Abstract
Background Shifts in health policy since 2010 have brought major structural changes to the English NHS, with government stating intentions to increase GPs’ autonomy and improve access to care. Meanwhile, GPs’ levels of job satisfaction are low, while stress levels are high. PulseToday is a popular UK general practice online magazine that provides a key discussion forum on news relevant to general practice.
Aim To analyse readers’ reactions to news stories about health policy changes published in an online general practice magazine.
Design and setting A qualitative ’netnography’ was undertaken of readers’ comments to PulseToday.
Method A sample of readers’ comments on articles published in PulseToday was collated and subjected to thematic analysis.
Results Around 300 comments on articles published between January 2012 and March 2016 were included in the analysis, using ‘access to care’ as a tracer theme. Concern about the demand and strain on general practice was perhaps to be expected. However, analysis revealed various dimensions to this concern: GPs’ underlying feelings about their work and place in the NHS; constraints to GPs’ control of their own working practices; a perceived loss of respect for the role of GP; and disappointment with representative bodies and GP leadership.
Conclusion This study shows a complex mix of resistance and resignation in general practice about the changing character of GPs’ roles. This ambivalence deserves further attention because it could potentially shape responses to further change in primary care in ways that are as yet unknown.
- access to health care
- general practice
- health services research
- healthcare reform
- qualitative research
- work–life balance
INTRODUCTION
Recent English health policy, as set out in the white paper Equity and Excellence in 20101 and implemented through the Health and Social Care Act 2012,2 has brought major structural changes for the NHS. The creation of clinical commissioning groups (CCGs) and development of new models of care, in particular, have had several implications for general practice. Each CCG covers the population registered at general practices in its area. The Health and Social Care Act returned responsibility for commissioning health services to GPs, by transferring the commissioning remit to CCGs, which were designed to put GPs at the heart of NHS planning decisions.3 Stated intentions of such policy changes were to increase the autonomy of GPs, by expanding their power over commissioning decisions while increasing accountability to patients through stronger governance and regulatory scrutiny, and reducing bureaucracy.1 Although UK health policy since 2000 has consistently emphasised improving accessibility,4 recent policy has emphasised improving access to primary care, framed largely as enabling patients to access GPs more quickly.5 To achieve this, NHS England has funded several ‘new care models’ programmes designed to improve access.6,7 There is some evidence that these changes have resulted in work intensification for GPs.8–10
Alongside these changes, GPs’ attitudes towards their work and to primary care reforms have followed a negative trend since 2000. The latest survey of GP work life showed that the level of overall job satisfaction reported by GPs in 2015 was lower than in all surveys undertaken since 2001, while reported levels of stress are at their highest since 1998.9 GPs reported that most stress was caused by ‘increasing workloads’ and ‘changes to meet requirements of external bodies’.9 Other recent research with GPs points to high levels of pressure, burnout, and intentions to quit general practice.8
Pulse magazine (www.pulsetoday.co.uk) is the UK’s most read GP news brand,11 and its online version PulseToday 12 is a widely read online GP magazine. PulseToday publishes political and financial news and debate, and clinical and professional updates. It includes a comments facility, where readers, who are registered site users, can respond to articles by posting comments, which appear below the article. Comments are displayed in the order in which they were posted. Each registered user has a profile and each comment appears with the contributor’s username as a header. All submitted content is published online; posts are reviewed within 48 hours and removed if they violate the standards that most publishers abide by, including containing offensive (such as racist, sexist, or libellous) content.
