Family Practice Vol. 17, No. 5, 364-371
© Oxford University Press 2000
GP job satisfaction in 1987, 1990 and 1998: lessons for the future?
National Primary Care Research and Development Centre, Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL,
a School of Management, Manchester Institute of Science and Technology and
b Department of Psychology and Speech Pathology, Manchester Metropolitan University, Manchester, UK.
Sibbald B, Enzer I, Cooper C, Rout U and Sutherland V. GP job satisfaction in 1987, 1990 and 1998: lessons for the future? Family Practice 2000; 17: 364–371.
Received 4 November 1999; Revised 4 May 2000; Accepted 17 May 2000.
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Abstract |
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Background. Job satisfaction is an important determinant of physician retention and turnover, and may also affect performance.
Objective. Our aim was to investigate changes in GP job satisfaction from 1987 to 1998, covering a period of major change in the organization of British general practice.
Methods. Postal surveys of random national samples of GPs were carried out by separate groups of investigators in 1987, 1990 and 1998. In each survey, the questionnaire contained a standardized job satisfaction scale and a list of 14 job stressors. The final samples consisted of 1817 GPs in 1987 (response rate 45%), 917 GPs in 1990 (response rate 61%) and 1828 GPs in 1998 (response rate 49%).
Results. For both men and women, overall job satisfaction declined from 1987 to 1990 and then improved from 1990 to 1998, although satisfaction in 1998 remained below that in 1987. Women tended to report higher levels of satisfaction than men in all 3 years. Satisfaction with nine specific aspects of work showed dissimilar patterns of change over time. From 1987 to 1990, reported levels of stress increased for eight of 14 job stressors. Of these, three subsequently declined in 1998, two remained unchanged and three continued to increase. Of the six job stressors which showed no change from 1987 to 1990, five subsequently increased as sources of stress. Men and women differed in their sources of stress, but the differences were not consistent over time.
Conclusions. The results suggest that GP job satisfaction has improved significantly from the low point reached following the introduction of the 1990/1991 NHS reforms, although reported levels of stress in relation to many aspects of work have continued to increase. The changes are discussed within the context of wider research into the determinants of GP job satisfaction in order to anticipate the likely effects on GPs of future organizational reforms.
Keywords. GP, job satisfaction, stress.
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Introduction |
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Job satisfaction is an important determinant of physician retention and turnover,1 and may also affect performance.2 It is therefore worthwhile monitoring changes in workforce satisfaction with a view to identifying adverse trends and their possible causes.
The National Health Service (NHS) reforms of 1990/ 1991 had a major and often negative effect on GPs' working lives. The ‘imposition’ of the 1990 GP contract by government was viewed as an attack on the ‘independent’ contractor status and professional autonomy of GPs.3,4 Workload was increased, particularly in relation to administration.5,6 GPs were, furthermore, suspicious of the motivation for change, believing that financial restraint, rather than health improvement, was the goal.4,7 By giving GPs greater responsibility for local resource allocation, fund holding also gave GPs greater responsibility for ‘rationing’ with a consequent pressure to move from a ‘personal’ to a ‘public’ ethos of doctoring.8 The feeling that GPs' professional status and autonomy was diminished was reinforced by wider societal changes which cast patients as ‘consumers’ and doctors as service providers whose responsiveness to consumers required attention.4 The subsequent introduction of the NHS Patient Charter and plans to ‘revalidate’ the qualifications of in-service GPs reflect this concern.
Not surprisingly, the immediate impact of the 1990/1991 reforms on GP job satisfaction was negative.7,9 However, it is uncertain whether this effect persisted. Our aim was to investigate changes in GP job satisfaction from 1987 to 1998 in order to see whether the workforce had recovered from the low point reached following the 1990/1991 NHS reforms. We hoped that insights gained from this analysis might enhance knowledge of the determinants of GP job satisfaction and so enable us to anticipate how GPs might react to future reforms.
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Methods |
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Postal surveys of GPs were carried out by separate groups of investigators in 1987, 1990 and 1998. In each, the questionnaire contained two components among others—a standardized job satisfaction scale and a list of job stressors. There were minor variations to the wording of some job stressor questions which we think unlikely to have affected responses. Otherwise identical questions were asked in all three surveys.
