Supplementary written evidence from Dr Emma Hayward (GP and clinical teacher at University of Leicester) (RTR0143)
I chose to share my own experience of burnout with the committee, aware that the danger in this approach is that the evidence can be dismissed as anecdotal. I wish to record here that since giving evidence I have had multiple messages from doctors fully endorsing what I said and thanking me for articulating what they are experiencing. One comment from a GP who took early retirement stated that they left “for exactly the reasons [I] gave”. I have received no messages at all saying that I have misrepresented the profession in any way.
My experience is in no way unique and appears to be representative of the experience of a large number of GPs in the UK, which should be a matter of utmost concern to the committee and the Department of Health.
Luke Evans raised the question of vocation, contrasting sessional GPs with those who are partners. Firstly, we need to agree on definitions. A vocation may include a sense of calling which means someone is willing to make personal sacrifices to serve in a particular area. It should not mean that a person is expected to sacrifice everything, including their own health, however noble the cause. There are moral overtones; people with a vocation being seen as “good” in contrast to those who do not. In some fora the term vocation appears to have been weaponised and used against doctors who have had the courage to stand up against workloads that are damaging their physical and mental health. The implication is that these people are less “good” than those who remain silent. I do wonder whether lionising people who pursue their vocation to the detriment of themselves and their families has contributed to the unrealistic expectations that UK society places on doctors.
All doctors by nature of their training and profession make sacrifices on a daily basis for the good of their patients. I do not believe that a younger generation of doctors has no sense of vocation – indeed they are paying a high price, graduating with debts of >£60,000. When their senior colleagues graduated the workload was different. The hours might have been longer but the workload was less intense, they were valued members of a team and support structures, such as accommodation, were taken care of. During my years as a junior doctor I witnessed the demise of the on-call room, the doctors’ mess, overnight catering and the ward-based team, all of which had enabled doctors to focus on the most important matter: patient care. Without these systemic support structures, doctors must now find their own ways of buffering themselves from the stresses of work. In primary care, the system is unable to protect doctors from excessive workload, hence many choosing to protect themselves by reducing their patient contact hours. Incidentally, when I mentioned that a GP working 3 days per week amounted to a 36 hour working week, this was an underestimate because I did not include the extra hours needed for professional development, training and appraisal needed to continue in the profession.
It is easy to fall into the trap of thinking that because the older generation of doctors “just got on with it” that they demonstrated a greater sense of vocation and can therefore claim
the moral high ground. This is an unhelpful paradigm. More recently qualified GPs are wisely choosing locum work, despite the drawbacks of lack of job security, unpaid leave and death in service benefits, to maintain their own wellbeing in order to be able to continue in their vocation. It is important that any recommendation made by the committee is not detrimental to this section of the workforce; indeed providing additional support for those who feel that this is the most appropriate career option will keep them in the workforce
longer, to everyone’s benefit. It should also be publically acknowledged that current workload in primary care is excessive and the major cause of GP burnout and attrition. This cannot be resolved by individual GPs or practices: it needs a systems based approach.
Suggestions about how this can be achieved have been submitted to the Future of General Practice Inquiry1.
The second aspect of vocation that I have reflected on is my own sense of calling. What am I called to? I conclude that my vocation is not to prop up a broken system, damaging my own health and family in the process. I, and I suspect most GPs, am called to people. I believe that our strong sense of vocation is actually contributing to the moral injury we experience when working in an over-stretched system. We care deeply about the wellbeing of our patients and it hurts when we cannot deliver the quality of care that we want, due to systems failures beyond our control. We also suffer moral injury when we struggle to balance the needs of our patients against our own health and wellbeing2. This is compounded by negative comments in the press and social media. As a nation we need to develop a new appreciation of general practice. A public information campaign that highlights the many successes of primary care and educates people about how to best utilise this valuable resource would be a start. Everyone, especially those with a public voice, has a responsibility to ensure that GPs are not denigrated unjustly and that inaccurate reporting is swiftly and robustly rebutted.
Whilst speaking to the panel about solutions for undergraduate training I mentioned an example of the costs that might be incurred by medical students travelling to placements in the community. It is important to note that every medical school has a different system for organising placements and that there is huge variation in cost and accessibility in different parts of the country. However, travel expenses are important for students at all medical schools and it means difficult trade-offs for medical schools around which sites they can use. In an ideal world, NHSBA would pick up these costs, as they do in year 5 (for English students). This would remove the inequities that currently exist and (in part) the disadvantage faced by the many students who cannot afford their own car.
The key message I wanted to convey to the panel is that improving recruitment into primary care is an uphill battle. From my discussions with my own tutees, I can say that many students arrive at medical school with a negative perception of primary care which they get
from media reports and family/friends. In order to reverse this negative perception we must provide them with high-quality teaching, useful clinical experience and an overall positive experience in primary care during their undergraduate studies. This can be done by:
- Removing unnecessary stressors such as inconvenient/costly accommodation and travel
- Investing in practices to provide enough physical space for students to consult with patients and to study, enabling medical schools greater choice of placements and increasing capacity
- Training and support for GPs involved in undergraduate teaching
In Leicester we have a large cohort of enthusiastic GP tutors but this is not true in every medical school. I believe we have this committed group because over the years we have developed a learning community and invested in their development as teachers which is now paying dividends. However, university finances are tight and we have nothing spare to invest in faculty development.
Nationally GPs are making difficult decisions about where to cut back on activity because of the overwhelming clinical pressures. We must invest in them as teachers or we will end up unable to educate future GPs.
After hearing the evidence I gave to the committee, some doctors commented that the scale of the problem regarding patient complaints, with the subsequent effects on doctor morale, had not been fully appreciated. One doctor wrote “We currently have the ludicrous situation whereby the most difficult complaints to deal with are the ones where nothing has gone wrong, which must be an indictment of the current procedure.” We are told to give an apology, an explanation and a description of changes to be made rather than close a complaint with no basis to it. We are not allowed to suggest that the situation has arisen
from the patient’s inappropriate use of the service. This takes time/resources and causes distress to doctors and staff.
Luke Evans reflected that GPs felt under pressure because complaints could lead to them losing their livelihood, which is true. However, this underestimates the risks we face. There are multiple routes for complaints to be pursued (with some complaints going through multiple channels e.g. the practice, CCG, CQC, GMC and legal routes) and one, that leads to a conviction of gross negligence manslaughter, could cost a doctor their liberty. Whilst this may be rare, the case of Dr Bawa-Gaba looms large. To GPs, judgements made in some cases appear capricious which increases our level of concern2. Of course it is imperative that patients have an avenue to raise concerns about clinical care. However, a brief look at a doctors’ forum thread shows that doctors in primary care face multiple complaints about
- Their personal appearance (age, dress, accent) which in some cases appear to be discriminatory
- Necessary surgery communications (messages informing patients that abuse of staff was inappropriate; notices about practice policy; change of music)
- Provision of appropriate clinical advice and treatment with which the patient disagreed or declined to follow (with subsequent negative outcome blamed on the GP).
These type of complaints are mentioned frequently as the reason doctors emigrate or retire and thus directly impact the workforce. Action is needed to protect all doctors from spurious and vexatious complaints. Systems failures beyond our control that put GPs at increased risk of making mistakes through excessive work and cognitive load, need to be highlighted and publically acknowledged. This will require public education about patients’ responsibility to use the NHS appropriately. Practices, and other organisations which receive complaints, should also be allowed to respond honestly when there is no case to answer, without lengthy investigation.