The comments facility on PulseToday is an example of an internet platform allowing people to voice their experiences and opinions online. Most newspapers and magazines published online provide similar functions, and a range of social media including networking sites, message boards, and blogs provide further forums for debate. Such forums are increasingly the focus of research interest.13 ‘Qualitative e-research’ is an umbrella term used to describe methodological traditions for using online technologies, including social media, to study experiences, perceptions, or behaviours through verbal or visual expressions, actions, or writings.14 Social media content is collected as research data and analysed, using qualitative data analysis methods traditionally employed in studies of texts transcribed from ethnographic observations (field notes), focus groups, or research interviews.15 In health research, there has been some interest in the use of internet technologies, for example, studies about the use of social media to share health information,16 and several analyses of the content of online discussion boards for specific health problems.17–20
How this fits in
General practice is experiencing high levels of pressure and burnout, coupled with low morale and job satisfaction; problems that have been linked to health policy changes, which state intentions to increase GP autonomy and improve patients’ access to general practice. Experiences and perceptions voiced online, through social media, are increasingly the focus of research interest, but little research has been conducted into views expressed online by GPs regarding the impact of health reforms and their changing professional role. This e-research study involves the novel application of qualitative methods in a previously unresearched setting and illustrates the internal debate in general practice. The results confirm and extend previous work: strong resentment of, and resistance to, changes in GPs’ work life, perceived as increased bureaucracy and control. This study also signals a deeper sense of powerlessness among GPs than previous research; such ambivalence deserves further attention, given the importance of the general practice workforce to the NHS.
Some research evidence exists about health professionals’ use of internet technologies, for example, analysing how doctors use social media,21 or assessing the ‘professionalism’ of comments posted by doctors online.22 However, e-research examining health professionals’ views about health policy or related changes is sparse; just one study was found of the opinions expressed online by GPs in relation to healthcare reforms or their working lives.23
PulseToday provides a forum to share responses to news that affects general practice. The authors’ interest in the focus of this article was prompted when they noticed high response levels on PulseToday to several articles about access to primary care and the changes implemented through the Health and Social Care Act. Nonetheless, the data offer a rich illustration of the internal debate in general practice and, thus, provide an important insight into GP attitudes. Accordingly, a study was designed to collect and analyse these responses. This study aimed to analyse readers’ reactions to news stories published on PulseToday about health policy changes.
METHOD
This study took an ethnographic approach to studying online behaviour, described by Kozinets24 as ‘netnography’. Netnography applies ethnographic approaches to online behaviour, drawing on publicly accessible online social interactions in the same way that an ethnographer observes human behaviour in the field.24 Similar approaches have been used previously, in qualitative studies of online health-related discussion boards.17–20 The sampling frame was articles published on PulseToday and reading revealed a large number of articles expressing a range of reactions to changes in general practice. Populations from which social media research data are drawn cannot be generalised.25 Accordingly, it should be acknowledged that views expressed on PulseToday are those of a particular subset of general practice. The authors did not seek to generalise or extrapolate findings across general practice, or purport to measure average opinions; rather, this study sought to analyse the dimensions of debate occurring between people in general practice. Access was recognised as a core focus of recent health policy initiatives, the aim of which has been contested among professionals. There was a pragmatic need for a core term, to generate a manageable data sample. Thus, the sampling strategy was opportunistic, with the sample covering all comments posted in response to articles published from the start of 2012, when the Health and Social Care Act became law.
The researchers treated access as a ‘tracer’ topic, that is, a topic of general concern that could be explored in a focused manner to identify a manageable sample of relevant material for analysis; articles containing the word ‘access’ were searched for and also where comments had been posted in response to the article. Comments on PulseToday can be considered ‘extant’ material, created independently of any intervention, influence, or prompts by the researcher.14 Data collection consisted of gathering the comments posted on PulseToday articles and was unobtrusive as the authors had no direct contact with the contributors of the comments.
All articles with comments were collected for the period 1 January 2012 to 31 March 2016, using the PulseToday search facility with the search term ‘access’. Comments were largely submitted anonymously or pseudonymously: the analysis therefore did not capture information on names attached to comments. The criteria were met by 331 articles out of a total of 1634 for that time period. All the comments posted in response to these articles were downloaded into a Word document. After initially reading all comments, those that were irrelevant to the research question, for example, those giving clinical advice, were discarded. This left around 300 comments containing around 21 000 words associated with the 331 articles. This formed the dataset on which thematic analysis was undertaken. Research team members read the comments, using access as a ‘tracer’ theme as well as looking for other emerging categories, and organised the data according to these categories. In analysing readers’ reactions to stories about health policy changes, attention was paid to both the content and tone of the comments. Data analysis was an iterative process; with the data read repeatedly, the initial categories were discussed in the team, refined, and grouped together into themes.
