‘How cognitive overload pushed me to become an accidental GP innovator’

Dr Paul McNamara reflects on how unsustainable workload and cognitive overload are pushing GPs to redesign the tools they rely on

Conflicts of interest declared: Dr McNamara is a co-founder a workflow optimisation tool

General practice is in a workload crisis. That much is obvious to anyone in the profession. What is less often acknowledged though is where the real pressure sits. It is not just in the number of consultations, but in the sheer volume of administrative and cognitive work now attached to every clinical decision we make.

I have been a doctor for 15 years and a GP for four, working in practices serving some of the most socioeconomically deprived communities in Glasgow. The clinical encounters themselves remain meaningful as ever. What has become overwhelming though, are the layers wrapped around them: results handling, documentation, coding, safety-netting, referrals, inboxes, appraisal evidence. These laborious tasks don’t fit neatly into the working day, but spill into the edges and erodes the thinking space GPs require for safe and humane medicine.

Most GPs do not need surveys to validate this experience. But the figures are stark. A 2019 BMA survey found that GPs are far more likely to do overtime due to workload; some 75% of GPs vs 43% of hospital doctors – with that figure rising to 84% in GP partners.

And those statistics are pre-pandemic. Since then, the pressure has only intensified. Analysis from the Health Foundation and RCGP shows that GPs are spending an increasing proportion of their working day on administrative and non-clinical tasks, with rising workload intensity and worsening fragmentation of care.

This has a devastating impact on doctors’ health: seven in 10 trainees report already suffering with burnout as a direct result of their clinical work, and more than half of GPs have had to reduce their sessions due to the stresses of the job. All this impacts upon each other – cognitive load rises; working days stretch; and continuity becomes harder to protect as the system fragments.

While these pressures are felt across all general practice, they are often magnified in Deep End settings. For those unfamiliar with the term, it refers to the 100 most deprived practices in Scotland, based on the number of deprived patients they have. We look after patients with complex multimorbidity, unstable housing, addiction, trauma and poverty, often all within the same consultation. These are the stories that never reach policy papers but shape every minute of our working day, placing sustained demands on clinicians whose cognitive bandwidth is already stretched.

For many of us, there is no single moment when the job suddenly becomes unmanageable. I experienced it as a gradual wearing down, with administrative demands steadily intruding on the thinking space I needed for clinical work. There simply were not enough hours in the working day to get through all the admin that needed to be done. The time and space required for safe and compassionate medicine was being eroded by the demands that surround it.

Like many GPs, I found myself doing the invisible parts of the job late at night, once my children were asleep and I should have been anywhere else but the surgery. I was trying to stay on top of the same tasks every clinician recognises: clarifying guidelines, checking interactions, drafting safety-netting advice, capturing learning for appraisal. It became clear that the problem wasn’t motivation – I’d go to the ends of the earth for our patients. The problem was the cognitive overload. The system asks us to remember too much, process too much, and document too much, all while delivering relational, complex care at pace.

This led me, like many others, to innovate out of necessity. I ended up helping build a workflow tool designed to reduce duplication. The aim was simple: workflow optimisation meaning fewer tabs less duplication and cognitive drag. I wasn’t coming at it as a tech entrepreneur, but instead as an ordinary GP, trying to make work more manageable. The word ‘founder’ still sits awkwardly with me. But over time it has become obvious that if clinicians don’t help shape the digital tools we use, someone else will – and those tools will not necessarily reflect the realities of general practice, particularly in deprived communities.

This experience is not unique at all. It shows up in conversations with colleagues, in WhatsApp groups and in shared folders passed quietly between practices, where GPs, trainees and allied health professionals create their own workarounds: templates, prescribing checks, shared protocols, small digital shortcuts. These are not innovative projects in the traditional sense; they exist simply because we need to get through the day.

This is not innovation driven by ambition or commercial instinct. It is innovation born of necessity, a survival response to an unsustainable workload. The shift from analogue to digital is already underway, and when used well, technology can reduce duplication and protect precious thinking space. But when used badly, it adds friction, fragments care and risks widening health inequalities. The difference lies in who designs it, and whether it reflects the realities of frontline clinical work.

GPs have always been innovators, and unfortunately that has all too often been due to systematic failures in the NHS. Our workload is too great for any one person, and it doesn’t seem as if the powers-that-may be will be doing anything to help us in that department anytime soon. So in the meanwhile, we are forced to take matters into their own hands – inventing workarounds and bending the system to meet patient need. It feels unfair, but as with anything in the NHS, we know that top-down policies and strategies rarely make work easier (and quite often do the opposite.)

No digital tool will fix the workforce crisis or undo the socioeconomic pressures shaping our patients’ lives. But tools that understand context may reduce some of the cognitive drag pushing doctors towards burnout. They may help trainees feel less overwhelmed, and allow experienced GPs to spend more time on the parts of the job that matter most.

Dr Paul McNamara is a GP partner in Glasgow, medical educator, author, and honorary clinical lecturer at the University of Glasgow