In Rachel Handscombe’s previous article for the British Journal of General Practice she reflected on what training for a marathon can tell us about achieving and sustaining peak performance as a GP. Her prescription was ‘more rest, variety, encouragement, and acknowledgement that we are doing our best’.1
This article is about the other side of the story, and it revolves around the person–situation debate (which has been raging since Sigmund Freud 130 years ago), that being: do we possess stable traits that can reliably predict the action we will take, or are we for the most part slaves to the situation? We struggle with the latter possibility because a sense of control is an important part of effective psychological functioning. However, an increasing number of psychologists are coming around to the view that we have far less agency than we think: ‘so decisions are being made, not by a conscious rational agent, but by the underlying [unconscious] processes. The rational self only notices the decisions being made and thinks that it is the author of these decisions.’2
THE SURVIVAL INSTINCT
The debate is highly relevant to the future of general practice in the UK. In 2017, the Daily Telegraph observed that ‘the average GP works a four-day week’.3 In the same article the Head of Health Education England was quoted as saying that ‘the millennial generation did not want to work the hours done by baby boomers’. He is clearly a fan of trait theory: the notion that our characters determine our actions. He probably sees millennials as being disorganised, emotionally unstable, and lacking perseverance; perhaps even in need of a course on personal resilience.
As a coach to a number of GPs, I see people with a wide range of traits all making similar decisions — to work part-time, to become locums, to leave the profession altogether. Somewhere deep within the human organism a subconscious survival instinct is being triggered. And no amount of personal resilience training can resist it.
I believe one can only understand what is happening from a situational or systems perspective: we need to think less about the so-called ‘feckless’ millennials and more about the system within which we expect them to work. The ‘system’ operates at different levels: the local GP practice, the local healthcare environment, the NHS as a whole, and nationally.
I might contend that the traits that GPs and their managers need most are not perseverance but curiosity and assertiveness. Curiosity for how the system within which they are working is contributing to — and when I say contributing, it is closer to dictating — their feelings of being on a treadmill, unappreciated, and having no variety. Assertiveness is required so that GPs can play their part in reinventing the system.
In the first instance, GPs need allies. They need more political influence in the higher echelons of the NHS and government. The role of GP practice in early intervention, managing frailty and, frankly, keeping people out of expensive acute hospitals, needs to be championed and articulated. The campaign can be coordinated nationally but needs an advocate in every NHS region and parliamentary constituency in the UK. How many people understand that the primary care system handles 90% of health-related contacts with 10% of the resource available to the NHS? With more political goodwill behind them, GPs and their practice managers could harness their curiosity and creativity to reimagine the service. Here are some examples.
SOLVING THE PROBLEM OF THE NHS
As a coach I receive supervision and so do my therapist friends, social workers, and many youth workers. This has both a normative and a restorative function. With GPs handling so many complex cases, regular supervision would offer them an important release valve and help address the retention crisis.
At the next level in the system, the local healthcare environment, further development of the alliance between primary care, secondary care, and social services can deliver cost-efficient care at home for many patients who are terminally ill. As Rachel Clarke4 observed in the Guardian last year, only one in five of us will die at home, despite two-thirds of us wishing to do so.
At NHS level, and as Paul Hodgkin recognised in the fable of the Gatekeeper and Wizard updated for the 21st century,5 the role of the GP needs to be redesigned to keep up with our digital times. In a beautiful turn of phrase Hodgkin says: ‘Standing in the wings of all our lives is the person we are about to become. Perhaps the person she was about to become was not a gatekeeper but a translator, positioned at the boundary between the patient’s old understanding of themselves and the new.’
Certainly in this increasingly fragmented world there is a need for someone who can integrate the psychological, social, and medical aspects of the individual.
This metamorphosis will not take place overnight, but we need to take the first steps towards it. And when it happens it is to be hoped that the GP will have retained that most vital of roles: the human face of the health service, providing continuity and one-to-one support, ensuring that the patient is not alone in their illness, an integral and indispensable part of the community.
A GP friend of mine who recently complained to her manager about her level of unpaid overtime was told ‘we can’t solve the problems of the NHS’. You can’t fail to spot the irony. The current generation of GPs is indeed trying to solve the problems of the NHS, but in a way that, although well intentioned, is misguided and ultimately self-defeating. We must find a new way to do it and assertiveness and curiosity are the building blocks.
- © British Journal of General Practice 2019