Reaching out to work with people and communities, a forgotten and undervalued role for sustainable general practice?

Problem

Healthy systems are equitable systems. For general practice to be equitable, it needs to be inclusive, and people and communities should be involved in its conception, (re)design, and delivery. Supporting this, recent policy encourages general practices to work with people and communities to reduce inequalities. However, there is little guidance on the role of GPs in this work. We aimed to explore the barriers, enablers, and impact of GPs working with people and communities to address inequalities.

Approach

Participatory action research with eight early career GPs working in areas of socioeconomic deprivation enrolled on a fellowship with funded time for service improvement.The GPs formed a co-operative inquiry (CI) group, with two researchers, to critically reflect on their service improvement work with local people and communities. Data were generated over one year using multiple methods: Seven CI group meetings, individual interviews at start, middle and end (n=20), and reflective written and audio diaries (n=32). Meetings and interviews were audio-recorded. All audio data was transcribed.Iterative data analysis based on rapid qualitative analysis was led by two researchers with support from nine experienced public contributors who listened to audio data, read transcripts, and attended six co-analysis meetings. Thematic summary sheets were completed for each data collection event. Themes were informed by the data and normalisation process theory (NPT) exploring the work of involving people and communities. The thematic analysis and constructive challenges were presented back to the GPs at subsequent CI meetings for refinement. Towards the end, the GPs, public contributors, and researchers participated in two day-long co-analysis workshops. This iterative analysis process resulted in rich understanding grounded in data, repeatedly tested, and constantly compared with new data and NPT.

Findings

These early career salaried GPs had little autonomy over their work and were socialised throughout training and practice to biomedical and transactional consultation work. This context affected their ability to value and prioritise working with people and communities. This was unfamiliar and often uncomfortable work, and needed effort and time to understand it, legitimise it, and develop new, mainly relational, skills. The amount of effort led some to question the role of GPs in this work. However, all recognised benefits to their service improvement projects of working with people and communities. Some GPs also described transformative impacts regarding how they view patients and practice populations, their approach within consultations, renewed purpose of GP work, and recognition of their power and advocacy role.

Consequences

Working with people and communities is unfamiliar and messy, but potentially transformational. To sustain patient-centred equitable general practice, working with people and communities needs to be recognised as a key part of the role of GPs with time and resources allocated to it, especially in areas of deprivation.