Twenty-three GPs working in 16 practices responded positively to the invitation to participate and, of these, 21 were interviewed. Eleven worked in urban practices, 14 had been practising as GPs for ≥10 years, and 14 worked in practices of ≥5 GPs. Median interview duration was 29 minutes (range = 12–48 minutes). It was found that GPs reported multiple operational failures that were hugely burdensome, and required what was termed ‘compensatory labour’ to address them.
Operational failures encountered during GPs’ work
GPs reported a significant burden of operational failures. The most common failures related to problems in the supply of information to them from sources outside of their own practice. Delayed or missing hospital discharge letters were frequent, but excessive information from hospitals was reported to be as much of a problem as too little information. For instance, GPs described important information being lost in 12-page discharge summaries where they ‘couldn’t work out the wood from the trees’ (GP18). Hospital letters often included recommendations for specific investigations or medications for patients but left it to GPs to clarify who was responsible for implementing them. Efforts to get necessary information from hospitals were further frustrated by hospital protocols stating that certain information (for example, laboratory results) could not be shared with practice clerical staff:
‘Time is often taken up with the interface for communication between us and secondary care. So letters that were meant to come but didn’t come, letters are not giving enough information, or not explicit. This morning I had a letter that was pretty ropey in all respects … if they’d just given me the dose it would have been straightforward .’
(GP2)
‘Information clutter is an absolutely overwhelmingly gargantuan issue.’
(GP6)
Operational failures also complicated GPs’ communication with hospitals, sometimes resulting in delays for patients. For instance, changes in care pathways and requirements for specific forms that themselves changed often made organising secondary care difficult and frustrating, with GPs’ referrals sometimes returned to the practice without any clinical action being taken:
‘We used to refer to the clinician that we thought was the correct clinician to see the patient, now we don’t have that option, they have to go through a central service, which causes a delay for the patient — the patient gets frustrated, we end up having to see the patient more often, that causes more inefficiency for the GP.’
(GP19)
GPs also reported problems associated with electronic referral systems to community and social care, which had replaced previous direct contact with colleagues. Electronic referrals left GPs uncertain when the patient would be seen, hindered their ability to offer multidisciplinary community-based care, and pushed them to refer patients to hospital that would otherwise have been cared for at home:
‘All of us can spend an hour sometimes trying to get somebody some care to keep them at home, and often there isn’t any, and we go round and round in circles. We spend an hour phoning up and then we get nowhere. So, I think we’ve all given up now. And then, of course, we send the people to hospital inappropriately […]but we feel guilty because it’s just not how we’re meant to practise.’
(GP18)
Communication with community pharmacies was also vulnerable to inadequate information transfer, for example, through the loss of electronic prescriptions in the journey between practice and pharmacy. This is an issue that was often left to GPs to resolve:
‘People say I ordered my prescription three days ago, for some reason they haven’t got the prescription between the prescription system or the pharmacist […]so you find the receptionist coming into the room to say we can’t find this prescription, it’s lost, can you duplicate, print and sign it.’
(GP11)
Processes within practices themselves were not immune to operational failures. GPs reported that their work was disrupted by failures relating to equipment, including broken electrocardiograph machines, missing thermometers, and unstocked materials such as urine containers. Technology problems, such as crashing or non-booting computers, interfered frequently with access to electronic health records and added pressure to already strained 10-minute consultations:
‘I was trying to do a prescription for a patient. The computer froze. I couldn’t get it to unfreeze. I stopped that consultation, had to re-boot the computer and then go back into all the different systems that I was in, get the prescription out and the patient had to wait ten minutes, it put me behind; that often happens.’
(GP1)
GPs also reported direct interruptions of their work by other practice staff. Some practices had introduced a system where all urgent queries were directed to the ‘duty doctor’ (a GP rostered to triage phone calls and see emergency cases) with the intention of shielding remaining GPs from unpredictable interruptions and ensuring their clinical sessions ran smoothly. Not all practices used this approach, and where it was in place it was often stressful for the doctor involved:
‘This is why we’ve brought the duty doctor system, so that all those interruptions go to somebody who is not running a normal surgery […] I agree we need to get to the bottom of the problem, but we feel that a typical day should be as smooth as possible.’
(GP11)
‘On a duty doctor day you will be disturbed significantly in terms of calls, knocks on the door, facilitating the nursing staff if they’ve got any questions plus dealing with any queries from reception.’
(GP5)
GPs in rural practices reported spending more time travelling to home visits, so failures relating to home visits disproportionately affected their work. Examples included being called out for duties that other services (for example, district nurses, community emergency response team) did not have the capacity to deliver, wasted journeys due to incorrect patient addresses, or being called to write up drug charts for care home patients that could have been written by hospital doctors:
‘We had a patient who had just been discharged from hospital to a nursing home […] they [the hospital staff] hadn’t written the drug chart. So this came in to be done urgently. And the system failure on our part was that the administrative staff who took the call to book the home visit did not put the new address […] so I went to their home and they were not there.’
(GP11)
Compensatory labour is required to address operational failures
GPs reported that, as patients’ first point of contact with the health service and as the physician responsible for generalist longitudinal care, they were exposed to operational failures in all facets of the healthcare system. GPs felt that their secondary and community care colleagues had both ‘unrealistic expectations’ (GP20) of what general practice could deliver and an inaccurate view of GPs as the ‘default person to look after things’ (GP8). These expectations compounded the effects of operational failures in primary care, resulting in GPs doing work that they felt would be done more quickly or effectively by others, was the clear responsibility of others, or for which they lacked system-level supports:
‘As a GP, I liaise with community rehabilitation or nursing or palliative care or other services and because these various services are quite fragmented and difficult to communicate with, certainly in the last year or two, that interferes or interrupts those kind of tasks. Coordinating complicated care often takes a lot longer than it used to.’
