The shortage of general practitioners in the NHS is widely acknowledged, but this has not resulted in the kinds of changes that will make a difference. Last week, Martin Marshall, chair of the Royal College of General Practitioners, spoke out about the current crisis in general practice. He highlighted how the shortage of GPs, coupled with increased patient demand, is leaving many GPs feeling that they cannot provide a safe level of care. As a result, many GPs are leaving the profession as a consequence of burnout, or are taking early retirement.
As part of our work at the Policy Research Unit in Behavioural Science, (a member of a National Institute for Health Research programme to deliver policy related research), we summarised the evidence about what motivates GPs to take early retirement and reduces occupational participation. We considered the strategies that may prevent withdrawal from the work force and help support increased GP recruitment especially in rural areas. We were also interested in the evidence of effectiveness for behavioural insights, aka nudge-style interventions.
The findings of our report were clear. GP work is increasingly stressful, forcing many to opt for early retirement. The financial arrangements allow many to do so. Golden handshakes alone won’t fix rural recruitment. And behavioural insight interventions are highly unlikely to play any effective role in keeping GPs in the profession.
The determinants of stress are numerous: excessive workload, fear of litigation, the administrative and emotional burden of medical revalidation, job dissatisfaction, poor work-life balance, and pessimism about the future of the profession. Qualitative research revealed a number of factors which all contribute to feelings of stress and anxiety among GPs—the emotional toll of managing patients’ psychosocial needs; abusive or confrontational patients; a practice culture characterised by conflict or bullying; working in isolation without support; work role demands, specifically a fear of making mistakes; managing patient complaints, appraisal, revalidation, CQC inspections, and financial pressures faced by partners.
Recruitment and retention in rural areas is complex. Multi-dimensional approaches may be more successful than those relying on financial incentives alone, as lifestyle or personal values are highly influential. Locations of family, partner or spouse were factors that were prioritised over financial incentives to accept a rural post, as well as the ability to control working hours, professional development, a preference for larger practices, paid holiday, and assistance with partners employment and childcare.
Behavioural insights tend to focus on automatic, often unconscious decisions. Instead of supporting individuals to make decisions where they will weigh-up costs and benefits, behavioural insights focus on configuring options to account for human fast thinking. For example advocating a policy intervention that makes changes to the context in which individuals make decisions, rather than attempting to change how individuals feel about/react to contexts. To this extent there are limited opportunities to reduce early retirement, as the choice to retire is conscious and not passive. This was backed-up by the limited number of studies and the modest evidence of effect. However, organisational initiatives that might help physicians deal with stress, include coping strategies, and reflective groups, in addition to configuring work to enable part-time and/or flexible working.
Will the covid-19 pandemic be the catalyst to deliver the seismic change to GP working practices? The additional pressures created by the pandemic, as well as changes to pensions, and a lack of funding, are all counterproductive to long term retention. GP leaders are also unimpressed with their perceived lack of support for clinical practice.
GPs want to work and they are vital. Their compassion and dedication has shone through in the response to covid-19. But achieving long-term retention, and reversing the decline in GPs’ morale, will take more than a nudge. It will require funding for more doctors, nurses, and support staff, pension reform, a reduction in workload demands, and additional mental health support. The will of GPs is clearly present, but the environmental conditions are missing.
Vivi Antonopoulou, Louis Goffe, Aikaterini Grimani and Carly Meyer are all post-doctoral researchers for the NIHR Policy Research Unit in Behavioural Science.
Falko Sniehotta is professor of Health Psychology & Behavioural Medicine at the Universities of Newcastle and Twente and Director of the NIHR Policy Research Unit Behavioural Science
Michael P Kelly is a senior visiting fellow at the Department of Public Health and Primary Care, University of Cambridge
Ivo Vlaev is a professor of Behavioural Science at the University of Warwick
Competing interests: none declared.
Funding statement: This project is funded by the National Institute for Health Research (NIHR) [Policy Research Programme (Policy Research Unit in Behavioural Science PR-PRU-1217-20501). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.