Abstract
Background In the context of the biggest GP workforce crisis since the NHS began, the alleged negative portrayal of UK general practice in the media is often cited as a reason for falling recruitment.
Aim To explore how general practice and GPs are depicted in UK national newspapers.
Design and setting A thematic analysis of all newspaper articles mentioning GPs or general practice published in the UK from late October 2016 to early October 2017 was undertaken, along with a sample of articles on hospital medicine.
Method Articles were identified through the LexisNexis® Academic UK search engine; relevant titles were tabulated and data extracted. A preliminary coding scheme was developed through discussion and used to categorise data; additional codes and categories were added iteratively as the analysis progressed.
Results In total, 403 articles on general practice or GPs were identified, and 100 on hospital specialists or specialties were sampled. Articles depicted UK general practice as a service in crisis, with low morale and high burnout, and leaving gaps in patient care. The traditional family doctor service was depicted as rapidly eroding through privatisation and fragmentation, with GPs portrayed as responsible for the crisis and the resulting negative impact on quality of care. Hospital specialties were also illustrated as under pressure, but this crisis was depicted as being the fault of the government. GP leaders interviewed in the press were usually defending their specialty; hospital doctors were usually sharing their expertise.
Conclusion Newspaper portrayals of general practice are currently very negative. Efforts to influence the media to provide a more balanced perspective of general practice should continue.
INTRODUCTION
General practice in the UK is facing an unprecedented recruitment and retention crisis. The General Practice Forward View 1 outlined plans to recruit 5000 new GPs and retain an additional 500 by 2020 through national campaigns, retainer schemes, and financial incentives. Despite these efforts, the number of practising GPs continues to decline.2 Research studies (mostly surveys) have explored why recruitment to general practice is at an all-time low. Medical students cited:
alleged denigration of general practice by hospital-based colleagues;
poor work–life balance;
a stressful working environment, with burnout witnessed on GP rotations;3,4 and
perceived low professional status, limited research opportunities, and low intellectual stimulation compared with hospital specialties.4
Foundation doctors and GP specialist trainees recalled being told that they were ‘too good’ for general practice when discussing future career paths.5 GP trainees who had made a commitment to general practice were put off partnership and full-time salaried opportunities through perceived:
A survey of GPs showed that up to 37% are highly likely to leave frontline general practice in the next 5 years.8 Qualitative research studies suggest that one of the reasons for this is the lack of perceived value of general practice-based health care by the government, NHS, and the media.9 This not only affects the morale of doctors, but also shapes the opinions of wider society.9
A recent Royal College of General Practitioners survey of medical students found that they believed that the current political environment, newspapers, and online and TV news portrayed general practice in a negative way,10 affirming previous research.6,8,9 The media is widely portrayed as depicting an underfunded specialty in crisis and is engaged in ‘constant GP bashing’;6 however, the authors could find no previous systematic studies of such depictions.
To redress this gap, the authors sought to review all UK newspaper articles related to general practice in a 12-month period. In particular, they wanted to explore how articles represented both GPs and the specialty of general practice to the public.
METHOD
A thematic content analysis, as outlined by Green and Thorogood,11 was undertaken on a corpus of newspaper stories relating to general practice, along with a smaller comparative sample about hospital medicine. Content analysis is a systematic approach to coding and synthesising large amounts of data, allowing for both description (overview of topics covered) and analysis (interpretation).12 The online database LexisNexis® Academic, UK (https://www.lexisnexis.com/ap/academic/form_news_wires.asp) was used to search for articles. Key search phrases included ‘general practice’, ‘GP’, ‘crisis’, ‘pay’, and ‘privatisation’; four different searches were undertaken to maximise the number of articles included. All titles relating to the primary care system, general practice as a specialty, and individual stories on GPs published from October 2016 to October 2017 were extracted.
How this fits in
Negative portrayals of general practice in the media have been shown by previous research to contribute to the current recruitment and retention crisis in general practice. In this study, just over 400 articles from national mainstream newspapers relating to GPs or general practice over a 12-month period were reviewed. These showed various ways in which general practice was depicted in a negative light. Most commonly, general practice was described as a specialty in crisis with staff shortages, poor accessibility, and inefficient organisation. GPs were depicted as clinically incompetent and lacking in virtues (being depicted, for example, as lazy, uncommitted, and greedy). Work needs to be done to encourage the lay press to convey a more balanced view of general practice and not blame its current crisis on GPs themselves.
