What’s the story behind NHS staff losing their sparkle? Research in the spotlight

Having recently joined the Health Foundation after a career trying to turn evidence into guidance at NICE, whenever I read a research output, I find my first question is still, ‘What recommendations can be derived from this research?’. Developing evidence-based guidance also taught me that there is very rarely a straightforward answer to the question of ‘what’: often ‘what’, and indeed ‘how’, can’t be answered without considering ‘why’.

The question of ‘why’ struck me when looking at the flurry of recent research outputs concerning workforce shortages in health and social care. This includes Health Foundation analysis indicating a shocking shortage of GPs in 2022 (estimated at 4,200 full-time equivalent), reinforced by data analysis from the BMA and NHS Digital workforce data. This quantitative data gives the people developing the forthcoming NHS workforce plan a very clear sense of the ‘what’, indicating the size of the problem. However, for the workforce plan to effectively tackle the problem, it will need to understand the complex reasons behind staff shortages, and, as an upcoming blog by colleagues in the REAL Centre will discuss, it must go beyond the numbers.

It has been asserted that the number of GPs leaving the profession is unprecedented. Although recent data on GP movement shows a more nuanced picture, the latest GP worklife survey conveys the extent of dissatisfaction, with a third of GPs planning to quit in the next 5 years. Quantitative research reveals some possible reasons: an ageing workforce and high reported burnout. And yet, there appears to be limited formal research going beyond the numbers.

The value of exploring why is underlined by a Health Foundation supported study of primary care staff experiences during the pandemic. While this qualitative data reinforces the quantitative findings around burnout, I was struck by two more complex and valuable conclusions. Firstly, the findings challenge the commonly cited positives of innovation in care enabled by disruption during the pandemic. Secondly, those findings emerge because disruption drives the researchers to adopt innovative methods.

In primary care, disruption and current pressures have led to a push for practices to adopt virtual consultations. However, this study indicates that the resultant change to ways of working also altered the nature of GP roles and ‘disrupted’ their sense of identity. Virtual consultations are perceived by GPs as creating a more transactional consultation, eroding their core role as providers of relational-based care and dulling their ‘clinical sparkle’. Virtual interactions also mean that they are unable to deploy skills fully, in the form of ‘cognitive shortcuts’, such as noting the way someone walks, a finding echoed by a wider study with GPs (Greenhalgh et al, 2022). Findings also illuminate an important thread behind the survey data, a perception that primary care is now ‘always open for business’. In turn this ‘supply-induced demand’ increases workload and compounds feelings of burnout.

Acknowledgement of burnout led to the second valuable conclusion (explored more fully by the authors in a methods piece); novel methods generated a deeper understanding of why. The researchers ‘ceded control’ over data collection and asked participants to contribute data in their preferred way over 11 months. This was initially driven by assumptions it would increase engagement, but the researchers found that ceding control and capturing ‘evolving’ experiences surfaced accounts which may not have been generated by more prescriptive methods. For the research, the disruption caused by the pandemic both demanded and enabled novel methods that enriched the data.

If I were still wearing my evidence-based guidance bowler hat and looking for recommendations, my first thought from the findings of this small-scale study would probably be a need for a review of evidence on virtual consultations from the perspective of GPs, drawing on a growing body of research. But in fact it is the methods that prompt a more novel potential recommendation for practice. Should we be waiting until staff leave to find out why in exit interviews (where those happen)? Perhaps we should be looking at more routine exploration of why, through approaches such as ‘stay interviews’, which may offer ways to improve staff retention and importantly surface more complex reasons for dissatisfaction.

Determining the ‘what’ without fully understanding the ‘why’ may lead to conclusions that the solution is simply more staff. Furthermore, the value of this study and its approach is in surfacing the complexity of reasons behind the ‘what’, that quantitative methods alone would not uncover. To tackle the current workforce crisis, this study underlines the need for recommendations that tackle not only disruption to delivery, but also disruption to self. As one participant’s response illuminates, ‘I won’t work unless I can be the GP I want to be’.

Justine Karpusheff (@JKsheff) is Assistant Director of Research at the Health Foundation.