Job satisfaction
The 10 item Warr–Cook–Wall job satisfaction scale was used to measure job satisfaction. Each item is rated on a seven-point scale where 1 = extreme dissatisfaction and 7 = extreme satisfaction. The reliability and validity of the scale have been evaluated.10
Job stressors
Cooper and colleagues developed a list of 38 job stressors which was used to investigate sources of stress in their 1987 and 1990 GP surveys.11 Of these, 14 items were used in the 1998 survey (Table 3
). Each item is scored on a five-point scale where 1 = no pressure and 5 = high pressure.
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1987 survey
Data were obtained from a postal survey conducted in 1987 by Cooper and colleagues in the University of Manchester Institute of Technology (UMIST).11 GPs were selected randomly from the lists of principals held by 20 Family Health Service Authorities in England. Of the 4000 questionnaires distributed, 1928 (48%) were returned, of which 1817 were usable. The demographic characteristics of the original sample were reported to be typical of GPs nationally with respect to all characteristics, except that slightly fewer doctors aged 65 years or older responded (Table 1
).
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A further 338 usable questionnaires, 221 from men and 117 from women, were received too late to be included in the original publication. We have used this larger sample in our analysis of gender differences in job satisfaction, as job satisfaction scores by gender were available for this larger sample but not for the published sample.
1990 survey
Data were obtained from a postal survey conducted in 1990 by Sutherland and Cooper at UMIST.9 A random, national sample of 1500 GPs was drawn. Questionnaires were returned by 1002 (67%), of which 917 were usable. The representativeness of the sample as compared with GPs nationally was not examined formally but was thought to be good (Table 1
).
1998 survey
The latest survey, carried out by the National Primary Care Research and Development Centre (NPCRDC), selected GPs from the Department of Health's list of principals for England in 1996. A random national sample of 400 GPs, stratified by age and sex, was surveyed in June 1998. A second sample, consisting of all GPs in 12 Health Authority areas, was surveyed in July–September 1998. The survey was carried out as part of a wider investigation into GPs' work life using a questionnaire with a large number of subscales. In order to minimize the burden on GPs, only 399 were sent the full questionnaire and the remainder received one of the two subscales reported here. Of 3734 GPs approached, 2064 received the Warr–Cook–Wall job satisfaction scale and 2069 received the job stressor questions. Usable responses were received from 1828 GPs in total, with response rates of 47% (974/2064) and 49% (1012/2069) in the two samples, respectively. Comparison with national figures showed the final sample to be representative of all English GPs in terms of age, sex, approved trainer status and full-time/part-time NHS contract. Ethnic minorities, however, were under-represented (Table 1).
Analysis
Unpaired Student's t-tests were used to compare the three samples. Males and females were analysed separately because there are known sex differences in job satisfaction and sources of stress, and the proportion of females increased over time. Unfortunately, no breakdown by sex for job stressors was available for the 1990 sample so limiting analysis to the 1987 and 1998 samples. Given the large sample sizes and large numbers of comparisons made, we have accepted as significant differences which reached statistical significance at the 0.1% level (i.e. P < 0.001) unless otherwise indicated. Analyses were based on summary statistics (means and standard deviations) from each data set.
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Results |
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Job satisfaction
Table 2
summarizes job satisfaction among GPs for 1987, 1990 and 1998. As analysis showed that there were no differences between men and women in the patterns of change over time for each of the 10 items of job satisfaction, we report here the findings for the samples as a whole.
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Overall job satisfaction declined from 1987 to 1990, but increased from 1990 to 1998. Overall satisfaction in 1998, however, remained below that in 1987. A downward trend in satisfaction from 1987 to 1990 was reversed subsequently by 1998 in relation to: recognition for good work; amount of variety in one's job; and physical working conditions. However, the downward trend in satisfaction from 1987 to 1990 showed no recovery in relation to freedom to choose one's own method of working and amount of responsibility given. Three aspects of satisfaction which improved from 1987 to 1990 have since declined. They were: rate of pay; hours of work; and opportunities to use one's abilities. Relations with colleagues showed no significant changes over the time period.