A limited search of stories related to hospital-based specialties was undertaken to provide a broadly comparative (but smaller) sample. Separate searches were performed using terms such as ‘hospital’, ‘doctor’, ‘crisis’, and ‘pay’ in different combinations.
The first step in the analysis was to gain familiarity with the data. One researcher read through the articles twice, making brief summary notes on recurring topics and issues in the data. Codes were then identified from the data, with details of each news article tabulated into Excel spreadsheets. This was initially performed for the first 100 newspaper articles. Codes were constructed through the identification of recurring topics within the dataset, looking for in vivo categories (words and phrases extracted directly from the articles) and exploring similarities and differences in the newspaper stories. Initial codes included, for example, ‘crisis’, ‘negligence’, ‘recruitment’, ‘retirement’, and ‘working conditions’.
The third step in the analysis was to apply the preliminary coding scheme to the subsequent set of newspaper articles and refine the codes as more data were added to the analysis. The same researcher who read the previous articles read all articles, producing a preliminary coding scheme on an Excel spreadsheet, and extracted data to populate this. A different researcher read a sample of a fifth of the articles from each set, that is, general practice and hospital-based care, and reviewed the coding of data extracts. Both authors then worked together in the fourth stage of the process to organise the codes into themes through an iterative process until agreement was achieved. Sections of data were grouped, then cut and pasted collectively into themes; for example, various codes (including mismanagement, accusations, and negligence) were brought together using the overarching theme of clinical performance.
Once the analysis was complete, the number of articles was tabulated by each publication under each theme. Daily and Sunday publications (for example, Daily Mail and Mail on Sunday) were combined, as it was found that the articles had similar perspectives and framings. Results were organised using reporting guidelines for qualitative studies, as outlined by O’Brien et al.13
RESULTS
A total of 403 articles on general practice and 100 on hospital-based care were extracted and reviewed. Five main themes emerged from the news articles related to general practice:
the workforce crisis;
patient access to general practice;
organisation of care;
GPs’ poor clinical performance; and
GPs’ personal vices (and absence of virtues).
Table 1 shows the number of articles by theme and newspaper. For each theme, key differences were found in the hospital dataset. There were striking differences in the level of coverage of general practice in the different newspapers. The Daily Mail / Mail on Sunday (which, at the time of the study, had the highest reach of all the newspapers in the UK through online and printed publications)14 published nearly one-third (30.0%) of all the articles and the largest number of articles (n = 121) across all themes.
Table 1. Number of published news articles on general practice by newspaper and theme
The five key themes are considered below. By far the most common were the workforce crisis and patient access to GPs (Table 1).
The workforce crisis
More than one-quarter of all articles described the diminishing general practice workforce, including problems retaining experienced GPs as well as recruiting new GPs. GPs were described as retiring early or leaving the profession due to heavy workload and high stress levels, and were reported as being able to do this due to high salaries that had filled their ‘pension pots’:
‘The normal GP retirement age is 60 [years] but many are opting to leave much earlier to avoid heavy taxes on their pensions. These kick in once a pension pot exceeds £1 million — many reach this limit by their 50s, thanks to their generous salaries.’
(Daily Mail, 14 October 2017)
Difficulty recruiting new GPs was attributed to rising workloads and indemnity costs, low morale, and exhaustion. The overall picture was often of a specialty in crisis with a highly uncertain future:
‘RCGP chair Prof Helen Stokes-Lampard warned GPs were “knackered”, “at the end of their tether”, and facing “burnout”.’
(Daily Mirror, 12 October 2017)
Another explanation offered for the workforce crisis was the increasing number of GPs opting to work fewer hours than full time, and turning down full-time positions as salaried GPs or GP partners. Younger GPs were often depicted as lazier than their older colleagues. Articles presenting this narrative implied that GPs had a duty to society to work full time, especially as there was a shortage in the profession. Some newspapers highlighted a particular ‘problem’ of female GPs who worked fewer than full-time hours due to family commitments:
‘The head of Health Education England (HEE) said the millennial generation did not want to work the hours done by baby boomers. Last year a study by the King’s Fund found only one in 10 trainee GPs plan to work full time. Patients’ groups said the trend was “extraordinary” and that family doctors were lucky to be able to afford to work part time, with average earnings of £100 000 for a GP partner. Two-thirds of GPs [aged] under 40 [years] are female, with part-time working popular among those raising families.’
