Same merde, different countries

GPs in the UK have the lowest morale of any. But colleagues in other countries have their own problems, as Jaimie Kaffash reports

‘Many family doctors are burnt out, reducing or modifying their clinical hours, retiring early or leaving the profession altogether. Family doctors are also working longer hours, seeing more complex patients and suffocating under administrative burden, most of which is unpaid.’

This quote could be taken from any LMCs conference or BMA press release from across the UK over the past few years. But it is from the College of Family Physicians of Canada. And, in truth, it could have come from a number of GP representative bodies from high-income countries. 

There are problems everywhere. The weighting of these problems might differ – the biggest concern might be pay in one country, bureaucracy in another. But there is an underlying cause – a global lack of GPs.

Yet, despite general practice in most countries being in different degrees of crisis, the UK stands out as the worst among equals, with higher stress levels, shorter appointment times and lower morale. Most gallingly, even in countries where GPs have serious concerns, leaders are optimistic about their governments’ intention to address their crises. 

So, with major contract negotiations on the horizon in England, is there anything the BMA can learn from other countries?

Workload and stress

It might come as a surprise that general practice in the UK is pretty much midtable when it comes to the hours worked and the number of patients seen. So why do UK GPs still lead the way in stress?

It is important to acknowledge that GPs in other countries are also struggling – the majority of GPs describe their job as at least ‘very stressful’ in the seminal Commonwealth Fund study.¹ Meanwhile, various professional bodies refer to general practice as being ‘at a tipping point as the work is relentless’ (New Zealand), ‘at a breaking point’ (Canada) and involving ‘burnout… dealing with administration and red tape’ (Australia). 

In Spain and France, GPs have gone as far as taking industrial action, with workload cited as one of the reasons  – 60-hour weeks, according to Spanish GP leaders.² 

But UK GPs face very particular problems. First, the figures don’t tell the whole story: many UK GPs cram a week’s work into three days, heightening stress levels. Pulse’s surveys have revealed that GPs do 13-hour days when working a full day, with an average of 37 daily patient contacts.^3,4

These long working days are compounded by the intense nature of their work. ‘UK GPs do more, to a greater degree of complexity than those in any other system,’ says outgoing RCGP president Professor Clare Gerada. ‘Most GPs across the world don’t, for example, do paediatrics, maternity, or might not do ophthalmology. 

‘The family doctor in America comes from three main routes: paediatrics, obs and gynae, and then family medicine. So, the physicians who do obstetrician work wouldn’t see children.’

This is borne out the 2023 Health Foundation report Stressed and overworked, which was based on Commonwealth Fund survey data. It found UK GPs scored highly compared with counterparts in other countries in terms of their confidence to manage care for patients with dementia, palliative care needs, mental illness and chronic conditions.⁵

The UK also suffers by having one of the ‘poorest infrastructures in secondary care’, says former BMA Council chair Dr Chaand Nagpaul. ‘We have the second fewest hospital beds per capita amongst EU OECD nations⁶, one-third of the hospital beds of a country like Germany… the unmet need of patients unable to access secondary care is having a direct workload impact on UK GPs in a way I do not believe is happening elsewhere.’

While general practice is almost universally a stressful job, it might be a bitter consolation to UK GPs to know their distress is not unwarranted.

Pay and funding models

Pay is almost impossible to compare across countries, as there are so many nuances. For example, taxation and benefits differ,  while the UK cost-of-living crisis artificially inflates their pay compared with international peers.  

The closest we get to a valid comparison is the OECD’s review of GP pay compared with the national average salary.⁷  In this, it is a positive picture for GPs.  However, UK GPs are still the second least satisfied group in terms of income  – perhaps reflecting a feeling that their pay does not compensate for the levels of stress and workload they face. 

Instead of pay, perhaps a more fruitful comparison can be found in how practices are paid in other countries. Although a lot has been made about co-payments  – ie, patient fees  – most of Europe operates state-backed insurance systems, with little or no direct costs for patients.  

These insurance models are split between predominantly payment by activity (eg, France)
and predominantly capitation payments (eg, Netherlands). BMA GP Committee negotiators indicated last year they are considering moving from capitation payments to payment by activity.⁸ 

But in the US, where healthcare is (in)famously insurance based, and GPs are paid though fees for service, there is a movement to implement a hybrid model.⁹ Beccy Baird, senior fellow at The King’s Fund, says: ‘In general, fee for service isn’t a great way of incentivising good practice and preventive care. If you pay for activity, you’ll generate activity.’

The other major change is a fully salaried service, which the Labour Party is to consider if elected next year and which operates in some European countries.

‘In Portugal, they’re not allowed to work more than 40 hours a week,’ says Dr Mary McCarthy, a recently retired GP in Shropshire and former vice-president of the European Union of GPs (UMEO). They will also get brand new surgeries if they can convince healthcare bosses, she says – but because they are salaried, they won’t reap any benefits financially. But Spain provides a red (and yellow striped) flag in terms of a wholly salaried service – pay hovers around the £60,000 mark¹⁰ and GPs have taken industrial action. 

It may be that funding models and structural changes can only bring limited improvements. Real change might only be possible with increased funding, a stronger overall health service and real efforts to tackle societal inequality – all far harder than introducing a fee-for-service system.

Appointment times

While it is BMA policy to move towards 15-minute appointments, this is yet another area where the UK lags behind comparator countries. 

A 2017 study on consultation times¹¹, led by Professor Greg Irving, a GP and director of the Health Research Institute at Edge Hill University, found the UK had longer consultations than only Austria and Germany among high-income countries. Austria has now surpassed the UK, and Germany has caught up.  