RESULTS
The posts sampled related to news articles about access to primary care and related government policy changes. Readers’ reactions were ostensibly about these topics and their concerns about the demand and strain on general practice. However, further analysis of the data showed that readers’ reactions also revealed underlying feelings about their work and place in the NHS. The results are organised into four sections. First, the main concerns expressed about access to primary care and government policy changes are outlined. The subsequent three sections present the key areas of concern about GPs’ work and place in the NHS: constraints to GPs’ control of their own working practices; a loss of respect for the role of the GP; and general practice as a divided sector.
Access to care and workload
There was consensus across the dataset that general practice was under-resourced and stretched, and that GPs were often working to meet demand for access in a pressured environment:
‘As money gets cut, we GPs simply have to work harder and longer for less. And get blamed for the waiting times and poor care. This is the reality, in spite of working harder every day to the point of complete physical and mental exhaustion, all the [news] papers point to how we do not do enough.’
Numerous comments were posted about GPs working excessively long hours, facing unsustainable workloads and the impact this had on their wellbeing, such as feeling under stress and burnt out:
‘There is one overworked and highly stressed workforce …’
‘Exhausted GPs can’t do or take any more. It’s not safe and it’s not fair.’
Opinions varied about the causes of the problem of meeting demand for access. Many contributors were critical of government cuts to resources:
‘The cuts made to our funding have put the future of the practice in jeopardy. General Practice has become the dumping ground for everything that no one else wants to do without the funding flowing in our direction … I have had enough of the stick and the carrots are no longer plentiful.’
(A GP who had retired early)
Several readers blamed patients for making unnecessary demands for appointments:
‘The problem is patient demand. If the bath is overflowing, turn off the tap, do not try and invent a new plughole! Until patients start to take responsibility for their lifestyle choices … demand will rise and GPs will continue to leave.’
Other contributors, however, thought that patients’ desire to access a GP when they wanted to was justified and were concerned about inability to meet patient demand:
‘It is now patients who surely are paying the penance, as well as us …’
Some comments raised the implications for patient safety of high workloads:
‘A locum was stating she saw 52 patients in one day. How can this be safe? Mistakes are bound to happen at those workloads …’
Several comments described a sector under pressure to provide access to care with decreased resources. Concerns were expressed for the wellbeing of GPs, with the unmanageable situation being blamed on the government and also on patients.
A small number of contributors expressed that patients’ desire for access was justified and concern was expressed for patient care and safety.
Constraints to GPs’ control of their own working practices
Much discussion centred on the burden of regulatory and incentive mechanisms for general practice and the bodies that introduced these, such as the Department of Health, CCGs, and the Care Quality Commission (CQC):
‘The bureaucratic monstrosity the Department of Health has foisted on us GPs actually gets in the way of treating our patients well and as individuals. It is leading directly to harm for our patients as we fob them off because we do not have the time needed to take a proper history and examine appropriately.’
These reporting requirements were seen as hindering the ability of GPs to give enough time to patients; ‘QOF’ (Quality and Outcomes Framework), ‘paperwork’, ‘admin’, ‘targets’, ‘inspection’, ‘micro-management’, ‘bureaucracy’, and ‘red tape’ were all mentioned:
‘Free GPs from the quagmire of the QOF and the CQC, and give them the tools to tackle patient demand …’
These requirements were often portrayed as undermining the principle that GPs should have freedom to make decisions and work in the way that they choose, as ‘independent’, ‘autonomous’ contractors:
‘Stop trying to standardise GPs, call a halt to the box-ticking and hoop-jumping … allow each GP or partnership to decide how it’s going to approach doing what most of us trained for.’
