Background

Doctors, including GPs, experience high levels of stress and burnout(Orton, Orton et al. 2012). Doctors who experience stress or mental distress and have difficulties coping, are less satisfied at work and are less likely to meet patients’ clinical and psychosocial needs.  The UK currently has 65,000 registered General Practitioners and it is estimated that one in five (or 13,000) GPs currently experience some form of anxiety or depression. There is evidence that doctors are at greater risk of suicide compared with the general population, female doctors being at higher risk.

Evidence suggests that the provision of a timely, accessible and appropriate support service in London has been economically and clinically effective. Despite recommendations to improve the care pathways and support services for doctors, there is a paucity of empirical evidence examining how and if such recommendations have been implemented and whether (or not) doctors are benefiting from and accessing current provision.  Little is known about the organisational culture of general practice in terms of what helps and hinders GPs from seeking support.  Moreover, little is known about the barriers and facilitators to help-seeking and GPs’ experience of returning to work after sickness absence for mental distress.

Project objectives

Our methodology will employ qualitative methods to explore the barriers and facilitators to help-seeking by GPs.  Undertaking this research will enable us to not only understand the barriers and facilitators to help-seeking, but also to identify solutions so that current and future doctors can access suitable care when necessary – accessing timely, good quality care and enabling doctors to return to work is crucial in ensuring the mental health needs of doctors are met.

Study Design

This is an exploratory study employing qualitative methods to explore the barriers and facilitators to help-seeking amongst General Practitioners. The study will employ a short survey to provide a snapshot of GPs’ current experiences of stress/distress and enable the researchers to purposively sample participants who give their consent to take part in the qualitative phase. Qualitative methods will include in-depth interviews, either face-to-face or by telephone and will explore the barriers and facilitators to help-seeking for mental health problems.  The sampling of participants will take account of the following: GPs with varying experiences of help-seeking for mental health symptoms (including mental health problems, stress and burnout), GPs who have returned to work after a period of sickness with a mental health problem and GPs who have no experience of such difficulties in order to determine their preferences for service provision.  Study sites will be based in Bristol, North Staffordshire, Manchester and London.

 Aims

•  To identify the causes of stress/distress amongst GP participants and explore how GPs cope with and manage mental health problems and stress in the workplace
• To identify the barriers and facilitators to help-seeking to understand why GPs do (or do not) seek help for mental health problems, stress or burnout
• To identify GPs’ experience of accessing and using primary care and dedicated services
• To understand GPs’ experience of returning to work after sickness absence for mental health problems/stress or burnout
• To identify GPs’ preferences for support and service provision

Objectives

•  Identify the socio-cultural barriers and facilitators to managing difficult emotions and help seeking, including examples of resilience, how concerns are raised with and responded to by colleagues, institutions, with other doctors (formally and informally) and other professional support [e.g. GMC’s Doctor Support Service, Practitioner Health Programme (London), LMCs].
• Identify the value and limitations of individual and collegial support, and the care pathways currently available to support GPs.
• Inform improvements to guidelines, designated care pathways and support systems so that current and future GPs can access care when necessary.

Changes to the original proposal

Originally, we stated that we would aim to recruit 40 GP participants but recruited 47 participants in total.  This was owing to a need to ensure participants represented a broad range of experiences of help-seeking in accordance with our original purposive sampling framework.

 

We originally proposed that we would write one peer-review paper but owing to the richness of data and important study findings, we aim to submit 4 papers (see Dissemination).

Brief summary

Methods

Interviews with 47 GPs from around England were conducted. Potential participants were contacted via emails to doctors attending a specialist service, as well as adverts to Local Medical Committees (LMCs) nationally, in GP publications and on social media. A total of 122 GPs got in touch, although 18 of these did not send a second response after receiving an information sheet.

 

Potential participants were asked which of these categories they most strongly identified with:

 

1. Living with mental distress (defined as anxiety, depression, stress and/or burnout)
2. Returning to work following treatment for such problems
3. Off sick or retired early because of mental distress
4. No lived experience of mental distress

 

Interested GPs were purposively sampled to represent a relatively even spread across these four groups, although the largest number of participants were in group 1. Once each group was well-represented, further GPs who expressed an interest in participation were politely thanked and turned away with an explanation about the high rates of interest in the study.

Data collection took place face to face or by telephone, between February and August 2016. Semi-structured, in-depth interviews consisted of questions exploring participants’ current wellbeing, stress management and experience of help seeking. Interviews lasted between 27 and 126 minutes (mean = 69 minutes), and were recorded and transcribed verbatim.

Transcripts were uploaded to NVivo 11 and analysed using thematic analysis. Each transcript led to emergent codes being extended and refined. Emerging themes were discussed and agreed among all authors. Once all transcripts had been analysed, the first author further refined each code. A code book of key points from all interviews was drawn up. This was audited by two of the authors (RR, MB), both experienced qualitative researchers. The multi-disciplinary research team independently analysed a sub-set of transcripts in order to contribute to the generation and refinement of codes to maximise rigour. Emergent themes were discussed by the whole team to ensure credibility and confirmability.

