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Campbell JL, Fletcher E, Abel G, et al. Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study. Southampton (UK): NIHR Journals Library; 2019 Apr. (Health Services and Delivery Research, No. 7.14.)

Cover of Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study

Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study.

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Chapter 4Workstream 3: qualitative research

Introduction

An increasing number of GPs are leaving direct patient care, significantly reducing their hours or retiring early, and recruiting new GPs has been difficult.93,94 The results from the ReGROUP (retaining experienced GPs and those taking a career break in direct patient care) GP Workforce Survey suggest that around two in every five GPs currently working in direct patient care intend to leave within 5 years.82 The systematic review of the literature describes factors that are involved in decisions to leave primary care, operating on an individual, practice and national level. The review of UK literature suggests that issues around workload, job dissatisfaction, work-related stress and work–life balance play a major part in decisions related to leaving, taking early retirement and moving to part-time working. In addition, change fatigue, deteriorating or unsupportive practice partner relationships and the cultural norm of early retirement may combine to influence GPs’ quit decisions.

It is widely acknowledged that GPs experience high levels of stress, burnout and emotional exhaustion,95,96 and previous research has found that burnout levels were higher among GPs than among other medical doctors.97 A substantial body of literature focusing on GP well-being, morale and job satisfaction already exists (e.g. Murray et al.98). A number of strategies and policies are in place – or are being introduced – to address some of these issues.99

Sansom et al.18 explored the quitting decisions of GPs who had either retired or reported being likely to leave or retire from the profession in the next 5 years. They found that, although participants faced numerous difficulties and cited negative experiences of working as a GP, those who left did so because they were in a position to or because other options became more attractive. To help retain the current GP workforce, it is important to understand GPs’ views of the options they have to manage and mitigate any negative experiences of working in primary care. This workstream sought to understand the lived experiences of GPs currently working within the profession, those returning after a break from direct patient care and those who had left or taken early retirement.

Aim

The aim of the qualitative workstream was to identify the potential content of policies and strategies aimed at retaining experienced GPs and/or supporting the return of GPs following a career break. To do this, an exploration of the lived experience of GPs was required, including the investigation of remaining/leaving decision-making processes among GPs.

Approach

We incorporated a thematic analysis of CQC practice report data to explore examples of potentially good and poor practice in south-west England in respect of the quality of care delivered, followed by semistructured interviews with GPs and key stakeholders. The CQC strand aimed to inform the content of interview questions and to provide contextual information to inform the RAM expert panel workstream. Interviews were undertaken to explore the lived experiences and perspectives of GPs and the impact of GP quitting decisions on practice management and organisation, and to further inform the content of policies and strategies.

Methods

Care Quality Commission inspection reports

The aim was to use CQC report data to produce a briefing document that could:

  • inform the content of interviews with GPs
  • provide contextual information and case examples to inform workstream 4.

Full details of the methodology are provided in Appendix 14. There were five key stages to working with the CQC report data:

  1. identification of general practices in south-west England that had been rated by the CQC, and their overall rating category
  2. familiarisation with the approach, content and report layout
  3. use of an iterative approach to determine the best method for extracting information and examples from the reports
  4. identification of a maximum variation sample consisting of CQC reports of general practices in south-west England
  5. extraction and summarising of report data.

Identifying the number of general practices in south-west England that had been reported on by the Care Quality Commission

Care Quality Commission report data are publicly accessible (see www.cqc.org.uk/content/how-get-and-re-use-cqc-information-and-data#directory; accessed 30 November 2017).

Sampling took place in January 2016 using the CQC data set that had been completed up to 1 December 2015. There were 442 active location practices in the ReGROUP catchment area, of which 227 (51.4%) had been inspected, rated and had their inspection results made publicly available (Table 11).

TABLE 11

TABLE 11

Practice ratings for practices in the ReGROUP south-west England catchment area

Sampling Care Quality Commission reports for analysis

A maximum variation sample was taken based on practice list size and urban or non-urban locality. The sample included 8 out of 16 (50%) ‘outstanding’ reports and 6 out of 8 (75%) ‘requires improvement’ and ‘inadequate’ reports (see Appendix 14, Tables 38 and 39, for full details). Practices rated ‘good’ were not included as it was agreed by the workstream 3 team that a sufficient number and range of examples could be drawn from those reports at the extremes of good and poor practice. Pragmatic considerations guided the number of sampled reports (Table 12).

TABLE 12

TABLE 12

Care Quality Commission report sampling frame

Determining the best method for extracting information and examples from the Care Quality Commission reports

An iterative approach was used to determine the best method for extracting information and examples from the CQC report secondary data. All approaches were discussed and reflected on by the workstream 3 team until a final decision about the methodology was reached.

The final approach was to categorise themes from the CQC’s own identified examples of good practice along with examples extracted from the sampled reports.100 These themes and examples were used to identify prompts and questions for GP interviews and to provide illustrated examples from practice. Full details of this approach are provided in Appendix 14.

This approach was used for four of the CQC’s five key lines of enquiry (KLOEs), namely whether or not services were ‘effective’, ‘responsive’, ‘caring’ and ‘well-led’. A modified approach was used for the fifth KLOE, ‘safe’, as the data for this question from the ‘outstanding’ rated south-west England reports were mainly merely confirmatory of the CQC’s inspection questioning. In order to explore items within ‘safe’ for examples that could be used in GP interviews, the extraction process was repeated using the sample of reports rated as ‘inadequate’ and as ‘requires improvement’.