(The Telegraph, 29 January 2017)
Articles describing comparable workforce problems in hospitals did not depict a lack of commitment on the part of the doctors. Rather, they portrayed the workforce crisis as being caused by government decisions, and hospital doctors as striving heroically to deliver the best care in difficult circumstances:
‘NHS staff can only do their best, but their best efforts are compromised by a staffing crisis that is growing ever more acute. That crisis is, at least in part, the consequence of political decisions that were made on the basis of short-term planning and expediency.’
(The Times, 27 July 2017)
Patient access to general practice
The dataset included many stories about GP practices that had closed their lists to new patients or closed down altogether (typically because of staffing shortages or other pressures), and about patients being unable to get appointments at their own GP surgery:
‘Millions of patients are being denied GP appointments in the week, MPs warn today. In a damning report, they say that half of England’s 7600 surgeries shut down at some point during the core hours of 8am and 6.30pm. Many take a 2-hour lunch break or have a midweek afternoon off.’
(Mail Online, 27 April 2017)
These stories presented patients as being inconvenienced and put at risk through disruptions in care.
In 2017, a winter crisis affected the NHS, with a lack of beds in hospitals, over-stretched accident and emergency (A&E) departments, and a lack of access to GP appointments. Most stories that covered this crisis depicted the government as assigning part of the blame to general practice and linked it to a policy push, at the time, for GPs to offer a 7-day service:
‘The Prime Minister has expressed frustration at the failure of more practices to offer extended opening hours and take pressure off swamped hospital A&E departments. Downing Street warned surgeries in England which refuse to move to 8am to 8pm opening, 7 days a week, will lose funding unless they prove there is no demand by patients.’
(Daily Express Online, 15 January, 2017)
Such accounts were sometimes explained in terms of GPs’ lack of commitment or professionalism:
‘… in place of the old tradition of selfless compassion and responsibility, there is, among some [GPs], a new spirit of greed and entitlement, masquerading as concern for the public …’
(Daily Mail, 12 January 2017)
Organisation of care
Stories about the organisation of general practice included changes in practice size, changes in staff, and new models of care (including full or partial privatisation). GPs were depicted as being ‘encouraged’ to form larger practices, which were viewed by government as offering the benefits of economies of scale and improved patient access:
‘Thousands of GP practices are under threat of closure as 7500 surgeries are transformed into 1500 “superhubs” under government plans to expand opening times … Officials said local GPs would be free to take their own decisions, though it would be difficult for practices to survive if they did not evolve.’
(The Telegraph, 17 March 2017)
No articles in the dataset explained the potential benefits of smaller practices to patients, such as greater continuity or personalised care.15 Articles describing the reassignment of professional tasks from GPs to other health professionals tended to depict these changes negatively; in particular as carrying unacceptable risks:
‘“It sounds very much to me like doctors on the cheap,” said Joyce Robins of Patient Concern. “I am really rather knocked back by it. Of course, doctors are overrun at the moment but this is worrying and I think patients will be concerned. It depends exactly on what they are doing but their role sounds quite extensive for just 2 years of training. My heart quakes”.’
(Daily Mail, 14 July 2017)
Articles on new service models focused on options that would (allegedly) provide prompt and flexible access to general practice, most commonly via a smartphone app offering a near-instant video consultation. This was depicted as something many people, especially young professionals, would be willing to pay for; perhaps through private providers:
‘Young people would prefer to pay for a same-day service than wait weeks for an NHS consultation. Around 40% of millennials say they feel rushed during their regular NHS appointments. It is clear that the existing NHS GP model is outdated and is unable to service the new millennial generation who want convenience.’
(Mail Online, 21 April 2017)
The emergence of ‘convenience’ services for millennials was not universally depicted as a good thing. Some articles highlighted a potential widening of inequalities:
‘NHS patients will become “second-class citizens” as general practice increasingly becomes a two-tier health service … They [private providers] offer times that suit patients and the chance to see the same GP at each visit, benefits that few NHS patients are offered any more because of the heavy and growing pressures on family doctor surgeries.’
(The Guardian, 8 February 2018)
Whereas GPs were typically depicted as seeking to personally profit from new, privatised (or part-privatised) service models, hospital doctors were depicted as challenging government plans for privatisation and defending the traditional NHS:
‘ [Hospital doctors agreed that] the crisis in NHS hospitals has been consciously created by the government, in order to accelerate its transformation plans for private sector takeover of health care in England.’
