Why it matters
Research in hospitals has demonstrated the impact of difficult work conditions. In particular, operational failures – defined as disruptions, errors, or inadequacies in the information, supplies, or equipment needed for patient care – are frustrating for staff and can impact patient experience and safety.
Despite their likely relevance for General Practitioners’ (GPs), operational failures are under-explored in primary care. This is important, given evidence of high levels of unmanageable workloads and burnout among GPs. We aimed to find out more about the operational failures found in everyday practice by NHS GPs, and to explore how these failures influence GPs’ work and their experiences of work.
We carried out interviews with 21 GPs in the East of England between February and July 2018. The GPs were spread across rural and inner-city practices, both large and small. We included GPs who were recently qualified and those who had much more experience.
Using a technique known as ‘chart-stimulated recall’, GPs were asked to describe operational failures they had experienced in their most recent clinical session, using their own schedules and patient notes as a reminder .
What we found
GPs told us they had to deal with a lot of operational failures. Some of the most common related to problems in the supply of information to them from other organisations. Delayed or missing hospital discharge letters were frequently cited, and excessive, poorly structured information from external organisations was as much of a problem as too little information.
GPs also reported problems in referring patients to hospital and to community and social care. Electronic forms and frequent changes in care pathways often made organising care difficult and frustrating, and sometimes resulted in delays for patients.
There were also failures with internal practice systems. GPs reported that their work was disrupted by failures relating to equipment and materials being out of stock. Technology problems, such as computers crashing and difficulties in accessing electronic health records caused many challenges.
Operational failures caused significant additional strain on GPs on top of their already very busy daily schedules. GPs did extra work or ‘compensatory labour’ to try to manage operation. However, this extra work remained largely invisible.
Changing processes within their own practices was not easy for GPs: just trying to get through the pressures of their work each day was hard, and they felt they lacked the time or capacity to design, implement, and oversee new processes. They expressed some uncertainties about legal issues too, for example relating to process improvements that involved delegating tasks to other practice staff.
Our study found that operational failures in primary care matter a great deal for GPs and their experience of work. The compensatory labour they have to do creates an extra burden on their time and energy, and does not make the best use of their knowledge and skills.
The extra work is often hidden, unpaid and likely to contribute to stress and burnout.
Recognition of the significance of operational failures should stimulate efforts to improve the primary care work environment.