Interviews

Eligible general practitioners

General practitioners were identified from responses to the GP Workforce Survey.82 The sample population was drawn from those who indicated a willingness to be interviewed and who met the eligibility criteria for one of five participant categories:

  1. GPs who had retired or taken early retirement (before the age of 60 years)
  2. GPs aged 50–59 years who reported being likely or very likely to take early retirement within 5 years
  3. GPs of any age who were currently on a career break or who reported being very likely to take a career break within 2 years
  4. GPs aged 35–49 years who had left direct patient care or who reported that they were very likely to leave within 2 years
  5. GPs who reported intending to remain in direct patient care for the next 5 years and reported their morale as high or very high.

Eligible stakeholders

Key stakeholder groups were identified by the research team: practice-level roles (practice managers, GPs interested in workforce issues, nurses, pharmacists and other allied health professionals) and area-level roles (representatives of LMCs, CCGs, the CQC and other regional bodies). Convenience sampling (based on local knowledge, information from the internet and snowballing) was used to identify people from different organisations, roles and areas within the south-west England region.

Recruitment

The details of eligible GPs in each of the participant categories were entered into a sampling frame (n = 694). A maximum variation approach was employed to identify a purposive subsample of potential participants from practices of varying size (small, medium and large) and deprivation (less deprived/more deprived), GP demographic profiles (age, gender, ethnicity) and GP role (partner, salaried or locum). A second sampling frame of practice-level (n = 10) and area-level (n = 10) potential stakeholder participants was also created.

All potential participants identified in the sampling frames received an invitation letter, the participant information sheet and a consent form (see Appendix 17). GPs were initially contacted by e-mail by the qualitative researchers (AS and RT), with subsequent approaches by e-mail or telephone. Stakeholders were contacted by the study lead (JLC) by e-mail (when publicly available) or post (details from the practice/organisation’s website). All approaches were followed up by the qualitative researchers. Potential participants were invited to respond (by e-mail or telephone) with their willingness and availability for interview. A maximum of three attempts were made to contact and schedule an interview with each potential participant before moving on to the next one on the list.

There was a pause halfway through recruitment to review the sample and to determine whether or not any adjustments were needed; these discussions were held by the workstream 3 researchers with the systematic review team, PPI members and the GP representative. There were three outcomes of these discussions: (1) the number of participants in each GP category was adjusted, (2) the fifth GP category of ‘staying GPs’ was introduced to capture a broader range of experiences and (3) additional stakeholders were identified using opportunistic and snowballing methods. Recruitment stopped when the workstream 3 team agreed that code and meaning saturation had been reached.101

Interview process

Semistructured interview schedules (see Appendix 17) were developed using themes identified from the literature and the CQC analysis and in discussion with the PPI group and GP representative. Interviews were conducted by telephone, face to face or via Skype™ (Microsoft Corporation, Redmond, WA, USA) depending on the participant’s preference. Participants provided verbal and written consent and were offered a gift voucher in acknowledgement of their time. Each interview was transcribed verbatim and anonymised. Interviews were conducted by Anna Sansom and Rohini Terry from May to November 2016.

Qualitative analysis

Transcripts from GP and stakeholder interviews were analysed together. The transcribed interviews were entered into data management software QSR NVivo version 11 and analysed using thematic analysis. An initial coding frame was independently constructed by Anna Sansom and Rohini Terry, based on the first five interviews. Following discussions, a consensus about the coding frame was reached and it was refined to reflect this. The new coding frame was then independently tested by Anna Sansom and Rohini Terry with two further interview transcripts, and final modifications were made. All transcripts were coded using this agreed coding frame. Detailed project notes were kept regarding the further refinement of any existing, or the addition of new, codes.

Key themes were identified from the codes, and cases and themes compared within and between one another using constant comparison techniques.102 Discussions about the emerging themes were held with the PPI group and GP representative. Descriptive accounts were prepared to identify key dimensions and to map the range and diversity of each phenomenon, followed by explanatory accounts to inform the findings and recommendations.

A protocol for assessing, reporting and monitoring risk was developed by the qualitative team to provide an agreed and documented route for the research team to discuss and report any issues that may potentially have an impact on the GP participant’s own health and safety, and/or that of their patients (see Appendix 18).

Results

Key findings from Care Quality Commission inspection reports

See Appendix 14 for detailed findings.

Examples of good practice: Care Quality Commission all-England

Twenty-one (45%) of the CQC’s all-England examples of good practice were used to identify categories related to:

  • sharing safety lessons
  • open safety culture
  • supporting patients’ emotional and social well-being
  • health promotion for patients
  • shifting care from secondary to primary care services
  • working with external or other community organisations
  • improving access to general practices for hard-to-reach groups
  • expanding the skill mix and roles within the general practice team
  • providing direct support to GPs (e.g. GP mentoring).

Examples of good practice: south-west

The categories identified from the CQC all-England examples were compared with the examples extracted from the subsample of the south-west ‘outstanding’-rated reports (n = 8). The workstream 3 team agreed that this sample was sufficient: no new factors were emerging and theoretical saturation was determined to have been reached in respect of each of the KLOEs: ‘effective’, ‘responsive’, ‘caring’ and ‘well-led’. The subsample of six ‘inadequate’/’requires improvement’ reports was determined to be sufficient for the additional exploration of the KLOE ‘safe’.

Sixty-five examples from the south-west reports were extracted. These examples provided the following additional thematic categories:

  • structuring and organising practice
  • forward planning
  • sharing with other practices
  • role of other practice staff in patient care
  • training opportunities
  • morale
  • use of technology.