(The Times, 27 June 2017)
Additional narratives on the organisation of care were related to safety concerns in general practice, including suggestions that the 10-minute consultation was too short to deliver effective care, and articles that claim to be based on Care Quality Commission reports, and which alleged that one in seven practices did not meet safety standards.
Poor clinical performance
One in eight articles in the dataset presented here described poor clinical performance of GPs; half of these were from the Daily Mail (Table 1). Only one article described a prompt diagnosis by a GP, which saved the patient’s life; the remainder constructed an overriding narrative of clinical failure characterised by missed diagnoses (particularly cancer), incorrect prescriptions, failure to prevent suicide, and refusal to treat patients who subsequently died:
‘Teenage girl, 19, dies of bowel cancer just months after her bungling GP dismissed the pain she was in as CONSTIPATION and prescribed her laxatives.’
(Mail Online, 16 June 2017)
Although there were examples of patients in hospital who were the subject of life-changing errors, these were typically depicted as having occurred due to pressures the doctors were under, not the doctors’ own incompetence:
‘The UK’s youngest doctors are making critical mistakes by being too stretched. Junior doctors have been filmed making potentially life-threatening errors during patient assessments — which they made while “under pressure” to free up hospital beds.’
(Mail Online, 24 April 2017)
Personal vices (and absence of virtues)
Hospital doctors were often depicted in terms of their personal virtues, being described as hardworking, heroic, and courageous:
‘The response from my colleagues represented everything great about this country. Compassion. Empathy. Tireless self-sacrifice and, above all else, profound unity.’
(Mail Online, 24 May 2017, describing hospital services under pressure)
However, some articles also described hospital doctors as at, or near, burnout because of overstretched services and workforce pressures. Articles about similar issues in general practice focused on the services themselves (described as ‘inadequate’) and did not highlight the personal qualities of GPs working under those pressures.
One in seven stories in the sample of articles on general practice covered GPs’ alleged vices (negative character traits); virtues were not a focus. Such stories included GPs perpetrating acts that were both illegal and unprofessional, including domestic violence, sexual harassment, assault, fraud, murder, and conducting sexual relationships with patients:
‘Perverted GP, 64, admits sexually abusing pregnant patients and girls as young as 12 in his surgery for decades.’
(Mail Online, 9 November 2017)
Nearly half of these were published by the Daily Mail. GPs were also depicted as greedy when they charged patients for non- core services, such as passport signatures.
DISCUSSION
Summary
This study of over 400 newspaper stories about general practice and GPs in the UK, with a smaller comparative sample of articles about hospital doctors, covered the workforce crisis (insufficient GPs), access to general practice (usually inadequate), organisation of care (often inefficient), GPs’ clinical performance (usually poor), and their personal characteristics (numerous vices or few virtues). The findings affirmed and extended previous research that had cited negative media portrayals as a major reason why general practice is currently seen as an unattractive specialty by medical students, junior doctors, and GPs in training,6,8–10 but which had not directly studied those media portrayals.
The authors acknowledge that many of the articles reviewed for this analysis offered a fair assessment of the current realities of UK general practice. Stories of high workload, low morale, exhaustion, and burnout among GPs have all been documented in recent years.7 But, almost without exception, newspaper articles framed this narrative in a particular way that reflected negatively on the GPs themselves. They depicted the overstretched service as being due primarily to GPs’ unwillingness to work hard (for example, working part- time, taking early retirement, and playing golf) rather than to structural or fiscal deficiencies, rising patient demand, or insufficient numbers of doctors entering general practice. There was a striking lack of balance in the news articles, with a near-absence of positive portrayals of the specialty and no articles examining the effect of government economic policies on general practice or offering positive coverage of extended-hours surgeries or 7-day access.
Strengths and limitations
This study was novel in that it directly and systematically analysed a corpus of over 400 news articles on general practice spanning a 12-month period. Those articles were compared with a smaller (but still extensive) sample of 100 articles on hospital medicine, allowing a novel comparison to be made of the language used to describe similar scenarios in different settings.
There are a number of limitations to using newspaper articles as sources, the chief one being that media portrayals may not reflect the wider public’s perceptions of the specialty. The LexisNexis® Academic system does not have as sophisticated a search engine as academic databases, so some articles may have been missed despite multiple searches. Newspaper articles tell us what is published but they do not give a direct insight into what is driving the negative portrayals of general practice or who stands to gain from these.
