Morale in UK general practice has dropped to a low ebb and a shortage of doctors is blamed for an increasing proportion of practices seeking to avoid accepting new patients. Yet week after week around 40,000 NHS GPs continue to work. Researcher and part-time GP Sharon Spooner explores the nature and significance of what motivates them.

Historically the popularity of working in general practice has varied. The severity of current difficulties with recruitment and retention of general practitioners has prompted innovative initiatives and proposals to boost interest in GP careers and to change to how primary care services are delivered (see the CfWI report, #nothing general campaign and the HEE Commission Report).

But during recent months a growing body of evidence from the 8^th National GP Work Life Survey, sequential BMA Tracker Surveys and media stories have confirmed a downward trend in job satisfaction alongside increased job-related stress for Britain’s GPs.

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The Guardian [07/01/2016]

NHS reorganisation causing GP retention crisis, study suggests

Amidst dominant discourses of doom and predictions of the imminent demise of NHS general practice, enthusiastic advocates for GP careers can echo like lone voices, their sentiments dismissed as detached from reality. Without denying the challenges and difficulties that GPs encounter, publication of Unfashionable tales: narratives about what is (still) great in NHS general practice (Spooner, 2016) draws attention to what is readily overlooked but remains good in the careers of general practitioners. Like others, this paper is a partial account, but one in which positive narratives are placed in the spotlight to achieve three key objectives;

First, to highlight what has been successful, productive and satisfying in the careers of mature GPs. It is common in the NHS to react by launching an in investigation to discover why something has gone badly – and undoubtedly it is appropriate to fully understand the background factors and make necessary changes for better outcomes. Less urgent and prominent attention is generally paid to things which go well – yet better understanding of what has made an initiative successful or delivered a good service ought also to be a priority area of investigation.

British general practice has been hailed as a major contributor to provision of universal health care and envied across the globe. Work is multi-faceted and unpredictable and GPs find themselves important and trusted resources for patients. The range of knowledge which can be required at this first point of medical contact has no limits but the extent to which GPs can help patients negotiate illness and difficulty is also limitless.

Enduring relationships with patients and colleagues feature strongly in positive stories from experienced GPs. A team culture which values high quality service delivery and mutual support is identified a sound basis for coherent and effective practice and facilitates the adjustments necessary as a result of changing contractual arrangements. Together, these narratives add evidence of how successful general practice can be experienced.

Secondly, doctors have spoken about the roles and working practices to which they attach greater value and believe are most beneficial when working with patients. Building on confirmation in the 8^thNational GP Worklife Survey that contemporary GPs experience most stress from factors such as increased workloads, imposed job changes, restricted time to do their job properly and time spent on paperwork, it should not be surprising that doctors identify these as unwelcome barriers or distractions from their achievement of satisfying work.

Having progressed through education and training these doctors acquired a professional identity which they prefer to enact and which may not sit comfortably with unquestioning adherence to numerous guidelines and protocols which can be difficult to navigate with patients who have co-existing health problems. Satisfaction is associated with correctly making an early or difficult diagnosis and recognising improvement for patients in terms of their health or access to appropriate services. Externally determined priorities and targets may also be poorly aligned with doctors’ expectations of their responsibilities.

In many senses, as these clinicians express ideas about who they are and what they do they reveal deeply ingrained value-systems just like any other group of workers. They speak about aspects of work which they truly believe in – work which fits with how they have learned their professional practice, how they have developed as people, and how as practising doctors they have witnessed patients benefit from and respond to the care they prefer to deliver.

Progressive changes in what is expected in GP workplaces and which pose an ongoing challenge for mature clinicians, may present a lesser obstacle for their successors, but constraints which decrease engagement with patients for no clear benefit seem unlikely to satisfy either party.

The final objective of this paper is to invite discussion on where the future of general practice lies in terms of encouraging recruitment and retention and in the effective employment of skilled GPs.

On one hand, constant negativity can be overpowering and self-perpetuating. If aspiring doctors hear only negative messages about working in primary care, they cannot be blamed for choosing something else. Voices of GPs who can and do find fulfilment and value in their work shouldn’t be lost in the noise, their experiences are an important part of the picture and a potentially vital component for attracting and retaining highly committed doctors as NHS GPs.

A global shortage of primary care doctors raises the stakes for an NHS which increasingly seeks to improve efficiency by developing community-based services. Proposals to re-design delivery of primary care services in an attempt to cope with the current deficit of qualified GPs, recommend early access for patients to a range of alternative care-providers in multidisciplinary teams HEE Commission Report.

However, further evaluations would be helpful to discover whether this suggested shift is an acceptable and effective solution for patients and to ascertain the net effects on GPs. In particular, it should be considered whether it might risk further contraction of those roles and responsibilities to which doctors attach greater intrinsic value and where adequate resources and support could attract and retain sufficient GPs in jobs where they feel successful, productive and satisfied.