Twenty-three of the extracted south-west examples were identified for use as prompts or suggestions for discussion within the GP interviews. In addition to their use as examples within the GP interviews, the categorised examples also suggested additional potential interview question areas for GPs concerning potential policy/strategy directions, namely:

  • additional members of staff for the practice
  • additional services or resources offered by the practice
  • working with other organisations
  • providing support for GPs
  • restructuring or reorganising practice
  • developing or better utilising GPs with specialisms.

Findings were shared and discussions were held with the research team members undertaking the RAM workstream to contribute to development of their statements and subgroups.

Recruitment and interviews

General practitioners

The GP Workforce Survey resulted in 2248 returned surveys (out of a possible 3370; 67% response rate). Of these, 1410 individuals (63%) had indicated their agreement to be contacted for interview. Nearly half (49%, n = 694) met the criteria for interview. Table 13 shows the number of GPs eligible for interview in each respondent category, the target number of interviews for each group and the final number interviewed.

TABLE 13

TABLE 13

Number of interviewees in each interview category

Forty-one GP interviews took place: eight face to face, 31 by telephone and two by Skype. Interviews lasted 15–71 minutes (mean = 38 minutes). Interviewees were distributed across the south-west and comprised partner, salaried and locum GPs. Tables 43 and 44 in Appendix 19 illustrate participants’ demographic and practice characteristics (when known). Scheduling difficulties resulted in three GPs who had agreed to interview not being interviewed.

Stakeholders

Invitations were sent to 41 stakeholders and 19 agreed to be interviewed. Table 14 shows the stakeholders’ roles and the organisations they represented. Participants were distributed across the south-west.

TABLE 14

TABLE 14

Stakeholder roles and organisations

Four stakeholder interviews were conducted face to face and 15 were conducted by telephone. Interviews lasted 17–73 minutes (mean = 43 minutes). Eleven of the stakeholders were, or had been, GPs in addition to any other role.

Key findings from interviews

To contextualise the findings, interview questions included an exploration and reiteration of the problems faced by GPs. It was clear that these were not ‘standalone’ issues but complex interactions of GP experiences. The problems/issues were divided into five main topics:

  1. workload
  2. GP health and well-being
  3. support and relationships
  4. finances, investment and fiscal reward
  5. change, uncertainty and the future.

Three underlying themes were identified concerning the GPs’ experiences and perceptions of their working lives and environment:

  1. identity and value
  2. fear and risk
  3. choice and volition.

General practitioners described a range of ‘push’ and ‘pull’ factors and how these influenced their own staying/quitting intentions and behaviours. Comments were also provided by stakeholders regarding GP experiences.

The following sections provide further details of the topics and themes related to the issues or problems identified by the participants and quitting decisions. These are followed by participants’ suggested ‘solutions’ to these issues, and the inherent tensions and contradictions that they identified within these.

Context and reiteration of issues faced by general practitioners working in direct patient care

Appendix 20 summarises the issues faced by GPs and concurs largely with what is already known from the literature (see Doran et al.51 and Sansom et al.;18 see also Chapter 2, Synthesis of qualitative studies). As this is broadly a reiteration of what is already known, and for brevity within this report, the findings are tabulated and summarised in Appendix 20.

Underlying themes that affect decisions to remain in or leave direct patient care

The analysis also identified three underlying themes that gave more in-depth understanding of the lived experiences of the GPs and helped to contextualise decision-making about remaining in or leaving direct patient care. The underlying themes were:

  1. identity and value
  2. fear and risk
  3. choice and volition.

Figure 7 illustrates the multidirectional relationships between the problems and solutions, the underlying themes, and also the influence of tensions and contradictions (see Tensions and contradictions). The underlying themes are presented in detail with illustrative quotations (with supplementary quotations in Appendix 21).

FIGURE 7. Illustrative model of the complexity and multilayered relationships between problems, solutions, GP perspectives and experiences.

FIGURE 7

Illustrative model of the complexity and multilayered relationships between problems, solutions, GP perspectives and experiences.

Identity and value

Participants described three key subthemes related to identity and value:

  1. the identity of general practice as a profession lacks clarity and boundaries
  2. GP identity, professionalism and morale
  3. being listened to and being valued.

Participants discussed how changes within general practice had led to a lack of clarity of professional boundaries and realistic expectations of what general practice could (and should) deliver. They identified unrealistic expectations from patients, government and secondary care, and voiced their own uncertainty about the future of general practice, along with personal experience of changing roles and organisational structures and systems.

Tensions were noted between the interface of primary and secondary care, and it was felt that general practice tended to ‘pick up’ and manage aspects of care that should be delivered by other services. A common experience was that ‘the buck stops’ with general practice:

GPs being the out-of-hospital doctors have had to pick up everything. We have an artificial divide in hospital that if you are within the walls of the hospital you come under a specialist; if you’re outside it you come under primary care . . . And eventually the buck stops with the GP.

SH1006 – GP stakeholder

General practitioner identity, professionalism and morale

Many GPs felt that their professional identity and ability to practise in their preferred ways were being compromised. This was considered to be partly due to unrealistic demands, concerns about complaints, targets and guidelines, the complexity of cases and lack of time to address them, a lack of continuity and loss of autonomy.

General practitioners felt compromised when trying to deliver high-quality care within the constraints and burdens they experienced. Compromising could lead to cutting corners and/or a negative impact on the GPs’ own well-being:

GPs tend to go down one of two routes: they either – to cope with demand – start to cut corners . . . Or . . . you overburden yourself and you won’t cut corners . . . and that has its consequences at the end of the day.