(GP14)
‘They make it very clear that they expect you to do it, and it’s really not appropriate — that can be annoying.’
(GP4)
GPs felt that, as the presumed coordinator of their patients’ care, there was an onus on them to work around the operational failures they encountered. As a result, they were forced into the role of compensating for operational failures, a role that had significant impacts on the character and volume of their work:
‘I’m in the boat where I’d rather do the best for my patient, so if it’s quicker for me to do it, I will just do it, I will take that extra work.’
(GP17)
‘If you’re busy and there’s resistance, you end up just caving in and getting on with it because it’ll be quicker that way.’
(GP1)
The bridging actions taken by GPs to close the gap between what patients needed and the operational failures that got in the way of meeting those needs were labelled as compensatory labour. Compensatory labour was required by the ubiquity of operational failures combined with GPs’ deeply felt responsibilities for synthesising information and coordinating care. The tasks of compensatory labour were characteristically mundane, but, in the context of highly pressurised schedules, they imposed significant burdens on GPs; the frequency of individually small compensations meant that cumulative time losses were highly impactful. Each extra step a GP had to take to deal with an operational failure added to the complexity of completing a task. Having to undertake often very significant amounts of compensatory labour actively configured the work that GPs were doing on a daily basis:
‘… you end up having to write a lot of letters to chase things up — the patient has already been to see you once, you then have to contact them again to explain the results. So, you end up doing three steps, where there could have been just one.’
(GP19)
‘I’m currently waiting on a clinic letter from a consultant that’s been at least around a month […] I will phone the consultant directly and the liaison officer can also help … you make the best of it, you just have to get around the problems.’
(GP12)
Compensatory labour also required trade-offs. Addressing failures as they occurred might achieve short-term benefits for one patient, but shifted risk to other patients by virtue of time pressures or cognitive overload:
‘It’s extra time for us to look through the notes, to chase up on blood test results and sort the problems out […] that limits the time for us doing other things.’
(GP15)
Repeatedly compensating for operational failures that were not of their own doing and were not related to their professional training added to GPs’ feelings of stress and low morale:
‘You feel quite stressed — I like things working efficiently instead of adding to your workload.’
(GP13)
Despite the burdensome nature of compensatory labour, GPs’ actions to remedy failures were generally invisible. Perhaps because compensating for the problems usually resolved them more quickly in the short term than redirecting them to the source, or perhaps because reporting operational failures was perceived as futile, only a small minority reported system-level operational failures to authorities such as GP liaison officers, commissioners, and others:
‘I know that I’ve got to write two letters today to the GP liaison officers — it just takes time […] The frustrating thing with the hospital is you write to them in the hope that they can learn from it and improve it, but what they do is they just fob you off.’
(GP20)
A further reason not to formally report operational failures lay in the perception that the patient safety threats they posed were not as great as in secondary care, or that they could be more readily addressed by compensatory labour. In contrast, participants did describe regular meetings (for example, quarterly) to discuss significant safety events:
‘In a hospital environment, if the equipment is not working and someone is being brought in by ambulance with an acute coronary syndrome and that equipment … you can’t say come back on Monday because that patient might be dead. So in general practice it’s inconveniences and delays but very rarely harm.’
(GP14)
‘… a significant event — usually it’s big, some harm has to come to the patient. But I really think we haven’t really focused on these nitty-gritty [operational failure] issues.’
(GP11)
GPs were also often reluctant to attempt to change processes within their own practices, in part because they felt they lacked time or capacity to design, implement, quality assure, and oversee new processes. A prominent feature of interviews was that GPs reported simply trying to get through the pressures of their work each day rather than make proactive operational changes, describing their current situation as ‘running bloody fast on the treadmill’ (GP6). Operational systems in smaller practices appeared to benefit from greater continuity with patients, but these practices struggled in other ways, such as generating the slack internally to reorganise practice processes:
‘… if you can achieve better continuity of care with the patient, so you know the patient, and you know a bit more about them, that does streamline the system better.’
(GP19)
‘Each change needs space to breathe and the capacity to do it and actually there’s a question of safety, while you are experimenting with this, while you’ve got [administrative staff] attempting to start coding your records, you need to create GP capacity to cross-check the coding, and actually when we are all at breaking point it is quicker to do it myself.’
(GP9)
A second challenge to process redesign was that the obvious solution for many issues — delegating to other practice staff — was a source of anxiety for GPs. They felt that delegation could further complicate workflows, increase the risk of something being missed, or might not be acceptable from a medicolegal perspective:
‘When these failures arise, it’s just easier for me to do them, as opposed to try and find a way to delegate them.’
(GP10)
‘It’s interesting the level of responsibility that the GMC [General Medical Council] and the legal side of things put on GPs. There’s a general confusion in primary care about what can be delegated and what can’t and how you can delegate and create at our scale teams with enough resilience to actually be able to cope with pathways of work, making the rules clear that this is appropriate for somebody with no clinical expertise, this is your role, this is your set. So, we do vast quantities of administrative work that is soul-destroying.’
(GP9)
