GPs: Why Are We Burning Out?

Article by Dr Jeff Foster

The term ’burnout‘ is not new, but it has been applied increasingly to NHS staff, and in particular to GPs, in an attempt to better define the growing feelings of pressure and stress within the service.

Although it can be defined in many ways, burnout is essentially a state of emotional, physical and mental exhaustion caused by prolonged or excessive stress.

It occurs when we feel overwhelmed or emotionally drained, or when we lose autonomy, and are unable to meet the demands of our job.

With the increasing and persistent pressures on Primary Care over the last few years, through a combination of decreased funding and GP numbers, increased patient demand and poor cohesion as a profession, General Practice has become the latest burnout candidate.

What is Burnout?

The World Health Organization refers to burnout as a syndrome conceptualised as resulting from chronic workplace stress, defined by three symptoms:

• Feelings of energy depletion or exhaustion

• Increased mental distance, or feeling negative towards your job or career

• Reduced professional productivity.

There are many websites and self-diagnosis tools available to help us test whether we might be at risk, and with up to 50% of General Practice consultations involving some kind of mental health element, GPs are only too well aware of the signs and symptoms of stress and anxiety. I don’t want to dwell here on the familiar coping strategies – getting better sleep, eating healthily, taking exercise, scheduling work breaks, and so on.

Rather, I want to argue for a more pragmatic and focused approach to dealing with burnout in Primary Care.

First, there has been a gradual and subtle erosion of autonomy in Primary Care. When asked why we went into medicine, most doctors include the phrase “because I wanted to help people”.

...it is not surprising that GPs feel a loss in autonomy and respect.

Yet most of us spend less time than we used to on patient care and more on trying to achieve mandatory targets such as Quality and Outcomes Framework (QOF) indicators, Clinical Commissioning Group (CCG) prescribing incentives, CCG monitored referral rates, Care Quality Commission (CQC) assessments, as well as local Federation and Network projects, and our own revalidation.

Meeting these requirements is not only time-consuming but runs counter to the emphasis on decision-making and patient-centred care that doctors receive during training.

In addition, funding issues and attempts to streamline care now mean that many of the decisions made by GPs are then reevaluated before they reach their intended Secondary Care destination. Screening centres such as the Improved Access to Psychological Therapies (IAPT), evaluate GP referrals to see if they meet the requirements set locally to see a psychiatrist.

Physiotherapists vet referrals to orthopaedics, and even other GPs are employed to scrutinise the referrals of their colleagues to see if they meet a standard required for referral. Medical school teaches us that pathology ’X‘ requires investigation ’Y‘, but it does not take into account the local CCG/hospital that has decided a GP is not qualified to order investigation ’Y‘, and instead, the GP must refer to an adjunct clinician, who will do the same assessment, and decide if the GP’s investigation request was worthy. Taken across multiple specialities, it is not surprising that GPs feel a loss in autonomy and respect.

Second, the perceived role of the GP is changing. The public and media have a superficial understanding of what the job involves and are, therefore, able to speculate on how they feel their patient journey should progress.

The public are able to google symptoms, can consult alternative therapists for similar conditions, and can discuss and compare with friends or family their individual experiences in General Practice. As a result, when there is a poor patient outcome, it is easy for the media or patients to protest that the GP failed to recognise their illness.

My colleague in anaesthetics has been pleasantly unaware of this pressure. The tabloids never scream “The Intensive Treatment Unit (ITU) doctor never gave my mum enough noradrenaline” because the public cannot directly access intensivists or anaesthetists in the same way they can GPs.

Furthermore, sub-specialities are one (or more) steps away from that initial presenting complaint of the patient, and it becomes harder to predict the treatment or outcome.

In fact, except for General Practice (and Emergency Medicine), virtually all other medical specialities have an initial patient–doctor consultation before their appointment, thereby removing a significant element of pressure. Both the referred patient and Secondary Care doctor already have some idea of what they can expect from the consultation, but by contrast with Primary Care, the patient is less likely to understand the specifics of the treatment process involved.

Third and last, there is the concept of unity and working towards a common goal of improved patient care. When primary, secondary, and community services all work closely together, there is obviously less pressure felt in each individual section.

But as expectations of the NHS have increased, Primary Care has become the effective dumping ground for unresolved issues. Examples include hospital discharge letters with a summary line of “scan requested and bloods, GP to chase and action”, as well as increased social care requests by carers for GP visits, or dentists and optometrists requesting GPs to resolve issues they are unsure of resolving themselves. More than ever, it seems that if in doubt, the advice is to “go ask your GP”.

This drift in expectations is unhappily understandable. Historically the GP was the centre of the medical community and had the knowledge and tools to address any problem to do with health or social need, and sometimes beyond.

As the pressures on Primary Care have surged, it has become increasingly difficult to accommodate this unidirectional traffic, and resistance by GPs is increasing. The British Medical Association now has a template letter advising clinicians who request tests to take responsibility for their execution.

Despite governmental promises to recruit thousands of new GPs, it is clear that numbers continue to drop and recruitment remains challenging. There are programmes to invite GPs from abroad to work in the UK and incentives to delay GPs in post from retiring. All this, though, is superficial and fails to address the underlying issues leading to burnout.

So, how do we tackle burnout?

A small way to start is to be more united at a local level. By supporting each other even within our own practices, and working together to promote professional cohesion, our wellbeing and productivity will increase, at least in our workplace.

We can also encourage Local Medical Committees (LMCs) and CCGs to reduce inappropriate demands from other specialties. We can be firmer in returning inappropriate requests to clinicians.

But more aggressive action – not working past our allotted contract time or receiving extra calls or making extra visits – all affect patient care and run counter to the ethical standards we have as GPs and doctors.

The only way to really reduce the problem of burnout in General Practice is to change the way the job is perceived and valued by patients, the media, Secondary Care, and by those who fund and structure it.

This challenge needs to be tackled at a national level so that General Practice becomes a speciality that is once again valued and enjoyed, rather than a burden to be endured.

Dr Jeff Foster

Dr Jeff Foster is a GP and Men's Health Specialist. If you have any questions on men's health, please contact Dr Foster at contact@drjefffoster.co.uk