GP322 – male, aged 40–49 years, locum GP, intending career break

‘Sacrifices’ were made in order to practise the kind of medicine they valued and to be a ‘good GP’:

. . . my practice is a high-earning practice, it’s a very efficient practice, but actually we spend a lot of money on our staff, so I don’t take home lots of money . . . we believe in providing personal care for our patients and that’s the sacrifice we decided to make to make sure we continue to do that.

SH1045 – CCG stakeholder

Morale and job satisfaction were influenced by enjoyment; however, general practice had become less enjoyable over recent years:

I stopped enjoying the job. I think that’s when I realised it was time to have a break.

GP412 – female, aged 30–39 years, GP partner, early leaver

The enjoyable aspects of the job included GP–patient interactions. However, it could be increasingly difficult to maintain continuity and doctor–patient relationships owing to part-time working and patient attitudes. Seeing only the complex patients [not the ‘people with things you can make better quickly’ (GP324 – female, aged 30–39 years, locum GP, intending career break)] made the role less enjoyable. Enjoyment also came from ‘being part of trying to figure out how the practice can deliver the best-quality care’ (GP509 – male, aged 40–49 years, GP partner, staying). Being part of a team and having supportive relationships with colleagues added to this.

Being listened to and being valued

General practitioners expressed their frustration over feelings of not being listened to or valued. They felt strongly that the government had failed to listen to them, to general practice as a profession, and to the BMA, about the impending workforce crisis. This was mirrored in matters relating to organisational change and demands on the service. When GPs did voice concerns or complain, the outcomes were generally unsatisfactory:

I don’t think politicians and managers necessarily manage professionals who complain, very well.

SH1006 – GP stakeholder

Participants highlighted the importance of feeling valued for one’s work, and the perceived lack of valuing of GPs by the general public, the NHS, the media and the government:

I think most people, if you ask them why they do jobs, it’s a complex mixture and a lot of it comes about being valued and appreciated. I mean, people always focus on incomes and things but, the more detailed the analysis is, it always comes back to things like being appreciated, feeling valued.

GP202 – male, aged ≥ 60 years, GP partner, intending retirement

Fear and risk

Participants described feelings of fear and anxiety that focused on different aspects of risk that had to be managed within the GP role. There was a general perception that risks had increased in recent years, practice had changed to accommodate those risks and the risks were ‘not proportional to the rewards’ (GP311 – male, aged 30–39 years, GP partner, intending career break). There were six subthemes:

  1. risk to patient care and safety
  2. fear of complaints and being sued
  3. risk to professional status and identity
  4. risk to own health and well-being
  5. uncertainty about the future of general practice
  6. financial risk.
Risk to patient care and safety

Participants described concerns about the safety of practice and the quality of care being delivered to patients. This arose from having to manage imposed ‘unmanageable’ workloads, and focused primarily on the large number of decisions that had to be made, the complexity of cases and the impact of accumulative decision-making throughout the day:

. . . you have to balance priorities and triage things and I think . . . the busier you get the more dangerous your decision-making becomes on that front, and the riskier it can get.

GP510 – female, aged 40-49 years, GP partner, staying

Fear of complaints and being sued

There was an acknowledgement that general practice has an inherent level of risk that may be different from other aspects of medicine:

I’m the paid risk-taker for the NHS . . . with specialists, everything will be excluded but it will cost a fortune. If you see a GP, it will be cheap, but occasionally things will go wrong. And that’s the nature of the risk.

SH1045 – CCG stakeholder

Owing to the nature and pace of work, ‘there was potential for error’ (GP101 – female, aged ≥ 60 years, GP partner, retired) and GPs who had not made a mistake were regarded as ‘fortunate’ or ‘lucky’ (SH1001 – GP stakeholder; SH1040 – CCG stakeholder).

Risk was exacerbated by the perceived culture of patients being encouraged, and having easy routes, to complain, contrasted with a lack of support and little recourse for GPs:

. . . there’s no recourse . . . patients can complain about you and you’re the one that gets penalised repeatedly.

GP322 – male, aged 40–49 years, locum GP, intending career break

The fear of making mistakes led to some GPs practising more defensively (e.g. spending more time writing notes, and choosing face-to-face rather than telephone consultations), thus adding further to their workload. This was directly linked to fear of litigation. One stakeholder termed this ‘legal-based medicine’:

We don’t really practise evidence-based medicine; we practise a sort of legal-based medicine.

SH1001 – GP stakeholder

Defensive practice was also seen as a response to patient expectations, with one GP describing the feeling of ‘I’d better give this person what they want or they will complain!’ (GP417 – male, aged 40–49 years, salaried GP, intended early leaver).

When complaints had been made, or GPs had been sued, the process had been drawn out and stressful for GPs. As well as fear about the outcome of any complaint, it was noted that complaints ‘wound the doctor severely . . . When you’re kicked in the teeth like that, either by the government or the patient, it really hurts’ (SH1006 – GP stakeholder).

Risk to professional status and identity

There was general agreement that ‘to survive in today’s NHS you have to be comfortable taking risks and cutting corners’ (SH1040 – CCG stakeholder). However, GPs reported tension between ‘cutting corners’ and being thorough and conscientious in their practice:

. . . that’s a very uncomfortable position for GPs in particular to be, and I think that then can cause them some problems as to quite what to do and there was a lot of feeling a bit trapped, I think.