An alternative approach to viewing how sources of job satisfaction may have changed over time is to rank items in ascending order of satisfaction for each year and observe how an item's rank has changed. Table 2 shows that in both 1987 and 1998 GPs were least satisfied with their rate of pay, hours of work and recognition for good work, whereas in 1990 only recognition for good work figured among the top three sources of job dissatisfaction.
Although changes over time in job satisfaction were similar among men and women, the sexes differed in their levels of satisfaction. For all 10 items of the job satisfaction scale in all 3 years, women tended to report higher levels of satisfaction than men, although the differences did not reach statistical significance in all instances. The sole exception to this occurred in relation to physical working conditions where men reported higher levels of satisfaction than women in 1987 alone [men: mean 5.09, standard deviation (SD) 1.43; women: mean 4.87, SD 1.50; P < 0.01]. In 1998, women were significantly (P < 0.001) more satisfied than men with respect to overall job satisfaction (men: mean 5.08, SD 1.24; women: mean 5.17, SD 1.14), rate of pay (men: 4.51, SD 1.64; women: 4.93, SD 1.53), opportunities to use one's abilities (men: 4.89, SD 1.41; women: 5.22, SD 1.22) and hours of work (men: mean 4.04, SD 1.80; women: mean 4.52, SD 1.52).
Job stressors
Table 3 summarizes GPs' levels of stress in relation to 14 job stressors for 1987, 1990 and 1998. From 1987 to 1990, stress increased for eight of the 14 stressors. Of these, three subsequently declined to 1998 (disturbance of home/family life, interruptions by emergency calls, night visits), two remained unchanged (dividing time between work and spouse/family, 24 h responsibility for patients) and three continued to increase (unrealistically high expectation of role by others, adverse publicity by the media, working environment). The remaining six job stressors showed no change from 1987 to 1990. However, five of these subsequently increased as sources of stress (dealing with problem patients, worrying about patient complaints, finding a locum, arranging hospital admissions and dealing with terminal illness). Stress relating to fear of assault declined to 1998.
Each stressor was ranked in descending order of importance for each year and the ranks compared (Table 3). Of the top four stressors in 1998, only one was consistently a major source of stress in previous years (dealing with problem patients). The three which rose markedly in their relative importance include: worrying about patient complaints; dividing time between work and family; and unrealistically high expectation of role by others. Of the bottom four stressors in 1998, three were also low sources of stress in previous years (dealing with terminal illness, working environment, fear of assault). However, the remaining stressor (night visits) was one of the top rated sources of stress in both 1987 and 1990.
Men and women differed in their reported levels of stress for some items (Table 4). Women reported significantly higher levels of stress than men in both 1987 and 1998 in relation to finding a locum and fear of assault. No marked sex differences were found in 1987 in relation to adverse publicity in the media and arranging hospital admissions, but in 1998 women were significantly more stressed than men by these factors. Women reported significantly more stress than men in relation to dividing time between work and family, and unrealistically high expectation of role by others in 1987 but not in 1998. The only factor for which men recorded significantly higher levels of stress than women was in relation to night visits in 1998.
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Discussion |
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The overall picture is one of decline in GP job satisfaction from 1987 to 1990 followed by partial recovery from 1990 to 1998. These changes are not an artefact of the increasing proportion of women in the workforce as the trends were evident in both sexes. Nor does it seem likely that they are a reflection of response bias. Although response rates were low in all three surveys, the resulting samples appeared representative of GPs generally in their demographic characteristics. Moreover, any bias towards negative (or positive) reporting by responders is likely to have been similar in all three surveys. It is likely, therefore, that the secular trends reported here reflect real changes in the GP workforce as a whole, if not for individuals.
The pace of recovery is difficult to judge without additional observations for the period 1990–1998. Two small GP surveys using the Warr–Cook–Wall job satisfaction scale were carried out in 1993 and 1994, respectively.12,13 Both showed improvements in satisfaction over 1990, suggesting that the workforce was quick to adapt. However, our findings also show that most aspects of job satisfaction have yet to return to 1987 levels. The reasons for these changes must remain speculative and open to interpretation. However, closer examination of the data, and appeal to other research, suggest possible reasons.
The NHS reforms of 1990/1991 gave GPs greater managerial control, albeit with enhanced accountability. Only a minority of GPs welcomed this opportunity.6 The overall decline in job satisfaction from 1987 to 1990, the declines in satisfaction with amount of responsibility given and opportunity to choose one's own method of working, and the failure of these to improve by 1998, all suggest that managerial control is not a key determinant of GP job satisfaction.
