Exploring ‘work–life balance’ at appraisal and how this links with organisational support

ACKNOWLEDGE AND ASSESS THE PROBLEM

In Wessex an optional WLB questionnaire was added to an online appraisal platform,⁸ to encourage doctors to think about their own WLB. This commenced in June 2018 and it has proved to be popular, being used in the first year by 2602 GPs (49% response).⁹ The quantitative results from the first 6 months (n = 1046) were used for statistical factor analysis, indicating that 54% of GPs responding have significant ‘work-overload risking burnout’. Could these results be biased by self-selecting responders who have poor WLB? This is a valid possibility, but the numbers and response rate are more than other studies, and the project continues to gather results extending to the non-responders.

The qualitative evaluation of the WLB questionnaire (n = 67, 25% response) shows that 88% found the WLB questions useful for reflection by raising awareness, prompting reflection, and quantifying WLB: ‘It made me think more about the different elements of WLB’; ‘It allows GPs’ voices to be heard’; ‘feels taboo to discuss this subject … opens it up for discussion’; ‘elephant in the room’; and ‘it would be good for a summary to be sent to the media … to highlight the crisis in the GP workforce’. The results show GPs tend to neglect their own health and avoid taking time off (presenteeism): ‘not surprised as I know home life is suffering’.

Twenty-eight per cent were surprised by their results: ‘I never realized the scale of pressure was so high’, with a ‘general low morale’. But many doctors have a good WLB, particularly by working part-time: ‘I knew my balance was good’, ‘happier since doing locum work’. And 22% made changes with lifestyle improvements, exercising and changing their work patterns: ‘I hadn’t realised how much an impact a change would have made.’ But some felt constrained from making changes because of staff shortages: ‘partner off sick’, ‘I have no option but to keep on working’, or because of financial commitments: ‘I can’t afford to with children at university.’ The questions were valued to help facilitate change: ‘reducing caffeine intake’, ‘enforcing lunch break’, ‘take a walk at lunch time’, and ‘cease working at weekends’. The WLB questionnaire is a step towards ‘acknowledgement and assessing WLB‘, it is popular, the cost minimal, and it could be extended to all GPs.

HARNESS THE POWER OF LEADERSHIP

GPs set an important example in promoting wellbeing programmes to everyone around them and to patients.¹⁰ At the RCGP Annual Conference 2019 there were some inspiring presentations by GPs encouraging their colleagues to improve their health and wellbeing.

DEVELOP AND IMPLEMENT TARGETED INTERVENTIONS

Inefficiency with administrative tasks, checking results and letters, is often cited as a reason for leaving the NHS for alternative work.³ By reviewing roles, delegating work, using clerical staff effectively, using integrated e-records, and devolving work to the healthcare team allows more time for better patient care. The GP practices that have successfully implemented changes are generally stable, well staffed, and with a good team ethos.¹¹

CULTIVATE COMMUNITY AT WORK

Peer support is vital for dealing with the pressures, significant events, and complaints that are now commonplace for GPs. Both formal meetings and informal coffee breaks enhance teamworking and professional relationships.¹² When GP practices are under pressure with staff shortages, these meetings are often dropped, with a knock-on decline in teamworking and morale.

USE REWARDS AND INCENTIVES WISELY

Productivity-based pay may lead to overwork and burnout. But opportunities for flexible working with a good WLB are important considerations for the new generation of GPs, combined with time for professional development in education, research, and leadership. First5 (the support network for newly qualified GPs in their first 5 years) and Associates in Training (AiT, the associate GP training programme) are encouraging more doctors to choose to become GPs. But incentives are important throughout careers to live healthily, stimulate interests, and defer early retirement through reducing work intensity and administration, with increased time for patient care and work–life flexibility.¹³

ALIGN VALUES AND STRENGTHEN CULTURE

Doctors are altruistic, with high professional and ethical values that focus on the patient. Sharing these values strengthens the organisation. And organisations that promote health and wellbeing for their workforce gain loyalty; ‘get a reputation as a good place to work‘, ‘really care about staff‘, and strengthen the culture and improve the wellbeing of the workforce,¹⁴ which brings benefits to patients too.

PROMOTE FLEXIBILITY AND WORK–LIFE INTEGRATION

Doctors’ work is often stressful, with long hours. Many value flexibility and part-time working to fit in with family commitments, which leads to improved satisfaction and wellbeing. This is important to attract and retain doctors in the NHS.¹³

PROVIDE RESOURCES TO PROMOTE RESILIENCE AND SELF-CARE

There has been some cynicism regarding resilience training: ‘you only want to make me more resilient, so you can keep piling work on me‘. But doctors who have a good WLB generally are healthier, feel better, enjoy work, and set a positive example. The NHS needs to promote WLB for all doctors, and there are all round benefits: healthier doctors, better patient care, and reduced healthcare costs.¹⁵ Around the UK there are some excellent examples: walking to collect patients from the waiting room, practice walks, park runs, and using bicycles for home visits.

FACILITATE RESEARCH AND SUPPORT FOR DOCTORS’ WELLBEING

The Mayo Clinic Program has reduced doctor burnout from 48.8% to 32.9%,⁶ but research needs to continue around WLB to guide support for GPs. Doctors suffering from poor WLB and burnout are often reluctant to seek help, but including WLB in the appraisal discussion is a method to ensure it is addressed.

FINAL THOUGHTS

Appraisal commenced in 2002 to promote lifelong learning and continuing professional development (CPD), but it changed with revalidation in 2012. Many doctors felt that appraisal became a summative assessment, losing the pastoral element. Appraisal has evolved, balancing educational development with the requirements of revalidation assessing clinical competence, but there are other core attributes to ‘being a good doctor’ such as care, compassion, and looking out for vulnerable colleagues.

The WLB questionnaire has shown that checking WLB is valued, encouraging doctors to take more personal responsibility about their WLB, and when combined with organisational support it can lead to significant improvements.