Professor Irving  says: ‘Interestingly, patient satisfaction hasn’t always followed longer consultations. But the benefits tend to be on the doctors’ side  – including lower levels of burnout.’ 

And in some counties, rushed consultations are anathema to GPs. As Dr McCarthy says: ‘If you talk to any Dutch GP, they’re surprised that you could see a patient in 10 minutes.’

Indeed, in New Zealand, 15-minute appointments were introduced in the 1990s, but are now being lamented as a ‘20th-century relic’, with calls for them to be extended.¹²

Workforce

GPs in countries with 1,000-1,500 patients per GP are the most confident in the sustainability of their profession, says Dr McCarthy. But even successful countries are now struggling. ‘GP numbers throughout Europe are going down,’ she says. 

This isn’t only true in Europe. The College of Family Physicians of Canada estimates that six million Canadians are without a family doctor. Australia is facing ‘workforce deficits’, and has been aggressively pursuing UK GPs as a result. The Royal New Zealand College of GPs says there are ‘fewer GPs due to low numbers being trained, and more leaving due to retirement and burnout’.

The underlying issues affect all professions, says Beccy Baird. ‘People are more focused on work-life balance, they’re thinking more about portfolio-type careers. People are having to work a lot longer too.’ In England, while GP numbers gradually rise, so do the numbers of those working less than full time, so full-time-equivalent numbers continue to fall. 

There are particular issues for rural practice. ‘Young people want to work in the cities in general, so in rural areas all over Europe, even in the Scandinavian countries, there is a shortage,’ says Dr McCarthy. 

‘In France, they have what are called “medical deserts” and the government is offering golden handshakes for those who are willing to work in the country,’ she says. 

But, again, UK general practice is worst among equals. The Commonwealth Fund survey of 10 high-income practices shows 67% of UK GPs aged 55 and over, and one in five aged below 55, are considering leaving within three years  – both the highest among all countries.¹ 

As the Health Foundation report⁵ puts it: ‘Policymakers must recognise training more GPs is little good if the NHS can’t retain them.’

Morale

Dr Lawrence Loh, CEO of the College of Family Physicians of Canada, says: ‘Family physicians are tired, frustrated and overworked, with a suffocating administrative burden. They also worry for patients  – if they retire, who will take on their patients’ care?’

The effects of the pandemic and a worldwide GP shortage are hitting morale everywhere. The Health Foundation report concluded ‘satisfaction has fallen over time across most countries’.⁵ 

Yet UK morale is lower than elsewhere. Jake Beech, policy fellow at the Health Foundation and lead author of the report, tells Pulse: ‘It’s fair to say UK GPs are among the least satisfied with various domains  – overall job satisfaction, work-life balance, workload, time with patients, and other key areas.’ 

It hasn’t always been like this. The report points out UK GPs were ‘among the most likely to report high satisfaction a decade ago in 2012’.

UK GPs who move abroad have positive experiences, says Dr McCarthy: ‘I know several UK GPs who have recently gone to Ireland and are saying it’s so much easier there – they regard their move to Ireland as really beneficial for themselves.’

But despite low morale, it is a blessed relief that UK GPs don’t face a very particular threat endured by colleagues in the US. 

In a 2022 survey, almost a third (31%) of all US physicians said that they had faced prior lawsuits, with these being so numerous that the American Medical Association has stated that being sued is ‘not necessarily indicative of medical error’.¹⁴

Conclusion

The UK is in the merde, even compared with problems in other countries. But it’s not clear the structure of general practice is solely to blame: it isn’t because of the lack of co-payments, or capitation funding or the independent contractor model. As recently as 2012, UK GP morale was among the best, and the structure hasn’t changed much. 

It is probably no coincidence that the UK has faced an austerity programme far harsher than anything seen by their European counterparts. This has not only affected funding in primary care, but across all the structures that are essential: strong secondary care service; social services to help prevent problems becoming medicalised; and a care service that can look after the most vulnerable in society.

Let’s not forget, the UK is competing with other countries for its home-trained GPs, and there is a worldwide shortage. The next government would do well to remember this.

Additional reporting: Sally Howard and Geetanjali Krishna

References 

1. Gumas E et al.  Overworked and undervalued: Unmasking primary care physicians’ dissatisfaction in 10 high-income countries. Commonwealth Fund, August 2023
2.  Morel S. In Spain, doctors are exhausted, angry and striking indefinitely. Le Monde, November 23, 2022
3.  Merrifield N. The new workload crisis. Pulse, April 2021
4.  Parr E. 40% of GP practices set limit on number of patients seen per day. PulseToday, 21 August 2023
5.  Beech J et al. Stressed and overworked. Health Foundation, March 2023
6.  NHS hospital beds data analysis. BMA, December, 2022
7.  Health at a Glance: Remuneration of doctors (GPs and specialists). OECD Library, November 2021
8.  Potter C. GP negotiators hint at payment-per-contact model. PulseToday, 13 October 2022
9.  Gunja M et al. Stressed Out and Burned Out: The Global Primary Care Crisis.Commonwealth Fund, November, 2022 
10.  Healthcare resources: Remuneration of health professionals. OECD.Stat, 2023
11.  Irving G et al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open 2017;7:e017902
12.  Dougan P. 15-minute appointments so ‘last century’. New Zealand Doctor, 1 February 2023
13.  Data provided by European Union of General Practitioners
14.  Guardado J. Medical liability claim frequency among U.S. physicians. American Medical Association, 2022