Written evidence submitted by the Institute for Employment Studies (IES) (FGP0299)

Context – Burnout in Primary Care

Burnout has frequently been described as a debilitating psychological syndrome. Maslach and Leiter (2016) identify burnout as ‘a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job’; although others also incorporate a physical dimension to their definition (Pines and Aronson, 1988). Burnout is widely held to comprise three components which distinguish it from common mental health problems (Figure 1).

Figure 1              Components of Burnout

Source: Institute for Employment Studies, 2021

It is important to recognise that, although physical and emotional exhaustion are important aspects of burnout, the growing cynicism, loss of idealism and the powerful and pervasive sense of inefficacy are essential dimensions which make burnout such a distinctive syndrome among workers. As Maslach et al (2001) argue:

What started as important, meaningful, and challenging work becomes unpleasant, unfulfilling, and meaningless. Energy turns to exhaustion, involvement into cynicism and efficacy turns into ineffectiveness.

Here the clear implication is that burnout reflects a process of declining resilience to and coping with sustained and unrelenting work-related challenges. It represents a steady erosion of an individual’s capacity to cope with and adapt to pressure, intensity, ambiguity, and disempowerment at work. This process can be especially debilitating if individuals do not recognise the signs of burnout themselves or, having recognised them, have no opportunities to seek support or to ‘decompress’. It can also be felt most acutely among those who have previously been high-achieving and professionally competent in their roles.

Exploring Evidence-Based Solutions

While much of the literature on GP burnout has focused on the causes and consequences, there is a now a growing body of work which has examined the appropriateness and effectiveness of several interventions to prevent and reduce its prevalence and impact. Figure 2 summarises the main themes emerging from this work.

Figure 2              Potential Solutions to the GP Burnout Challenge

Source: The Institute for Employment Studies, 2021

As Wass et al (2016) have illustrated, the challenges faced by GPS in a changing NHS have, for some medical students, negatively affected the ‘brand’ of general practice. The likelihood is that this problem will have been amplified by the experience of the pandemic. Part of the solution here is to ensure that careers in primary care are showcased more effectively in the early stages of medical education. The Wass review highlights some promising examples of local initiatives to achieve this, but it is also important to:

• Counter any anti-general practice bias or stigma which is being promoted however implicitly in medical schools.
• Find ways for experienced GPs to be released from some of their duties (and funded) to play a more active part in medical education and to promote the benefits of general practice.
• Ensure that student placements in general practice are effectively planned structured and executed to ensure that the range, richness, and impact which a career in general practice can have is showcased.

These efforts should not be about ‘sugar coating’ the picture of modern general practice or inauthentically de-emphasising the difficult or demanding aspects of the role. There is plenty of long-standing research which tells us that giving recruits a realistic view of the demands and rewards of a job before they take it up will discourage those who would leave anyway and attract those who are likely to thrive, perform and stay (Wanous, 1980).

A major post-lockdown challenge for most organisations is that of managing a significant increase in demand for flexible working arrangements, especially amongst workers who have been obliged to work in intense working environments where long hours working has become an expectation. Over 50% of GPs, for example, report working outside of their regular working hours (BMA 2016). As we have seen, (Baird 2016) there is a growing desire among some GPs to reduce their hours by working part time. Improvements here may require a great degree of contractual flexibility, for example, to allow some GPs to work fewer hours or to take on a portfolio of duties such as teaching and supervision.

For others it may mean providing them with opportunities and support for more ‘job crafting’ which would allow GPs the chance to flex their hours and duties in line with workload peaks or to even out periods of work intensity with tasks which align more with their professional development aspirations (Kinman and Teoh, 2018). If, as we have seen, a growing proportion of GPs have found matching their psychological resources to the demands of their jobs, then novel approaches to job design may need to be explored together with further experimentation with skill mix in primary care (Bakker and Demerouti, 2007). Here the role boundaries with practice managers, practice nurses and other members of the extended multidisciplinary team (e.g., physiotherapists & occupational health advisors) may help GPs to prioritise and delegate some work more appropriately.

In the case of burnout, the irony of the term ‘physician heal thyself’ in modern general practice has perhaps never been more striking. We have seen that some GPs remain reluctant to admit they are ill or to seek support, and it is unlikely that the current ‘patchwork’ of occupational health provision is doing as much as is needed to rectify this. While there is a variety of support from occupational health specialists available through a mix of providers (with considerable regional differences) many appear to be focused on ‘patching up’ GPs who present with illness or injury and getting them back into the frontline as quickly as possible. Less common is a more comprehensive and preventative approach to occupational health which deploys surveillance, risk assessment and primary prevention tools to identify the work-related drivers of poor physical and mental health. Since burnout is, for many, characterised by a cumulative process during which exhaustion, fatigue, cynicism, and disengagement develop over time, it is likely that this more comprehensive and preventative approach to occupational health provision will be better suited to the cause of reducing GP burnout. This requirement should be baked into all future commissioning of GP focused services.