‘I need to be my own boss, or at least think I am.’
Disapproval of perceived political interference with the running of the NHS overall, and general practice in particular, was strong. Many contributors expressed frustration at the influence of politicians, who it was argued do not have a proper understanding of the issues facing general practice:
‘I am now completely demoralised and demotivated. Since when did an MP know better than a GP about clinical care?’
Government control over GPs’ working conditions, particularly their contract and the requirements to work during evenings and weekends, were particular sources of dissatisfaction. A small number of posts suggested that the way for GPs to regain control over their work was to practise privately:
‘The only way this will ever work is if you allow more private GP services to operate within NHS premises. For instance, a practice could offer X amount of NHS appointments and Y amount of private ones like the dentists do.’
Contributors resented the constraints on GPs’ freedom to practise in the way they wanted to, imposed by excessive bureaucracy and by pressure to meet patient demands.
Loss of respect for the role of GP
There was a considerable amount of debate about perceptions of and attitudes towards GPs, in terms of how they are seen by patients and their place in society. Many contributors felt that, in past times, GPs were held in high regard as trusted professionals, but that often this was no longer the case:
‘We are supposedly one of the most intelligent groups of professionals, so why do we accept all this rubbish from the government?’
‘Old GPs were valued in other ways apart from money. They were trusted and respected and listened to. Now we are inspected, criticised, and undermined.’
Many contributors suggested that nowadays GPs were not just underappreciated, but ‘scapegoated’, being criticised and unfairly blamed for problems including difficulties meeting patient demand for appointments. The government and the media were cited as the main adversaries; ‘GP bashing’ and being ‘hounded’ and ‘battered’ were all mentioned:
‘With all the stick we get from the government, media, and patients, is it worth subjecting your health and sanity all because you get paid well?’
Some GPs were upset that they were not recognised as professionals with special training and skills, fulfilling an important role:
‘We are all viewed as dispensable machines … there to abuse until the pieces fall apart and then discard … Demonised and blamed for society’s ills by the politicians … I fear what the “final solution” will be for GPs.’
Fear of a controlling government was expressed, with GPs described as ‘slaves to the state’ and ‘serfs at the Hell that the coal face has become’, afraid or unable to make a stand:
‘(Sorry for [being] “anonymous” but I am terrified of the CQC commissars).’
Contributors also feared a predatory private sector:
‘I think GP practices are in a mess … my strong feeling is GP practices will land [in] private company’s hand.’
This perception of powerlessness in the face of external threats and demands extended to GPs’ relationships with patients, with many posts about unreasonable requests for appointments, with the GP as victim:
‘The “free at the point of abuse” NHS.’
In the quotes above, contributors express very little possibility of a proactive response, but there were some calls for GPs to stand up and take back control. Those who argued that GPs do possess power typically emphasised that, in order to be able to exercise this effectively, they need to come together:
‘The power we have is as a united front … the GP “masses” need to pull together and shout “No more!” Let’s start to fight for our profession and hold our heads up high again.’
Overall, contributors were concerned about a decline in respect for the role of GP; instead, they felt criticised, undermined, and attacked. Threats were perceived to come from the government, from the private sector, and from patients.
Divided general practice
Much discussion focused on organisations that exist to represent and support general practice. Posts relating to these bodies were very negative, with the British Medical Association (BMA) General Practitioners Committee and Royal College of General Practitioners (RCGP) singled out for repeated criticism. Many contributors expressed disappointment and lack of faith in the ability of these organisations to protect the welfare of GPs or meet their needs, either professionally or in terms of their health and wellbeing. Several posts expressed a sense that the needs of patients were prioritised above those of GPs:
‘ [The] RCGP statement [says] — always put the patient first, at all times. They need to revisit the Hierarchy of Needs in their basic training — I need to eat, sleep, live free of fear, and have hope and some form of reward a long way before I need to serve others to the end of my days.’
