‘It’s not just about seeing patients as a GP’ : the need to acknowledge, make visible and allocate time for hidden work in general practice

Problem

Popular media and scholarly work highlight the ever-increasing workload of GPs in the UK. Providing safe and co-ordinated care for patients involves substantial behind-the-scenes ‘hidden’ work whose component parts are often not recorded and remain invisible even within the organisation. Making the invisible visible by logging this work could contribute to understanding its nature and scale and support development of changes that would enhance GP well-being and retention, support patient care and reduce health inequalities. The aims of this study were: 1) to increase understanding of the nature, extent and impact of ‘hidden’ work, and the potential for change, and 2) to explore the feasibility of using qualitative methods to conduct such research in GP practices in the current landscape of overstretched primary care services.

Approach

Researchers conducted four months of ethnographic research in two urban GP practices in England, one North and one South. Data comprised fieldnotes documenting over 100 hours of observation, semi-structured interviews with eight GPs and eight other members of practice staff and a workshop towards the end of fieldwork at each site. There are two key stages to the analysis. The first stage is based on interview and workshop data and uses the Listening Guide (Voice Centred Relational Method) to facilitate in-depth understanding of individual perspectives of ‘hidden’ work. The second stage will involve gerund (action) coding of the full data set to identify the various ‘practices’ that create and sustain hidden work. Meanings will be explored through the lens of Practice Theory.

Findings

Preliminary analysis of interview and workshop data suggests that tasks relating to indirect patient care are less acknowledged in general practice than patient-facing work or time spent teaching trainees. While the latter are carefully scheduled and recorded, by contrast, time allocated to undertake other tasks is generally not associated with specific work or adjusted to fit actual workloads. As a result, much of the background work undertaken by GPs is invisible to practice staff, GP colleagues, and patients, and cannot be accurately measured. Making hidden work visible by, for example, explicitly ‘booking’ tasks that arise from checking test results or responding to hospital specialists’ recommendations, etc., provides an opportunity for staff to recognise the importance and impact of this work, and, by examining their processes and practices, to devise and implement more sustainable and effective ways of working.

Consequences

This paper generates new understanding of tensions associated with recognition and performance of non-patient facing work. Naming these tensions can support teams in exploring how practices may be amenable to and benefit from change.