GPs are consistently being asked to work even harder than we already are. We see endless news stories about falling GP appointment numbers and suboptimal patient care due to lack of GP availability. We hear it from our patients, sometimes in gentle coded language (‘I know you are busy, but surely you can squeeze me in tomorrow?’) and sometimes in more explicit terms (‘I never used to wait so long for an appointment, things have really changed … ’). And as a profession we all too often tell each other we need to work harder, with GP partners and practice managers, understandably, trying to maximise the number of appointments offered to satisfy a seemingly infinite clinical demand.
As the data show, general practice clinicians are, in fact, working very hard indeed. Record numbers of general practice appointments are now being provided in England (34 199 547 in October 2023 compared to 30 297 111 in October 20211), and GP responders to the 2021 GP Worklife Survey reported working faster and more intensely than in previous years.2 However, to fully understand our increasing workload, we need to not only assess the numbers of appointments we provide, but also carefully examine the full spectrum of work carried out in general practice.
‘Hidden’ workload in general practice?
The paradigm that our specialty, as well as the government and wider public, has unfortunately come to accept when assessing general practice workload is fundamentally based on episodic care and the number of appointments we offer. The way in which NHS Digital monitors and reports general practice workload reinforces this way of thinking, with numbers of appointments, length of appointment, and which clinician provides each appointment being the main metrics used to measure the content of our workdays.3 However, measuring numbers of appointments alone does not truly reflect the reality of our workload.
Anyone who has spent time working in general practice will tell you that appointments with patients are only one limited aspect of our overall daily workload. The 2021 GP Worklife Survey found that on average 40% of responder’s workdays were spent on activities other than direct patient interaction.2 This included acknowledgement and actioning of test results and correspondence, sending referrals, practice administration, and external meetings. As such, over two-thirds of GPs’ daily work is potentially being omitted from routinely recorded and publicly reported NHS general practice workload data. Therefore, there is a clear need to accurately measure and categorise the work done in general practice beyond patient-facing appointments, which has sometimes been referred to as our ‘hidden’ workload. For future reference, we would define hidden workload as ‘all work undertaken in general practice other than planned direct clinical contacts with patients’.
The urgent need to understand our hidden workload
So, beyond the inherent merits of accurately reporting our daily work, what else do we gain by better understanding our hidden workload?
First, unless we quantify all aspects of our work, we cannot fully appreciate the impact that caring for increasing numbers of patients who are older, have more long-term conditions, or are more socially disadvantaged has had on general practice workload. For example, the British Medical Association (BMA) provide guidance that 25% of each GP clinical session should be allocated to administrative tasks.4 Apart from this being far below the reported non-direct clinical workload of 40%, as mentioned above, this recommended ratio also does not consider the additional administrative workload that tends to be generated by caring for patients with more complex medical or social backgrounds. Furthermore, GPs, who we must continue to reiterate are consultants in general practice and routinely manage high levels of clinical complexity and uncertainty,5 currently see 37 patients per day on average.6 This is far above the BMA’s safe-working recommendations of seeing between 10 and 25 patients per day, depending on the complexity and needs of the patients seen.7 If we can begin to understand the additional hidden workload generated by our most challenging clinical encounters, we may also start to develop a better appreciation of the time and effort needed to provide high-quality holistic care for our most vulnerable patients. This in turn could be used to inform the organisational design of general practice and better distribute clinical resources at a population health-level.
Second, the rapidly changing interprofessional structure of general practice may also lead to changes in general practice workload composition. As the number of appointments provided by nurses, physician associates, and other allied health professionals increases,3 so too will the supervisory workload for GPs. Importantly, this additional workload is not unidirectional, and time dedicated to supervision and personal development will need to also be properly integrated into the workday structure of these colleagues. With more funding being made available for practices to recruit for roles other than GPs, such as via the Additional Roles Reimbursement Scheme,8 this need for both supervisory and supervision time allocation in the workday is likely to increase further. Notwithstanding the wide range of managerial tasks that GPs already do, this is an additional example of the consultant-level roles being undertaken by GPs of all experience levels, but not being recognised within contemporary workload modelling.
And finally, understanding and properly acknowledging the full scope of our workload is key to addressing the ever-growing issues of burnout and retention in general practice. Increasing clinical demand, workload, and stress are frequently reported as reasons why GPs are leaving direct patient care.2,9 Unless we can quantify all aspects of our work, we will struggle to start improving the sustainability of current general practice workloads.
Beginning to measure our hidden workload
While the benefits of better understanding the content of our workdays are clear, measuring hidden workload is unfortunately very difficult. Appointment data are easily recordable and can be collected remotely and en masse from practices. On the other hand, largely due to the limitations of how clinical workload is currently recorded via electronic patient records, accurately measuring hidden workload is labour intensive and generally requires individual clinicians to manually record their minute-to-minute work activities. While an evidence base examining contemporary general practice workload is starting to develop,10–12 there is still a dearth of research investigating hidden workload within general practice.
The Primary care Academic CollaboraTive (PACT; https://www.gppact.org) is a new collaborative research network of over 700 members, including GPs, junior doctors, nurses, physician associates, pharmacists, paramedics, and other healthcare professionals, and offers a unique platform to further explore general practice workload in a naturalistic way. PACT’s next project, The Hidden Workload Study, will utilise this collaborative research network and ask PACT members across England to accurately record all tasks undertaken during their workday and additionally explore how local demographics might affect clinicians’ workload utilising mixed methodology. As there is a clear and urgent need to comprehensively understand general practice workload, we hope that The Hidden Workload Study can act as the foundation for much needed further research into this topic.
Notes
Provenance
Commissioned; not externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2024