Research suggests that, for medical professionals, clinical autonomy is a more important determinant of job satisfaction than is managerial autonomy.1 Declining satisfaction with opportunity to choose one's own method of working is consistent with GPs' expressed views that the 1990 contract eroded their clinical autonomy. The introduction in 1999 of new systems of clinical governance within the NHS was designed to improve quality and enhance accountability. As with the introduction of the 1990/1991 reforms, GPs are concerned that their clinical autonomy may be diminished. Should these fears be realized, then GP satisfaction might decline. Increased managerial control of medical organizations, however, need not reduce clinical autonomy and may even enhance it by increasing the resources available to doctors.1 Moreover, as GPs have the opportunity to take managerial control of Primary Care Group development, it is to be expected that they will be able to shape these organizations to meet their own concerns.
The 1990/1991 NHS reforms increased workload and required that full-time GPs spread their work over a 5-day week. However, satisfaction with hours of work paradoxically rose from 1987 to 1990. Research suggests that increases in the volume or complexity of work will not necessarily lead to lower job satisfaction if changes are accompanied by increased decision latitude (i.e. control over how work is to be accomplished).14 Many general practices availed themselves of the greater freedom to hire nurses, administrators and others to carry out much of the extra work associated with the health service reforms, particularly in relation to health promotion and disease prevention. This ability to delegate work to others may have offset initial concerns about increased workload. The marked decline in satisfaction with hours of work from 1990 to 1998 raises the possibility that workload has increased further and/or that the ability to control workload has declined.
Target levels of remuneration were increased by the new contract, and satisfaction with pay accordingly increased from 1987 to 1990. However, the findings indicate that there is a non-linear relationship between pay and overall job satisfaction. Although satisfaction with pay increased from 1987 to 1990, overall satisfaction and satisfaction with most other dimensions of work declined. Similarly, satisfaction with pay has decreased from 1990 to 1998, although overall job satisfaction has increased. This supports the view that, while low pay may be a significant source of job dissatisfaction, high pay has a limited ability to offset dissatisfaction with other aspects of work.
Other research has shown that the method of payment may alter physicians' reported sources of job stress.1 Capitation and salaried status are associated with greater dissatisfaction with patient demands because these increase workload within the time allotted for work. In contrast, fee-for-service is associated with greater dissatisfaction with hours worked because doctors have the financial incentive to respond to patient demands by increasing their hours. GPs have a mixed payment system which places most emphasis on capitation. In this respect, it is interesting to note that dealing with problem patients was among the top stressors for GPs in all years.
The rise of consumerism within society generally has challenged the status of medical professionals. GPs are of the opinion that the public is more demanding, more discerning and less respectful of medical professionals.4 Our data support this view in showing rising GP dissatisfaction with recognition for good work and increased stress associated with worry about patient complaints, an unrealistically high expectation of their role by others and adverse publicity in the media.
The most notable change in GP stressors, however, relates to night visits. This was one of the top two stressors in both 1987 and 1990 but fell to become one of the bottom three stressors in 1998. This may be attributable to the introduction of GP co-operatives for managing out-of-hours calls.15 Their success may also explain the reported reduction by 1998 in stress attributable to disturbance of home/family life.
The rising proportion of women in the GP workforce makes attention to their job satisfaction important. We found that women were generally more satisfied with their work than were men, possibly because they were more likely to work part time. Women, however, differed from men in their reported sources of stress. Our finding that women experienced higher levels of stress in 1987 and 1990 with regard to dividing time between work and family is consistent with other research which shows that women take greater responsibility than men for domestic affairs.16 However, we also found no difference between men and women in this stressor in 1998, which suggests a move towards greater equality between the sexes.
It is likely that recovery in GP job satisfaction following the 1990/1991 reforms reflects adaptation of the workforce to change. However, it may also be attributable in part to an increase in part-time and flexible working which rose markedly over this period.17 Others have shown that part-time working is associated with generally lower levels of stress and higher levels of job satisfaction than is full-time working.18 Another factor affecting secular trends in satisfaction may be the changing age structure of the workforce. The 1990 sample of GPs was generally younger than the 1987 sample, and the 1998 sample had proportionately more GPs in the middle age groups (35–54 years) than the two previous surveys. Research has shown that older doctors are more generally satisfied with their jobs than are younger doctors,19,20 which may partly explain the fall in satisfaction in 1990 and its subsequent rise in 1998.