SH1027 – LMC stakeholder

Risk to own health and well-being

The consequences of experiencing fear and anxiety, and of having to manage risks, were noted as potentially affecting the GP’s own health and well-being. Participants described seeing GP colleagues going off sick as a result of the pressures of work. Some GP participants also had direct experience of work negatively affecting their own health:

I was just working at such a pace and I knew I was making myself ill.

GP201 – female, aged 50–59 years, locum GP, intending retirement

One GP described how the fear of becoming ill compounds the fear of making mistakes:

You can’t make yourself ill. If you make yourself ill, you’re going to make mistakes anyway and no one wants that.

GP311 – male, aged 30–39 years, GP partner, intending career break

Uncertainty about the future of general practice

Some participants had a pessimistic view of the future:

There seems to be a lack of belief that the NHS will survive, let alone GPs [as] part of it.

SH1042 – CQC stakeholder

They described how this directly affected decisions about staying in or returning to direct patient care. One GP described a colleague’s decision to leave:

I prefer to get out of this before it gets worse, which is sort of the sense that it’s only going to get harder.

GP510 – female, aged 40–49 years, GP partner, staying

A GP on a career break described uncertainty about the situation improving as a barrier to returning to practice:

. . . it feels like something in crisis and who wants to jump into that?

GP307 – male, aged 50–59 years, GP partner, on career break

Within this uncertainty was also frustration at a lack of ability to determine the future of general practice, and the lack of a unified model that could be implemented:

There is so much uncertainty and the biggest frustration of being a GP is that you’re beholden to whatever the NHS England decision is, or whatever the Department of Health’s decision is . . .

GP501 – male, aged 40–49 years, GP partner, staying

Financial risk

Participants described how the risk of financial investment in a practice was perceived to be greater than in previous times and how this was both a burden and a barrier to investment. GPs felt that they were exposing themselves to the risk of personal debt if they bought into a practice, and also to increased stress. Whereas, traditionally, GPs may have been willing to make a long-term financial investment, other pressures on personal finances, uncertainty about the viability of long-term commitment and concerns about the future of general practice meant that younger GPs were reluctant to invest:

. . . if I had been willing to take on the whole practice and just tough it out, there’s a chance that in 20 years I would have £800,000 of equity in a building, but there is an equal chance I would burn out, be reported to the GMC, gone crazy . . .

GP311 – male, aged 30–39 years, GP partner, intending career break

Older GPs who had previously invested were also experiencing stress and anxiety owing to concerns about changes to practice mortgages, the threat of having to make staff redundant or practice closure, and responsibilities arising from joint civil liability for a practice.

Choice and volition

The theme choice and volition concerns the feelings that participants had about making their decisions to leave or to remain and the degree of choice they felt they had.

Four subthemes were identified:

  1. accumulation, compounding and combinations of factors
  2. GP resilience
  3. decisions do not happen in isolation
  4. the only route left.
Accumulation, compounding and combination of factors

Many GPs described a range of inter-related factors that had contributed to their decision-making: factors relating to workload, their practice, their personal circumstances and the wider social context (e.g. ‘GP bashing’). GPs described how these factors accumulated and how each had a compounding effect, to create a ‘perfect storm’ situation over time that ultimately could lead to decisions to leave or to reduce their hours. Most GPs described this process as happening over a period of time:

It’s really like an insidious, drip drip drip thing really that’s been happening for 10 plus years, really. There’s more and more and more things coming our way.

GP207 – male, aged 50–59 years, GP locum, intending retirement

For some GPs, there had been a key point at which a range of factors came together in a much shorter space of time and led to a quicker decision-making process:

. . . everything happened at once: the menopause, the awful complaint, my in-laws being ill, the locum work that I wasn’t particularly enjoying . . . and I got to the stage of thinking, ‘I don’t have to do this. I’m not enjoying it. Why am I doing it? Let’s just stop and see if I miss it’.

GP108 – female, aged 50–59 years, GP locum, retired

General practitioner resilience

Participants noted that GPs’ resilience had been eroded over recent years; however, there was strong agreement from a number of GPs that the solution to the current workforce crisis was not simply to make GPs more resilient:

I teach people stress relief, self-care, time-management if you like. But that is the wrong approach from my point of view because, if you look at doctors, these are people who are highly resilient already . . . ultimately if you are teaching burnt out, stressed people about . . . self-care, self-worth, the only consequence would have to be to leave that system . . . the system is so cruel . . . You’ve got to make changes to the system. Just supporting people is the wrong approach.

GP404 – female, aged 40–49 years, GP locum, early leaver

Erosion of resilience was linked to a loss of control:

. . . not feeling in control of where the money’s coming from, not feeling in control of your future because if you’re going to have contracts imposed on you by the government, you’re not in control. So that’s where I feel the loss of resilience is coming from, primarily.

GP505 – female, aged 40–49 years, salaried GP, staying

Those participants who had personal experience of GP burnout, as well as those who had observed the impact of work-related stress on colleagues and peers, all agreed that the system had to be addressed rather than there being a focus solely on increasing GP resilience:

If the purpose of resilience is to enable the same workforce to cope with every increasing demand, that’s not on, we actually have to make the job doable.

SH1006 – GP stakeholder

Decisions do not happen in isolation

Participants identified different routes to decision-making about whether to remain in, take a break from/return to or permanently leave direct patient care. For some, there was a stepped approach that involved reducing hours or taking a career break before deciding to permanently leave. Many of the GPs described this stepped process as coping strategies adopted at different stages in their careers.

Four key coping strategies were identified:

  1. reducing hours/number of sessions worked
  2. change in role (e.g. from partner or salaried GP to locum)
  3. taking a career break
  4. portfolio working.

