Changing Social Defence Systems: Narratives of UK General Practice

Twelve senior general practitioners (GPs) participated in interviews exploring their career stories. They described their experiences of professional practice in the changing context of the NHS. The GPs in this cohort had all originally made a commitment to a community of patients that extended throughout the day and year. Most of the GPs had been inspired by Balint's work, seeing their relationships with patients as inherently therapeutic. Although some of the accounts describe intense anxiety related to the responsibilities in their work, their distress escalated as care became increasingly fragmented, and professional autonomy eroded. The accounts describe progressive alienation from patients, colleagues, and the wider National Health Service (NHS). Despite Menzies' illuminating work fifty years ago the NHS continues to be beset by difficulties in containing the anxiety inherent in health care. The hypothesis explored here is that managerial initiatives in general practice have imposed extra-professional social defences, in a rational-instrumental attempt to control dependency and erase doubt. This has reduced opportunities for reparative satisfaction, eroded the resources available for managing the anxieties arising from the work, and, in part, contributes to reduced recruitment and retention of general practitioners (GPs). In the light of the current GP workforce crisis it is particularly timely to consider how to make the work of a GP psychologically sustainable. Changes in service organisation need to take the “psychological contract” into account—how to contain anxiety and support satisfying work. Useful approaches could promote peer support, genuine multidisciplinary working, and continuity of care, alongside changes to workload and intensity. A systemic approach would also promote containment, not only at clinical level, but throughout the hierarchies of the health care institution, including those of policy-makers and commissioners.