The prospects for the future are uncertain. Change, whether positive or negative, is stressful, and it may be that overall job satisfaction will decline from 1999 until GPs adjust to the latest NHS reforms. Improved remuneration and the preservation of GPs' clinical autonomy may offset this tendency. The move towards increased part-time working and the rising proportion of women GPs are likely to have a positive effect on workforce satisfaction. Societal trends towards increasing patient demand and diminishing medical status seem less likely to change and may continue adversely to affect GP satisfaction.
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Acknowledgments |
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The work was funded by the National Primary Care Research and Development Centre which is a Department of Health funded research institution.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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1 Lichenstein RL. The job satisfaction and retention of physicians in organised settings: a literature review. Med Care 1998; 41: 139–179.
2
Grol R, Mokkink H, Smits A, Van Eijk J, Mesker P, Mesker-Niesten J. (1985) Work satisfaction of general practitioners and the quality of patient care. Fam Pract 1985; 2: 128–135.
3 Lewis J. Independent Contractors. GPs and the GP Contract in the Post-War Period. Manchester: National Primary Care Research and Development Centre, 1997.
4 Calnan M, Williams S. Challenges to professional autonomy in the United Kingdom? The perceptions of general practitioners. Int J Health Serv 1995; 25: 219–241.[ISI][Medline]
5 Hannay D, Usherwood T, Platts M. Workload of general practitioners before and after the new contract. Br Med J 1992; 304: 615–618.
6 Leese B, Bosanquet N. Changes in general practice organisation: survey of general practitioners' views on the 1990 contract and fundholding. Br J Gen Pract 1996; 46: 95–99.[ISI][Medline]
7 Myerson S. The effects of policy change on family doctors: stress in general practice under the new contract. J Manag Med 1993; 7: 7–26.
8 Royal College of General Practitioners. The Nature of General Medical Practice. Report from General Practice 27. London: Royal College of General Practitioners, 1996.
9 Sutherland VJ, Cooper CL. Job stress, satisfaction, and mental health among general practitioners before and after introduction of the new contract. Br Med J, 1992; 304: 1545–1548.
10 Warr P, Cook J, Wall T. Scales for the measurement of some work attitudes and aspects of psychological well-being. J Occupat Psychol 1979; 52: 129–148.
11 Cooper CL, Rout U, Faragher B. Mental heath, job satisfaction, and job stress among general practitioners. Br Med J 1989; 298: 366–370.
12
Rout U, Rout JK. Job satisfaction, mental health and job stress among general practitioners before and after the new contract —a comparative study. Fam Pract 1994; 11: 300–306.
13 Appleton K, House A, Dowell A. A survey of job satisfaction, sources of stress and psychological symptoms among general practitioners in Leeds. Br J Gen Pract 1998; 48: 1059–1063.[ISI][Medline]
14 Karasek RA. Job demands, job decision latitude, and mental strain: implications for job redesign. Admin Sci Q 1979; 24: 285–308.
15 Heaney D, Gorman D, Porter M. Self-recorded stress levels for general practitioners before and after forming an out-of-hour primary care centre. Br J Gen Pract 1998; 48: 1077–1078.[ISI][Medline]
16
Pinder R. On the margins: belonging in general practice for women part-timers and non-principals. Fam Pract 1998; 15: 363–368.
17
Taylor DH, Leese B. Recruitment, retention and time commitment change of general practitioners in England and Wales, 1990–4: a retrospective study. Br Med J 1997; 314: 1806–1810.
18 Kirwan M, Armstrong D. Investigation of burnout in a sample of British general practitioners. Br J Gen Pract 1995; 45: 259–260.[ISI][Medline]
19
Branthwaite A, Ross A. Satisfaction and job stress in general practice. Fam Pract 1988; 5: 83–93.
20
Winefield HR, Anstey TJ. Job stress in general practice: practitioners age, sex and attitudes as predictors. Fam Pract 1991; 8: 140–144.
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