Tables of themes were drawn up for the major codes. Analysis continued into the writing process, when adjustments were made to ensure that each theme was explored optimally.

Findings against objectives:

Objective one Identify thesocio-cultural barriers and facilitators to managing difficult emotions and help seeking, including examples of resilience, how concerns are raised with and responded to by colleagues, institutions, with other doctors (formally and informally) and other professional support [e.g.GMC’s Doctor Support Service, Practitioner Health Programme (London),LMCs]. 

GPs’ main barriers and facilitators to help seeking for distress were work and symptom related.

Work related barriers and facilitators included a need to attend work (sometimes known as ‘presenteeism’); internalised and perceived stigma within the practice relating to mental illness; and concerns around confidentiality, time and identity.

Symptom related barriers and facilitators included a difficulty with acknowledging symptoms, the inertia related to depression, and the motivation of reaching crisis point.

Objective two Identify the value and limitations of individual and collegial support, and the care pathways currently available to support GPs.

GP participants talked about the varying quality of treatment they had received, which came from specialised services, the NHS and private therapy. While some of the treatment was praised, other aspects were inadequate, with participants reporting brief and inappropriate talking therapies or unsupportive treatment from their own GPs. The importance of information about relevant services was highlighted, and the benefits of both specialised services and supportive work environments were extolled.

Objective three Inform improvements to guidelines, designated care pathways and support systems so that current and future GPs can access care when necessary.

Findings from our study have informed the recent Royal Medical Benevolent Fund’s Vital Signs in Primary Care guide (2016). We also fed back early findings and concerns to NHS England during the planning stages for the new NHS GP Health service.

In addition, we have listed the following recommendations based on our work:

•  Removing systemic stigma around mental ill health within healthcare organisations should be a key area for researchers and policy makers.
• Individual practices, the RCGP, Deaneries, CCGs, LMCs and the Department of Health need do more to advertise specialist centres for treating doctors, such as the new NHS GP Health service.
• GPs should be offered specific training about how to effectively support and treat their GP and other medical colleagues when they attend as patients, since effective primary care may be an essential lifeline for doctors in distress.
• We suggest researchers and policy makers respond to research such as ours by investigating and developing organisational changes for the workload stresses experienced by GPs to become more manageable for individuals, whilst ensuring sufficient resource and practitioners for the delivery of good medical care for all.
• The RCGP and GP practices should provide a safe space for GPs to process and debrief the emotional and clinical content of their work and the stress related to the organisational culture (i.e. bulling in the workplace) and relationships at work (collegial conflict).

The use of collegial support groups such as Balint groups or supervision sessions are good protective factors for mental health and so should be considered and instigated wherever possible. 

• There needs to be a culture change within medicine, with a shift to more supportive, compassionate and open work cultures.
• Encouragement of a professional responsibility to recognise mental illness, seek help and support colleagues.

Additional findings The exploratory nature of qualitative research means that findings may often exceed objectives. This has been the case in this study, which has also produced papers on the following topics.

Sources of stress and distress for GPs These included emotional labour, such as managing emotions arising from difficult consultations, and abusive behaviour from patients and press; practice culture, such as bullying or toxic partnerships, isolation and lack of support; and work role and demands, such as complaints and inquests, fear of making mistakes, revalidation and financial worries.

GPs experiences of living and working with mental distress and illness GPs related concerning levels of distress, which broadly broke down into the areas of burnout, anxiety, depression (including suicidal ideation) and shame or fear of failure.

A fourth paper using the in-depth qualitative method Interpretative Phenomenological Analysis (IPA) and focusing specifically on the experiences of GP partners with more than 10 years of experience is currently being written up. This paper is likely to focus on conflicted identities for these doctors.

Conclusions

Findings from this timely study have uncovered a concerning level of GP stress and distress, emerging from a range of work-related sources including emotional labour, bullying and isolated working. GP participants discussed high levels of anxiety, depression and burnout, with 19 of the 47 reporting suicidal ideation. We uncovered a comprehensive set of barriers and facilitators to help seeking for this group, which included the continuing stigmatisation of mental illness, concerns around confidentiality, the difficulty of acknowledging symptoms, and the motivation of reaching crisis point. Based on our extensive interviews and analysis, we have recommended various GP, practice and profession wide actions, including work to remove the stigma around mental illness; the creation of safe spaces so that GPs can debrief about challenging consultations or stressors; and encouragement of a professional responsibility to recognise mental illness, seek help and support colleagues. 

Plain English summary

General Practitioners (GPs) are under increasing pressure due to a lack of resources, a diminishing workforce and rising patient demand. As a result, they may feel stressed, burnt out, anxious or depressed. However, little is known about how this group experience that distress or how they go about accessing support. We used qualitative methods to explore the experiences and help seeking behaviours of 47 GPs living and working in England. Participants self-identified as 1) currently living with mental distress, 2) returning to work following treatment, 3) off sick or retired early as a result of mental distress or 4) without experience of mental distress. Interviews were conducted face to face or over the telephone and then analysed using the computer programme NVivo 11. Findings covered three main areas: the sources of distress for this group, which included the emotional labour of caring for others and the sense of being an isolated worker; the experience of being a GP living and working with distress, which encompassed participant accounts of burnout, anxiety, depression and shame; and the barrier and facilitators to help seeking for the group, which highlighted concerns around confidentiality and stigma, and suggested that GPs may wait until they reach crisis point before they seek help. Findings demonstrate toxic working environments, deep and concerning levels of distress, and inadequate support for those living with that distress. We conclude that a culture shift is needed within general practice to decrease stigma and increase openness and support around stress. This shift needs to be systemic, and be driven by the RCGP and practices as well as individual GPs.