Several contributors lamented that the BMA did not act as a union and there were calls for GPs to form a new union and some threats to resign from the BMA and RCGP. GPs did not feel that the organisations necessarily worked in their interests, but were instead political organisations. There were numerous criticisms of the leaders of the organisations for colluding with, or being, politicians:
‘I never had any faith in RCGP leaders. They are politicians.’
‘I am utterly despairing of the responses from our “leaders”. It is completely unrepresentative of the vast majority of grassroots GPs. There will be no action from the RCGP. It’s time to form a new union or leave. I am totally gutted.’
Some contributors presented themselves as the ‘rank and file’ of general practice, working hard to meet the needs of patients, in contrast with those GPs who had taken on senior management roles in CCGs, or positions on committees. GPs who had taken on these roles were described in disparaging terms, as undertaking activities that were of low value, or even damaging:
‘ [Referring to the new contract] usual utter meaningless tosh, negotiated by our “colleagues” that spend more time in meetings than consulting.’
‘We are being psychologically abused by psychopathic snakes in suits, some of whom are doctors who have gone over to the dark side.’
Analysis revealed a sense of being let down by professional organisations and betrayed by colleagues. Contributors suggested that GPs taking on senior management roles have abandoned them, leaving them to do the important clinical work.
DISCUSSION
Summary
This study explored readers’ reactions to articles published on a widely read online general practice website, PulseToday, through analysis of readers’ comments. The aim was to explore reactions to news stories published on PulseToday about health policy changes, with a focus on access to care. Analysis focused on dimensions of a debate taking place between people involved in general practice, about the changing role of the GP and their position in society. Although the sample was non-representative, access is a core current policy focus4,6,7 and contested topic,5 and the debate is therefore one that merits attention. Concern about the demand and strain on general practice was perhaps to be expected. However, the analysis revealed several dimensions to this concern: contributors’ underlying feelings about their work and place in the NHS; constraints to GPs’ control of their own working practices; a perceived loss of respect for the role of the GP; and disappointment with representative bodies and GP leadership. Contributors presented themselves as the rank and file of general practice, working hard to meet the needs of patients, differentiating themselves from GPs who had taken on management and leadership roles. Some GPs seemed fearful of the implications of government policy, the private sector, their own leaders, and even patients.
Strengths and limitations
This study gathered perspectives expressed in a forum that had not been studied previously. Using a ‘netnographic’ approach meant that data were collected from the field and were unsolicited and spontaneous, unlike other forms of qualitative data such as those generated through interviews, in which topics are introduced by the researcher. Data were collected from an online community that posts comments in relation to material published in one online magazine. The authors did not have access to any detail about contributors beyond the content of their posts. In line with the online ethnographic approach,24 and considering limitations that apply to social media research in general,25 the sample is unlikely to be representative of GPs as a whole and the findings cannot be generalised across general practice.
Furthermore, there are issues pertinent to research using online commentary: commentators may present a performance online that does not actually reflect their offline life,26 they may post comments intended to provoke a reaction from others — commonly known as ‘baiting’ or ‘trolling’, or they may look to conform with the views of, or impress, others who they know will see their comments, including ‘anonymous’ users who actually know each other offline.
In relation to the study sample, it is possible that those commenting on PulseToday have more negative perceptions, greater strength of feeling, or more extreme views than most GPs. Therefore, the findings should not be interpreted as a barometer of average GP opinion. Nonetheless, the data collected have internal validity as they represent dimensions of the debate as presented publicly in the main online UK GP magazine. Also, the analysis reveals the way in which GPs included in the sample framed their reactions to and positions on current changes in primary care. Although potentially extreme, these views are publicly available, widely read, and, according to the authors’ own anecdotal experience, often hotly debated among some GPs and other health professionals, as well as linking to broader debates in both the popular and academic press.
