Uncovering hidden challenges in general practice
As a practising GP, Dr Carol Sinnott knows first-hand how overstretched GPs can be. And it’s not just because the workload is heavy. Many issues, broadly termed “operational failures”, make life in general practice harder. These include missing or unclear information, equipment failures, IT glitches, complex communication channels, and frequent interruptions.
An academic as well as a clinician, Carol’s current research focus is on exploring operational failures in general practice. She recently published two papers and more research is underway. We spoke to Carol to find out more.
Why did you decide to investigate operational failures in general practice?
When I trained as a doctor, I first worked in hospitals, where there was a strong emphasis on engaging in research programmes to improve the evidence base behind treatments. Then I decided to move to general practice, as I felt more comfortable taking a “whole patient” approach. I noticed there wasn’t the same focus on research in that environment, even though GPs cover huge breadth and depth and are evaluating and refining their practice all the time. I wanted to contribute to filling that research gap, so I decided to do a PhD in general practice.
I’m particularly interested in the complexity of care in general practice, meaning not just the medical aspects, but also organizational questions. I was delighted to have the opportunity to explore some of these aspects of general practice through my work at THIS Institute.
What is challenging about exploring operational failures in general practice? How does it differ from similar research in hospitals?
Doing research in general practice is complicated for several reasons. There are over 9000 GP surgeries in the UK, and each one is different, depending on where it is, how it was set up, the nature of the staff, the patient population, and so on. And surgeries are such busy places. They often don’t have the chance to design their processes and protocols from a blank canvas. They grow organically in a system where demand is surging and numbers of trained GPs are falling.
Of course hospitals are busy places too, but they typically have dedicated managerial staff whose remit is to set up standard operating procedures and look after operational issues. In contrast, a lot of processes in general practice often go unwritten or are never purposefully designed. So teasing out exactly what contributes to an operational failure in general practice tends to be more complicated than it would be in a hospital.
Tell me more about how you are approaching your research on operational failures in general practice?
It’s a four-stage process. We’ve completed the first two phases and we’ve published a paper from each. The first phase was a literature review, to see what had already been covered. Most of those studies were carried out in the US. In the second phase, we interviewed GPs to fill in gaps and to understand how some of the issues discussed in the literature apply in the NHS.
I particularly remember one of the interviews during phase two. I was asking one GP what disrupts his work. While we were talking, his phone rang at least three times and two or three people came into the room to ask about different things. Even though those interruptions were so disruptive, it didn’t occur to him to tell me that interruptions were an issue. It highlighted the value of the third phase of the project, where we observed about 60 GPs at work to see what issues they face. I’m working with Mary Dixon-Woods to analyse the data from that phase now. In the final phase, we plan to hold consensus-building workshops to agree which targets to prioritise for improvement. We will have to rethink how we run those workshops, as the pandemic will mean we won’t be able to meet in person.
Has your personal perspective as a GP made a difference to the research process?
Carrying out this research as a practising GP has its pros and cons. It’s helpful to understand the pressures that GPs face. For example, GPs are saturated with information. They spend all day looking at test reports and letters and emails and so on, and their time is very stretched. So to recruit GPs to the study, I knew our invitations needed to be very succinct, three lines of text at the very most.
But there are drawbacks too. I’m so familiar with the way GPs work, I can sometimes struggle to see how things could be different. We call that “conceptual blindness”. And I might be less objective, perhaps overly sympathetic to the issues that GPs face, more inclined to find fault with the system when in some cases the issue might lie more on the GP’s doorstep. So for the first two phases of this project I worked with a colleague, Alex Georgiadis, who has a background in psychology. His perspective was extremely helpful in making sure I didn’t allow my emotional involvement with some of the issues to colour the research.
How have GPs reacted to the research so far?
The level of interest from GPs has been huge. Practices were really keen to participate in our work and were very glad that someone was coming to shine a light on the challenges they face. As well as highlighting so many issues, we have shown how much extra effort GPs put in to find workarounds to overcome operational failures. Mary Dixon-Woods and I named this effort “compensatory labour”. It’s often invisible to others and because it goes on under the radar, GPs can feel very unappreciated. Highlighting this should help to support GPs, and in turn help the health service to function better as a whole.
How has COVID-19 affected the research?
Apart from having to rethink the format of our stakeholder workshops, COVID-19 hasn’t really affected the research process because most of the work was complete by the time it hit. We’re working hard on analysis, and it shouldn’t affect our output. But the pandemic has shown us all that when there is a strong sense of shared purpose, change can happen incredibly quickly. GPs have talked for years about holding video consultations with patients, prioritising which patients need to come to the surgery, and the potential of replacing paper prescriptions with electronic ones. And then so much changed with COVID-19. For example, we’ve used phone consultations to a limited extent for a while. But over the course of a weekend, phone consultations just became the norm, with very little resistance from either GPs or patients. The ability of people to flex and change is greater than anyone imagined.
What does the future hold for this research?
The work I’ve been talking about will highlight the issues that need to be improved to make general practice run more smoothly. The next step will be to run another set of projects to generate sustainable solutions to the most important issues we have uncovered. So this is just the start of our journey