These strategies generally illustrated attempts by the GPs to make their working lives more sustainable:

I have got friends in their late 40s who’ve just actually had enough . . . They’ve given up on being partners, they might be doing some locum sessions, but actually, they’re back in control . . . I’ve still maintained working half-time in the practice but I have other stuff happening on other days to keep things in perspective . . . I admire anybody who does the job full-time now, because I don’t think I would be able to sustain that myself, personally.

SH1011 – LMC stakeholder

However, there was also awareness that individual decisions often had an impact on colleagues, peers, patients and the profession in general, for example in terms of the decision to retire early from a partner position when the practice was experiencing recruitment difficulties, or the decision to work part-time knowing that others would need to provide cover:

And if individual partners jumped ship, it was incredibly disruptive . . . Certainly, that had a knock-on effect, not just within the doctors who are the partners, but the wider staff, the nurses, the receptionists, everybody. And it was a less good place to come to work.

GP107 – male, aged 50–59 years, GP partner, retired

For some, the decision to leave or stay was interpreted as being for their own best self-interest; however, for others, there was also an altruistic element:

The worry is about being miserable around people who don’t need misery . . . Like I say, sever the gangrenous limb and you save the patient! And it’s funny feeling like that, I’ve never thought of myself as a gangrenous limb, but actually perhaps that’s what happens when you get older in a practice. That is coming to terms with the fact that the best thing you could do is leave so that actually you’re not polluting in any way.

GP212 – male, aged 50–59 years, GP partner, intending retirement

The only route left

The range and combination of push and pull factors were individualised, as were the decisions the GP participants made about their role, number of sessions and when to leave or return to direct patient care. Concern was expressed about GPs reaching a point at which the only route left was to ‘vote with their feet’:

I’ve just become more and more desperate . . . in past years I have just felt terribly angry with the way things are going and now I think, ‘I can’t actually do anything more about it’. And if I could do anything but vote with my feet, but ultimately it’s the only vote which they’re going to listen to. And one does definitely feel guilty about leaving one’s partners trying to . . . keep the boat afloat as it were. But, I can’t . . . there just comes a point, you’ve got one life and one can’t sacrifice oneself totally, so, yeah, I’m gonna go.

GP208 – male, aged 50–59 years, GP partner, intending retirement

Reasons for retiring, leaving or taking a career break

Participants recognised that an accumulation of factors generally led to decisions to leave direct patient care. Different combinations of factors could feature, and there was often a compounding effect. For some, depending on the combination of push and pull factors they experienced, leaving general practice, retiring (often earlier than planned), taking a career break or substantially reducing the number of hours worked was the only solution they saw as being available to them.

Appendix 22 details the variety of stated factors for each GP interview category that contributed to leaving, taking a break from or remaining in direct patient care, and (when known) the intentions of GPs at the time of the interview.

Possible solutions/participant suggestions and experiences about what might help to retain experienced general practitioners

Participants suggested a multilayered and multifactored approach to retaining GPs:

. . . the answer is multilayered. The issues – from a top-down perspective – there are issues around the NHS valuing what we’re doing, giving us enough money to deliver high-quality patient care, at scale. There are issues around the morale and how the media portrays what we’re doing, and how other elements of the profession perceives what we’re doing. And then at a local level, it’s about making sure that we’ve got space for GPs to figure out how to run the system better and more effectively with less money and with all the other pressures that we’ve got to factor in. And it’s also about making sure that the job is enjoyable on the ground. For people to be able to want to stick in the practices. Because, if everybody’s just going to locum, it’s going to fall apart quite quickly. And so, there’s no one thing that’s going to make a big difference. It’s got to be all of those factors, all put together.

GP509 – male, aged 40–49 years, GP partner, staying

Three key topics were discussed:

  1. changes to the way primary health care is financed, organised and delivered
  2. showing that the GP role is valued through support, flexible working, streamlined return-to-work processes and changes to the complaints system
  3. creating a new culture and systems to help GPs meet the demands of their job, including supporting GP well-being, changing the appraisals and revalidation system, improving the primary–secondary care interface, branding and defining general practice and managing patient expectations.

Further details are provided in Appendix 23.

Tensions and contradictions

Participants described inherent tensions and contradictions within the current structure and delivery of general practice. Solutions that could potentially benefit some GPs could simultaneously disadvantage others. Thus, participants noted that there was no one ‘ideal’ solution to address the workforce crisis.

Six topics were identified:

  1. GP roles – individual GP choices versus impact on practice and colleagues
  2. GP health and well-being – the need to maintain good health versus stresses and barriers to this
  3. expanding the practice team – optimum team size, composition and funding versus availability, confidence and trust
  4. practice size and federations – need to be responsive to local population versus optimum business models
  5. access to GP services – managing workload versus availability of resources and impact on GPs and patients
  6. how practices cope – being proactive versus being reactive.

These topics are discussed in Appendix 24.

Discussion

This study identified three underlying themes that may influence GPs’ experiences and decisions about remaining in or leaving direct patient care, namely (1) identity and value, (2) fear and risk and (3) choice and volition. The findings also provided insight into some of the tensions and contradictions that exist within the problems and potential solutions in the GP workforce crisis, suggesting the need for detailed consideration of the pros and cons of any proposed policy or strategy.

