Dr Anne Noble reflects on experiencing moral injury after a decade of working as a GP partner in an area of high socioeconomic deprivation
The cry ‘general practice is in crisis’ has been heard for the past 10 years. It is true, but despite this and my struggle to cope with the demands of the work, it is still the job I wish to do. When I’m sitting with a patient in the consulting room, the rewards are the same as they have always been.
The collective committed will of general practice teams to serve their communities remains strong, and it is the reason patients are still receiving a service in these trying times. But sadly, the value of this care and will is not recognised by the Government because it does not understand it.
This summer I’m returning to my GP practice in a deprived urban area of England after a year of working on a Scottish island. Working in the Highlands had always been a dream, and the pandemic became the catalyst for making it a reality, not to mention the best option for staying in general practice. Now, my will is to rejoin my colleagues in Sheffield and be people’s family doctor as best we can in a broken system. My challenge, however, will be remaining well under this pressure.
My wish to care began years before medical school, and the sense of duty began when I took a place at university. My personality traits of trying hard and people pleasing were stoked by the culture of success and avoidance of failure. After qualifying as a doctor, I continued to jump through hoops and successfully completed training posts and exams. On the outside, I was doing well at life; in reality, I was doing what I thought I should (that word!), and having a choice was an alien concept. Junior doctors cared for others, not themselves. When my friend died suddenly, I went to work the next day, not considering my fitness to work. I was adept at lidding my emotions, an essential skill to survive the training years.
Then, once I qualified as a GP, I became a partner in my training practice. It was exactly where I wanted to be, but the work was immediately intense and hard. I often thought that if I could just go faster, or be better, then I could provide my patients with the care they deserved. But the system was already stretched, and it was impossible to meet such unrealistic expectations.
As I built relationships with patients, I was able to save time and resources due to a bank of trust and knowledge of past problems within the context of the community. But in a deprived area, every consultation involves multiple problems (not enough appointments), is complex (multi-morbidity) and emotionally challenging (due to your limitations in addressing patients’ social circumstances). In December 2020, there were on average 1.4 fewer FTE GPs per 10,000 patients in England’s most deprived areas. Little research exploring possible reasons, such as higher GP burnout, exists; but the bigger issue is the inequity in access to medical care that patients in deprived areas experience.
After 10 years of partnership, two children and a pandemic, I had four weeks off sick with stress. The toll of providing inadequate access for my patients and holding the mental anguish of those not able to access mental health services all became too great. While walking away from my patients and practice team was hard, I could finally see that taking on the suffering of others was not sustainable. The term ‘moral distress’ now existed, which helped me shift some blame to political choices. But ultimately, I knew I needed to do something different.
And so, I moved from Steel City to the Misty Isle. The change in intensity has been the greatest difference in my work. The hours are similar, but the number of decisions and emotional toll is much less. Here I have learned that general practice can be fantastic for patients and doctors, and it has made me even more convinced that it should be for everyone.
Staying in the game
Reflecting on this journey now, I realise that the predictability of these events may seem stark. Caring and conscientious NHS staff prevented from providing adequate care are living against their values, which is a recipe for distress and burnout. Yet, the personality traits that have seen me struggle in a system in which I have experienced moral injury also make me a compassionate and effective GP.
The crisis in which GPs are finding any way to cope – whether that is by reducing hours, leaving the profession, or giving up partnerships – is accelerating, and if you are in my boat, know that you are not the problem. Do what you can, whatever your personality type, to stay in the game. Patients need and deserve GPs, even if governments ignore the strong evidence of this.
Medical schools and GP training schemes should teach students and trainees about the reality of working in today’s NHS. Modules in self-care and exploring moral distress would help, and emphasis should be placed upon realistic limits of personal responsibility. Mentoring and coaching have been key in helping me foster a healthy mindset, and it could be made widely available to junior doctors.
Although cultivating professional resilience is a critical part of becoming a doctor, especially for those working in deprived areas, it should never compensate for a flawed system. If policy makers wish to tackle health inequalities, then they need to resource general practice in deprived areas and, more importantly, address the wider social determinants of health. The additional roles that GPs have in such areas should be further researched, recognised, and resourced, too.
In my experience, GPs working in deprived areas absolutely want to be there. Strong GP teams with dedication and drive are passionately caring for huge numbers of patients living in poor health – and if adequately resourced, the potential to improve health inequalities is great.
Dr Anne Noble is a salaried GP in Skye, returning to work in Sheffield in July 2023