changing the shape and direction of primary care. Simultaneously, the NHS is struggling to recruit and retain General Practitioners (GPs) for patient facing work This study focussed upon understanding the perceived pressures that GPs working in the National Health Service in England face, and the strategies which individuals use to cope with and manage these.

Approach

A sequential mixed methods design, underpinned by critical realism allowed in-depth exploration of GPs perceptions of their working life. Qualitative interviews considered doctors’ interpretations of their working lives. Theory generated in the first phase was refined using analysis of data collected in a questionnaire from a broader range of GPs. In the third and final phase, theory gleaned in the initial phases was consolidated in stakeholder interviews. Retroduction was used to identify possible underpinning mechanisms for GP workplace stress.

Findings

The initial phase identified themes relating to GPs perceptions and management of their working lives. Exploration in the questionnaire demonstrated significant distress in the GP workforce (using standard instruments). The nature and degree of this was related to personal characteristics and professional workplace factors. At an individual level, constraints on moral agency and the work of emotional labour engender internal conflict. These constructs were examined, considering links to underpinning models of stress (such as allostatic load). The findings are consistent with Karasek’s (1979) Demand-Control model of job stress.The stakeholder interview phase confirmed the earlier findings. The critical realist approach enabled consideration of the generative mechanisms which offer plausible explanations for the empirical findings. These include wider social structures as well as the specific structures of the NHS and the medical profession. The complex intersection of these impacts upon the agency of the individual GP.

Consequences

This study has corroborated the findings of multiple studies demonstrating deterioration in GP wellbeing. Additionally, it has recognised possible courses of action to improve workforce wellbeing. At a local level, this could include review of practice support structures, review of administrative workload, and reduction in the allostatic burden resulting from multiple interruptions and decision density. At a wider system level is a mismatch in understanding the expectations of the GP role between GPs and other stakeholders. Where there is policy change impacting upon GPs, there needs to be clear and direct communication of this, allowing adequate time for implementation and evaluation of change. There are significant structural inequalities in medicine which must be addressed.