Le Floch et al.103 found general profession-related themes and specific GP factors related to GPs’ job satisfaction (a key aspect of retention identified in the systematic review). Also common to other professions, they found that workload, income and the balance between them, and having responsibility and recognition for work were key factors in satisfaction. Specific GP factors included feeling competent; being able to be the kind of GP they wanted to be; the GP’s own good health; opportunities for intellectual stimulation, variety, professional challenges and continuing professional development; and relationships with patients and with other professionals. The current study identified similar factors and, because a number of these could be generalisable to other professions, there is an opportunity to explore how generic workplace theories and models could inform strategies and policies aimed at GPs. There is a paucity of applied theories in the GP workforce literature. Drawing on the wider literature (including from occupational psychology and occupational health) has the potential to add to current understanding of GP workforce issues. Such theories include those related to organisational justice/fairness, psychosocial safety climate (PSC)/psychological health and safety, burnout and positive mental well-being. These may help to better understand the impact of the different factors and underlying themes (and therefore how to mitigate them). For example, theories of organisational justice could help to inform the theme identity and value, psychological safety climate could inform fear and risk and positive mental well-being could inform choice and volition. The following discussion provides further details and illustrates why a climate that is perceived as fair and safe and that promotes GP well-being could help to retain GPs, and how the study findings suggest that this climate is currently lacking for many GPs.

Many of the GPs described their role as a ‘vocation’, emphasising that ‘it’s not about the money’. However, the large majority of those interviewed felt let down by what they perceived as a lack of fairness within the primary care system. Organisational justice theory posits that judgements of fairness stem from the perception of input or contribution to a role or job (e.g. knowledge and effort) in relation to outcomes (e.g. pay or recognition).104 Heponiemi et al.105 found a decrease in job satisfaction and job involvement when GPs perceived some degree of unfairness. Participants in the current study repeatedly described a perception of unfairness and feeling undervalued, sometimes using colloquialisms such as ‘GP bashing’. Miller106 suggests that individuals experience injustice when they perceive that they are treated in a way that they do not deserve, or that they are not treated as they deserve to be. In the current study, unfairness and undervaluing were described by participants as stemming from within individual practices (e.g. descriptions of bullying or allocation of responsibility), or from perceived constant demands being placed on GPs (e.g. by government guidelines, and unrealistic expectations held by the government, patients and the media).

A study of Finnish physicians found that problems with their health could push older physicians towards retirement.31 Organisational injustice and low job control added to retirement intentions. Therefore, it seems reasonable to suggest that supporting GP health, and promoting control opportunities and organisational justice, could reduce early retirement and potentially assist GPs to remain in direct patient care.

Sutinen et al.107 explored organisational fairness among hospital physicians. They found an association (for male doctors) between low organisational fairness and the risk of psychological distress (mediated by decreased job control and increased workload). Dollard and Bakker108 offer a theoretical model of PSC that relates to policies, practices and procedures to protect workers’ psychological health and safety. PSC affects a range of psychosocial factors, including work pressure and job control. They conclude that PSC is a logical focus for workplace stress intervention, through its relationships with psychological health and job demands. GPs in the current study suggested that the current climate of general practice was one of high risk, and they identified elements that could cause them fear and anxiety. Thus, creating a ‘fairer’ and ‘safer’ work environment for GPs could be key to helping decrease the fear and risk they currently experience, and the negative outcomes associated with this.

There also needs to be a focus on GPs’ well-being. Orton et al.109 found that 46% of UK GPs reported high levels of emotional exhaustion, 42% reported depersonalisation and only 34% reported personal accomplishment [the three components of burnout as measured by the validated Maslach Burnout Inventory (MBI)110]. The MBI defines burnout as an imbalance between the demands and the resources available to the individual. GPs in the current study talked about different coping strategies they had adopted (e.g. part-time working) to try and balance their personal resources (e.g. time, stamina) with the demands of their role (e.g. high workload, complex cases, long working days). Torppa et al.96 found that emotional exhaustion (a signal of the development of burnout) was common among Finnish GPs. It was associated with older age, high workload, fear of medical errors and feelings of isolation at work (all factors described by GPs in this current study). Torppa et al.96 concluded that GPs should receive more support throughout their careers, including clinical supervision and peer support.

Murray et al.98 discuss rising levels of job-related stress and falling job satisfaction for GPs and the need to protect GPs’ mental health and to promote positive mental well-being. However, their systematic review found only four studies detailing successful interventions for GPs’ self-reported mental health, revealing a research and knowledge gap about interventions to support GP positive mental health and well-being. GPs in the current study felt strongly that the ‘answer’ was not simply to make GPs more resilient (changes were required at a systems level). However, supporting GPs’ positive mental well-being could also be important.

The findings from this qualitative study suggest that addressing GPs’ well-being, psychological health and safety, and organisational fairness (including job control) could all be important elements of policies and strategies to help retain the experienced GP workforce. Appendix 25 offers recommendations for the content of policies and strategies based on the findings of this qualitative workstream.

Strengths and limitations

Strengths

A key strength of this study was the number of in-depth interviews conducted with a range of GPs and with stakeholders. These provided rich data and the opportunity to explore similar and divergent opinions and experiences. Sampling GPs from the survey returns gave a large pool to draw from and also provided the opportunity to ensure a maximum variation sample. Given the expressed time pressures and constraints of many of the respondents, it is gratifying that so many GPs were willing to engage beyond the brief survey stage of this programme of research. It is also notable that the GPs who were interviewed were all forthcoming with their views and experiences and were willing to answer the questions from a personal perspective and to consider the wider context of the experiences of their colleagues and peers. The identification of stakeholders enabled us to approach participants across the south-west of England, who had a range of roles within key organisations. Researchers were able to offer flexibility in the mode and timing of the interviews.

