Your consultation may be over, but your care is not.

By Rachel Barnard

My mum and her neighbour were at the bus stop bemoaning how hard it was to see a GP. I’d just had a paper accepted about GP workload, so why did I say nothing? My silence speaks volumes about the minefield this topic has become. I want my mum to be able to see her GP face to face if she needs to. But I also want to counter media messages suggesting GPs are part-timers who could be working harder. It’s true that GPs are reducing contracted hours – they are responding to intolerable workloads. In practice, they often work many more hours than they are paid for. The extra time they put in is needed to keep up with non-patient-facing work. Some also have other jobs, such as roles with integrated care boards, GP training schemes or universities.

We did a study to understand what GPs do when they’re not speaking to patients. Work that is hidden from view. Our findings are now published in a paper which shows that non-patient-facing work is often complex and involves uncertainties, just like patient-facing work. For example, GPs might need to decide what to do about a test result that is borderline abnormal. They might need to liaise with a consultant about a referral. We call it hidden care work to highlight that this under-acknowledged work is integral to caring for patients.

Giving good care was important to the GPs in our study. They wanted to make the right decisions. But with long lists of patients to see, it was hard to find time to think. They found this time by working outside of expected hours – staying late, coming in early or working on days off.

Why does it matter?

 It is important because GPs are carrying larger lists of patients. With more patients comes more of the hidden care work associated with it. There are many reasons why patient lists are growing: problems recruiting and retaining GPs, transfer of responsibilities from secondary care to primary care, surgery closures, and other factors. Everyone wants better access to primary care. But if complex work is misunderstood as simple work, policy solutions may not succeed.  GP retention will remain a problem.

Practice managers sometimes ring-fenced time for GPs to do non-patient-facing work. We observed GPs struggling to protect this time. During a two-hour period allocated to work on clinical documents, the GP reflected in this cartoon sketch (right) was frequently interrupted. In half the allotted time, she had only dealt with three documents, leaving 22 for the remaining hour. It was important to her that trainees and other staff felt welcome to ask for help. At the same time, she wanted to complete the work and not stay too late. GPs felt overwhelmed by their workload.

Example of cartoon illustration of observed scenario. Rachel Barnard. CC-BY licence.

GPs could be quite self-critical when they pushed work forward to be done later. It feels wrong that they should think of themselves as slow or inefficient when they are doing their best to give patients good care.

What I should have said to my mum is that that we only see a small part of what GPs do. When her appointment is over, the GP might still be working behind the scenes on her behalf. Her care is not over.

Hidden in plain sight: the unseen work of general practitioners in general practice. Funded by NIHR School of Primary Care. Sharon Spooner, Deborah Swinglehurst, John Campbell, Kath Checkland, Rachel Barnard, Michaela Hubmann.


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