Comparison with existing literature
To the authors’ knowledge, this is the only review analysing the portrayal of GPs and general practice as a medical specialty in the national lay media. The first four themes described in the summary above have been found by other recent researchers, who have shown general practice to be perceived by medical students and doctors as a low-status, under-resourced, under- staffed, and high-stress specialty in which professional fulfilment is increasingly hard to find.6,8–10 The fifth theme — that GPs are morally deficient (exhibiting many vices and few virtues) — is a new, important, and somewhat alarming finding.
The findings show that the traditional public image of the family doctor as a ‘virtuous practitioner’ (upstanding, honourable, courageous, and selfless) who was personally devoted to their patients and retired only after providing decades of uninterrupted service to a particular community16,17 has been replaced in the media by images depicting GPs’ moral failings (lazy, greedy, uncommitted, selfish, sexually disinhibited, and even violent). This ‘moral decline’ of the GP was not, apparently, cited in surveys as a reason for students’ and trainees’ reluctance to enter general practice (though closed-item questionnaires may not have asked the relevant question), but it may have important subliminal effects on both the public and young clinicians.
Implications for research and practice
The negative depiction of GPs and general practice in the mainstream media has important implications for both research and practice. The most pressing research question is surely how these entrenched negative stereotypes can best be countered — among the lay public, doctors, and medical students — while also acknowledging the grain of truth in some of the portrayals (especially in relation to workload and morale).
To counter the depiction that GPs themselves are responsible for the escalating workforce crisis in general practice, it is perhaps necessary to convey an evidence-based account of how the increasingly diverse and ‘part-time’ GP workforce contributes to the resilience of the current service. General practice is now 52% female18 and many GPs of both sexes choose to work less than full-time; either for personal reasons or as part of a portfolio career that might include, for example, a clinical specialist, commissioning, teaching, or research role. Contrary to the depiction of part-time GPs as selfish and uncommitted, evidence suggests that portfolio careers and flexibility may be associated with greater job satisfaction and lower levels of stress and burnout,3 and such flexibility has been one of the traditional selling points of general practice.
It is also, arguably, necessary to produce a counter-narrative to the uncritically positive depiction of the new service model of video consultations offered by private providers. Targeted mainly at young, working patients who seek convenient (prompt or remote) consultations for one-off problems, these ‘doctor in your pocket’ services are presented in the mainstream media as a solution to the problem of poor access to GPs. A more critical perspective, evident in the medical media, depicts these services as ‘cream skimming’ healthy patients, offering little support for those with chronic conditions or mental health needs, and threatening the financial viability of the local family doctor.19,20
To counter the depiction in the mainstream media of general practice as disorganised and inefficient, realistic messages about the funding crisis in general practice need to be conveyed. In addition, the reorganisation of primary care services to compensate for the worsening shortage of GPs could and should be depicted in a more positive light. Various initiatives have been introduced in recent years to extend the scope of practice of other professions including community pharmacists, nurse practitioners, and physician assistants21–24 to take on various roles traditionally performed by GPs, as well as training receptionists in extended roles such as care navigators.25 The evidence base on this new skill mix is relatively sparse but positive in relation to patient satisfaction, safety, and outcomes.21–25
The finding that GPs tend to be depicted in the mainstream media not just as clinically incompetent but also as morally deficient again highlights the need for a strong and consistent counter-narrative. Notwithstanding the fact that ‘bad apples’ exist and the public has a right to know about them, perhaps it is time for a concerted campaign to remind the public of the core values of primary care; including relationship-based care, continuity of care, care that is undifferentiated by age, gender or disease modality, and care that is oriented to protecting the vulnerable and reducing inequalities.26
In addition to the need to challenge negative stereotypes of GPs and general practice in the mainstream media, this study offers a partial explanation for the ‘GP bashing’ by hospital consultants reported by a large sample of Oxford medical students.4 If consultants get their views about GPs partly from distorted media depictions, it is perhaps unsurprising that these views are sometimes negative. The implication for practice is that hospital doctors need to be offered a more evidence-based picture of their primary care colleagues.
This paper has analysed the depiction of general practice and GPs in UK national newspapers over a 1-year period and identified various ways in which the specialty is framed in a negative light. Importantly, GPs themselves are depicted as contributing to the problem, both through their actions (for example, taking early retirement) and more fundamentally through their poor character. Given the falling numbers of doctors entering general practice, it is an urgent priority to challenge this depiction by the media and encourage more positive depictions of the specialty and its members; perhaps by seeking out positive stories and crafting and circulating press releases about them. Further research is needed to understand how negative messages in the mainstream media can be systematically countered.