Patient and public involvement and project team discussion enabled modification of the original sample targets to ensure that the views and experiences of ‘staying’ GPs were also captured. The PPI group and the GP representative supported the analysis process and reflective practice.

Finally, the conduct of a previous, preliminary study by one of the qualitative researchers (AS) contributed further to the analysis and understanding of the findings and implications of the current study. Having a team of qualitative researchers (AS, RT and SGD) engaged in this workstream added to the rigour and trustworthiness of the analysis process and the findings presented.

Limitations

The main limitation was that the GPs were self-selecting: they responded to the original survey and agreed to be contacted about possible interview, and they also consented to interview. It is possible that those GPs who were not available for interview may have had different experiences to report. Although self-selection is a limitation of the current study, given the similarities between the findings of this study and those identified within the literature review, it seems likely that the interview sample was not particularly unusual in their views or experiences.

Of the survey returns (workstream 1), 93% of respondents were white and 96% of those eligible for interview were white. GPs from other ethnic groups were approached but none agreed to be interviewed.

It is also of note that all of those GPs interviewed and who were attached to one practice were from practices rated as ‘good’ or ‘outstanding’ by the CQC. Data were not collected to determine whether or not any of the locum or retired GPs were attached to practices rated as ‘inadequate’ or ‘requires improvement’. However, the interview sample reflects the regional CQC reporting data: only 4% of practices in the ReGROUP south-west catchment area (see Table 1, based on 1 December 2015 data) were rated as ‘requires improvement’ or ‘inadequate’, and the majority (89%) were rated as ‘good’ [also confirmed for the data collection period using data from the archived CQC Directory with Ratings, May 2016; see https://drive.google.com/drive/folders/0B1jvn_rdpdEzX3RxZ21kZHdkYTA (accessed 26 April 2017)].

Finally, a proportion of time was initially spent analysing CQC reports. One output of this part of the study was questions and case examples that could be used as prompts during interviews. However, these were not necessary for the majority of the interviews as participants (in general) required little prompting to elicit their responses.

Patient and public involvement group comments

A meeting with five members of the PPI group was held (May 2017) to discuss the findings of the qualitative workstream and to gain their perspectives on the underlying themes.

The group expressed general sympathy towards, and understanding of, the pressures that GPs can experience, and noted the potential negative impact on patients of GPs being under pressure. The PPI members noted that there is an opportunity, and desire, for patients to be more involved in supporting GPs and the organisation and delivery of primary care. There was agreement that more involvement and inclusion of patient participation groups (PPGs) could benefit GPs: positive interactions with patient representatives could help to reduce GP anxiety (e.g. about complaints). However, it was also noted that, for PPGs to be of value to GPs, there was a need for practice staff and patient representatives to be perceived as ‘all being on the same side’, and for GPs and non-clinical staff to trust patients as part of the practice team. The PPI members felt that there was a role for PPGs to be supportive of GPs, namely helping GPs to feel more valued. They identified a ‘positive feedback loop of fear’: when doctors change their working practices, patients change their habits in response, but without clear communication this leads to anxiety, fear and irritation in both groups. The PPI members noted that more involvement and inclusion of patients, along with good communication, could aid the relationship between patients and practice staff and, thus, help to address patient demands and expectations. The PPI members suggested that involving PPGs as part of the practice team could help the identification of models and examples of good practice that could then be shared by PPGs with other practices.

The discussion also highlighted some of the limitations or disadvantages of PPGs: they can be used as platforms for disgruntled patients, they may not be very representative of the local population and they can feel unwanted by the practice staff (clinical and/or non-clinical). Thus, the PPI group identified an opportunity for proactive recruitment of PPG members and promotion of a culture of mutual support and trust.

How workstream 3 adds to ReGROUP

The findings from the qualitative workstream informed the qualitative modelling and verification of findings from the evidence synthesis of qualitative studies, the background contextual information and the development of statements and subgroups used for the RAM workstream. They also helped to inform the content and direction of the stakeholder consultations.

Recommendations directly arising from workstream 3 are provided in Appendix 25.

Conclusion

The breadth of issues influencing GPs’ decisions to leave direct patient care has been extensively reported. This current research found that the same issues are still identified by GPs, at a time of rapid introductions of policy and strategy aimed at ameliorating the workforce crisis. This study indicated that, in order to address the issues, each issue should not be taken in isolation. Rather, the findings from this study showed that (1) factors and issues need to be addressed collectively, (2) there are inherent tensions and contradictions within potential solutions that need to be considered and (3) there is also a need to address GPs’ lived experiences of their work and role in the current health-care climate. The lived experience was illustrated through three underlying themes that emerged from the data: (1) identity and value, (2) fear and risk and (3) choice and volition.

The application of theories and models may help to further an understanding of the implications of GPs’ feelings and experiences (the underlying themes) on GP retention. Use of evidence from occupational and workplace literature adds weight to the argument that solutions should not be ‘sticking plasters’ but rather implementable policies and strategies that will help to (1) increase the perceived value and clarify the identity and future of general practice, (2) reduce the levels of fear and risk that GPs are experiencing (to acceptable and manageable levels) and (3) provide GPs with feasible, acceptable and sustainable routes to remaining in direct patient care.

The findings from this workstream add to the ReGROUP study, providing further insight into ways to help retain the experienced GP workforce and giving a ‘voice’ to GPs at this pivotal time of change and initiative.

Copyright © Queen’s Printer and Controller of HMSO 2019. This work was produced by Campbell et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Bookshelf ID: NBK539937
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