Comparison with existing literature
There are parallels between the findings of this study and recent evidence about GPs’ attitudes to their work life: negative media portrayal,9,10 meeting the requirements of external bodies,9 a target-driven culture,10 paperwork,9 and increased demand from patients9 have all been found to impact on GPs’ job satisfaction. Previous research found that GPs were resentful of changes to their contractual conditions27 or the implementation of government policy around governance arrangements and increased bureaucratic accountability,28 which they saw as reducing their freedom to organise their own work.
Beneath these concerns lay a deeper reflection on understandings of professionalism and professional identity in general practice. Autonomy and self-regulation have traditionally been central to understandings of professionalism in medicine as a whole.29 At the inception of the NHS, GPs retained their status as self-employed business people,23 unlike salaried hospital consultants. Some argue that this independent status inhibits managers’ capacity to influence general practices.30 Tensions between professional and managerial work have received much attention in the literature, in terms of debate around what happens when professionals are faced with bureaucratic rules or control mechanisms, such as guidelines, frameworks, or reporting requirements.23 In general practice, some research has found that GPs may resent the introduction of, for example, clinical guidelines but do not actively oppose them,28 while other evidence suggests a more resistant stance.23 The findings align closely with those of Harrison and Lim,23 which found that GPs are resistant to bureaucracy, and it is notable that a resistant stance was found previously in a study of online debate between GPs.28
Contributors in the study sample seemed to differentiate themselves from GPs who had taken on management or committee roles. In previous research with GPs who have become managers, some clearly self-identified as GPs rather than as managers,31 whereas others perceived tensions between their identities as clinicians and as managers, wanting to retain a strong clinical identity but finding this difficult in reality.32 The analysis did not suggest any such recognition of this tension experienced by GPs who had taken on senior management roles. It may be that the study sample includes GPs who have a traditional view of what it means to be a GP — one that precludes taking on a management role — or it may be that their views reflect a more widespread cynicism.
Beyond extant findings, this study signals a deeper sense of powerlessness among some GPs than previous studies, which is sometimes expressed as a kind of victimhood. The passivity with which victimhood was expressed stood in tension with more strident calls for opposition and with the ultimate threat of leaving general practice work. Alongside the resistance observed, there was also therefore a strong sense of resignation to the status quo, often combined with nostalgia for how things ‘used to be’.
Previous research has depicted the NHS as an institution with an ethos and set of values with which its workforce as a whole identifies: egalitarianism, public service, and an emphasis on patient welfare.32,33 Although there is some espousal of these values among the posts analysed, there were also criticisms and blame of patients, as well as calls for GPs to move to private practice. It is possible that these posts reflect a different, less altruistic set of values, or they may be the result of contributors seeing private practice as the only way for general practice to survive and, at least partially, preserve the stated values of the NHS.
Implications for research and practice
Further validation of the study findings is evidenced by their consonance with previous research showing dissatisfaction among GPs, resentment of and opposition to policy changes, and demonstrating sharp divisions in general practice, particularly over the issue of private practice. This study contributes a novel empirical site to this debate, the findings from which suggest a complex mix of resistance and resignation among GPs about the changing character of their role and the organisations and institutions in which they are situated. This ambivalence deserves further attention as it has potential to shape responses to further change in unpredictable ways. These findings also have relevance for general practice workforce policy and planning. GP retention and recruitment are inherently linked to a strong NHS, but recruitment efforts of recent years have not met their goals and further work is required to recruit and retain GPs. By extending understanding of widely recognised GP dissatisfaction, these findings could help guide policymakers and professional leaders in their GP workforce endeavours.
Notes
Funding
This project was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Greater Manchester. The views expressed in this article are those of the authors and not necessarily those of the NIHR.
Ethical approval
The process for notifying the university of primary research projects was followed; confirmation was received from the university that the study did not require review by an ethics committee.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
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- Received October 8, 2017.
- Revision requested November 17, 2017.
- Accepted January 19, 2018.
- © British Journal of General Practice 2018
This article is Open Access: CC BY-NC 4.0 licence (http://creativecommons.org/licences/by-nc/4.0/).