Finally, more progress towards effective models of supported self-care and peer support needs to be made. There are now more targeted resources available to GPs which can help them to identify and self-manage different aspects of psychological wellbeing and stress (Kinman and Teoh, 2018). Most of these are robust and accessible, but only to those predisposed to accessing them.

The academic literature does not offer very strong evidence to support some of the measures and interventions which have been deployed to support the mental health of GPs. For example, Murray et al (2016) carried out a systematic review which examined over 5000 studies. It found most were either poorly designed, reported results of only moderate and short-term success, and included little or no longer-term follow-up. Some studies show mixed results, especially in relation to burnout. For example, Barcons et al (2019) found that multi-modal training programmes (MTP) which involved 9 weeks of psych-education conducted in group settings covering aspects of clinical psychology and mental health awareness. The study found that several aspects of the psychological wellbeing of GPs improved following the intervention (self-reported mental health, job satisfaction and anti-depressant use) although there was no effect for burnout. In another example (Hamilton-West et al, 2018), a programme of mindfulness-based cognitive therapy was offered to GPs in eight, weekly, two-hour sessions. Both immediately after the programme and at a three-month follow-up assessment, emotional exhaustion scores among participants were significantly lower and personal accomplishment scores were significantly higher than at baseline. Participants also reported that the course helped them to manage work pressures, to feel more relaxed, enjoy their work and experience greater empathy and compassion (for self, colleagues, and patients).

Peer support models may offer more hope of sustained impact on burnout, more specifically. While the use of Schwartz Rounds in healthcare settings has been growing in recent years, they are less common in primary care (Maben et al, 2021). This approach allows healthcare staff a structured environment within which to discuss the emotional and social aspects of their work. Along with interventions such as resilience training, concern is often expressed by GPs and other staff working in primary care that those most likely to benefit from them were the least likely to engage, as stress and heavy workloads mitigated against engagement. Participants in a qualitative study conducted by Cheshire et al (2017) also emphasised that training should not only place the focus on the individual, but also focus on the organisational issues which may hinder coping and wellbeing, an argument supported by other authors (Lemaire and Wallace, 2017).

A related intervention, the Balint Group, is also now being used more to support coping and to alleviate the causes of burnout (Wuan et al, 2021). Originally established as a facilitated small group forum for clinicians to present case studies from their own practice to discuss the clinician–patient relationship, there is a growing number of examples of these peer support sessions being used to address issues of psychological wellbeing (Popa-Velea et al, 2021). Examples of the use of Balint Groups in both Singapore and Romania suggest that the use of simple narrative case studies have high face validity among GPs because, while intended to support mental health and reduce burnout, they also offer the chance to discuss patient-focused problems in a way which encourages reflective practice.

Future Impact of Unchecked Burnout on GP Recruitment and Retention

As we have seen, aside from the personal and professional consequences of burnout for GPs themselves, burnout represents a significant threat to the ability of the NHS meet its goal of increasing and sustaining the supply of fully qualified GPs into the future. While it is not the only key to the resourcing challenges ahead, burnout is one of the factors which is within the control of the NHS and its institutions. As it stands, the impact of GP burnout on the efficiency of the general practice staffing ‘pipeline’ is clear, and this is illustrated in Figure 3.

Figure 3              Impact of GP Burnout on the Workforce Pipeline

Source: The Institute for Employment Studies, 2021

Given the importance of this ‘pipeline’ to both the current provision of high-quality care in primary care settings and to the future supply of talent into the sector, it remains the case that evidence gaps remain in many of these areas, especially in the post-Covid 19 environment. For example, how might recruitment practices be improved? What models of job-redesign, job crafting and flexible working be adapted and embedded into general practice? How can a sustainable GP retention strategy be developed which focuses on the work environment, the reduction of burnout and its causes, and the framing of careers in General Practice which appeal to a new generation of medical students who have lived and trained through a pandemic?

While it may be tempting to focus measures to reduce GP burnout on GPs themselves, the evidence is that there are also important ‘system-level’ challenges which also need to be addressed.  Efforts to support GPs need to be sustained and intensified but, unless issues of work organisation, work intensity and workload can be ameliorated, it is likely that efforts to reduce the impact of burnout will lean more towards treating the symptoms and ignoring the underlying causes. Another danger is that burnout becomes too closely associated with general practice than other medical specialties and toxifies its ‘brand’ with potential recruits. It is clear, of course, that a career in general practice can be a rewarding and fulfilling vocation and that many GPs thrive and deliver heroically. The risk is that the levels of burnout being reported among GPs will ‘crowd out’ the undeniably good news stories which medical students should also be hearing.

IES is currently conducting case study research in GP practices examining the impact of job crafting and flexible working practices on workloads, work intensity and morale/burnout. Results will be available in April 2022.

Dec 2021