Dissemination

Spiers, J., Buszewicz, M., Chew-Graham, C., Gerada, C., Kessler, D., Leggett, N., Manning, C., Taylor, A., Thornton, G. & Riley, R. (2016). Who cares for the clinicians? The mental health crisis in the GP workforce. BJGP, 66(648), 344-345

Spiers, J., Buszewicz, M., Chew-Graham, C., Gerada, C., Kessler, D., Leggett, N., Manning, C., Taylor, A., Thornton, G. & Riley, R. (Under review). What are the barriers, facilitators and survival strategies for GPs seeking treatment for distress? A qualitative study

Riley, R., Spiers, J., Chew-Graham, C., Taylor, A., Thornton, G. & Buszewicz, M., (In preparation). Sources of Stress and Distress in General Practitioners: A Qualitative Study

Riley, R., Spiers, J., Chew-Graham, C., Taylor, A., Thornton, G. & Buszewicz, M., (In preparation). ‘Treading water but drowning slowly’: GPs’ experiences of living and working with mental illness and distress – a qualitative study

Spiers, J., Buszewicz, M., Chew-Graham, C., Riley, R. (In preparation) The experiences of GP partners living and working with distress: An interpretative phenomenological analysis.

 

Public involvement

We used two PPI contributors on this project, who were helpful at all stages of the work. These contributors gave input around the design of the study and the analysis, and were co-authors on our editorial and one of the peer reviewed papers.

One of the contributors (Gail Thornton) had previous research experience and showed a knack for qualitative research, and so became involved at a deeper level with further training and support provided by the project researchers. She transcribed several of the interviews and joined a smaller sub-set of the team to co-author two additional papers.

Insights from both PPI contributors resulted in changes to the analysis and final drafts of the papers; for example, Nick Legget made the point that one quote that had been suggested for a paper around levels of confidentiality between GPs ran the risk of being mis-reported by the right wing press, and working against general practitioners. This quote was then replaced with another, less potentially incendiary quote.

The key lesson learnt would have been to factor in more allocated time to support and communicate with our patients/public contributors as involving individuals meaningfully, which we endeavoured to do, is extremely time consuming.

Impact

Findings from our study have already made an impact within both General Practice and the public, and we have sown the seeds to ensure that they continue to do so.

 

As detailed above, we have published an editorial in the BJGP, and have four papers in preparation which we have sent or will be sending to the BJGP, BMJ Open, Psychological Medicine and Psychology & Health, all high-impact journals.

 

In addition to this, we have presented findings from the study at two conferences: the RCGP in October 2016 and the SPCR in November. We have also had abstracts accepted at the QMiP (Qualitative Methods in Psychology) and IPA conferences, and are waiting to hear about our submission to SAPC, all of which are taking place over summer 2017.

As previously noted, study results have informed the recent Royal Medical Benevolent Fund’s Vital Signs in Primary Care guide (2016). We also fed back early findings and concerns to NHS England during the planning stages for the new NHS GP Health service.

In addition to these traditional pathways to impact, we have engaged in more accessible and innovative approaches. Blogs about the work have been posted on sites including GPOnline, the BJGP blog, the UCL blog and Bristol’s CAPC (Centre for Academic Primary Care) site.

More innovatively, our research has informed a 40 minute performance piece called Pre Scribed: a life written for me. This piece was devised and performed by artist Viv Gordon, following a commission from ourselves and the University of Bristol’s Feel It Festival. Based on anonymised research transcripts, the play uses movement, music and monologues to tell the story of a GP who is struggling with the pressures of work and family life. The piece received extremely positive feedback from the audiences who saw it during the Feel It Festival, many of whom were GPs themselves; these GPs reported feeling validated and moved by the piece.

Johanna Spiers, the named researcher on the project, was invited to give an after dinner talk to a group of GP trainers at the Thames Valley deanery. She and Viv spoke together about the research and Pre Scribed, generating further interest in both.

There are plans to develop and extendPreScribed, and to perform it at various events including the Edinburgh Fringe, the Practitioner Health Programme conference, the Elizabeth Blackwell Institute’s Annual Lecture, the Being Human festival and various GP training events. This will extend the impact of our research in a powerful and accessible manner. By performing the piece for both GPs and the general public, we will show GPs that they are being listened to, and help balance the debate around general practice within the public sphere, which is currently dominated by negative stories from the right wing press.

All performances of PreScribed will contain a Q&A with Viv and one or two of the research team after the show.  

Project website: http://www.bristol.ac.uk/primaryhealthcare/researchthemes/improving-support/

 

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 282)

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.