Health at work in the general practice.

BACKGROUND: Poor mental health and high stress levels have been reported in staff working in general practice. Little is known about how practices are tackling these and other issues of health at work in the absence of an established occupational healthcare service. AIM: To establish the extent of knowledge and good practice of health at work policies for staff working in general practice. METHOD: Practice managers in 450 randomly selected general practices in England were interviewed by telephone, and the general practitioner (GP) with lead responsibility for workplace health in the same practice was surveyed by postal questionnaire. We surveyed the existence and implementation of practice policies, causes and effects of stress on practice staff, and agreement between practice managers and GPs on these issues. RESULTS: Seventy-one per cent of GPs and 76% of practice managers responded, with at least one reply from 408 (91%) practices and responses from both the practice manager and GPs from 252 (56%) practices. Seventy-nine per cent of practices had a policy on monitoring risks and hazards. The proportion of practices with other workplace health policies ranged from 21% (policy to minimize stress) to 91% (policy on staff smoking). There was a tendency for practices to have policies but not to implement them. The three causes of stress for practice staff most commonly cites by both GP and practice manager responders were 'patient demands', 'too much work', and 'patient abuse/aggression'. Sixty-five per cent of GPs felt that stress had caused mistakes in their practices. Although there was general agreement between the two groups, there was a considerable lack of agreement between responders working in the same practices. CONCLUSIONS: The study revealed substantial neglect of workplace health issues with many practices falling foul of health and safety legislation. This report should help general practices identify issues to tackle to improve their workplace health, and the Health at Work in the NHS project to focus on areas where their targeted help will be most worthwhile.     

Access to complementary medicine via general practice.

BACKGROUND: The popularity of complementary medicine continues to be asserted by the professional associations and umbrella organisations of these therapies. Within conventional medicine there are also signs that attitudes towards some of the complementary therapies are changing. AIM: To describe the scale and scope of access to complementary therapies (acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism, and osteopathy) via general practice in England. DESIGN OF STUDY: A postal questionnaire sent to 1226 individual general practitioners (GPs) in a random cluster sample of GP partnerships in England. GPs received up to three reminders. SETTING: One in eight (1226) GP partnerships in England in 1995. METHOD: Postal questionnaire to assess estimates of the number of practices offering 'in-house' access to a range of complementary therapies or making National Health Service (NHS) referrals outside the practice; sources of funding for provision and variations by practice characteristics. RESULTS: A total of 964 GPs replied (78.6%). Of these, 760 provided detailed information. An estimated 39.5% (95% CI = 35%-43%) of GP partnerships in England provided access to some form of complementary therapy for their NHS patients. If all non-responding partnerships are assumed to be non-providers, the lowest possible estimate is 30.3%. An estimated 21.4% (95% CI = 19%-24%) were offering access via the provision of treatment by a member of the primary health care team, 6.1% (95% CI = 2%-10%) employed an 'independent' complementary therapist, and an estimated 24.6% of partnerships (95% CI = 21%-28%) had made NHS referrals for complementary therapies. The reported volume of provision within any individual service tended to be low. Acupuncture and homoeopathy were the most commonly available therapies. Patients made some payment for 25% of practice-based provision. Former fundholding practices were significantly more likely to offer complementary therapies than non-fundholding practices, (45% versus 36%, P = 0.02). Fundholding did not affect the range of therapies offered, and patients from former fundholding practices were no more likely to pay for treatment. CONCLUSION: Access to complementary health care for NHS patients was widespread in English general practices in 1995. This data suggests that a limited range of complementary therapies were acceptable to a large proportion of GPs. Fundholding clearly provided a mechanism for the provision of complementary therapies in primary care. Patterns of provision are likely to alter with the demise of fundholding and existing provision may significantly reduce unless the Primary Care Groups or Primary Care Trusts are prepared to support the 'levelling up' of some services.     

Retention of young general practitioners entering the NHS from 1991-1992.

BACKGROUND: The supply of general practitioners (GPs) in the National Health Service (NHS) is dynamic and there are fears that there will be an inadequate number of doctors to meet the needs of the NHS. There are particular concerns about changes in the career trajectory of young GPs and what they mean for overall supply. AIM: To identify predictors of retention among young, new entrant GPs entering the NHS between 1 October 1991 and 1 October 1992. METHOD: Two-year retention rates of young (35 years of age or less) new entrant GPs have been modelled using a multilevel logit model. Retention is defined as young, new entrant GPs remaining in their initial health authority for two years or more. RESULTS: Two hundred and fifty-two (13.0%) members of the study group left general practice within two years of entry (i.e. were not retained). Sex (females had lower retention [95% CI = 0.43-0.75]), practice size (young GPs in larger practices had higher retention [95% CI = 1.10-1.29]), and belonging to a practice in one of 16 Greater London Health Authorities (which had lower retention [95% CI = 0.39-0.82]) were identified as major predictors of retention. Deprivation, measured at the individual GP patient list level, had a very slight association with retention (P = 0.097; 95% CI = 1.00-1.02). Deprivation measured at the health authority level (95% CI = 0.99-1.01) was not found to be a statistically significant predictor of retention (P = 0.83). CONCLUSION: None of the statistically significant predictors of retention suggest any policy panacea to end this phenomenon. The challenge for policy is to learn to deal with the dynamic nature of the GP workforce with a non-crisis mentality.     

Preferences for general practice jobs: a survey of principals and sessional GPs.

BACKGROUND: Many countries are experiencing recruitment and retention problems in general practice, particularly in rural areas. In the United Kingdom (UK), recent contractual changes aim to address general practitioner (GP) recruitment and retention difficulties. However, the evidence base for their impact is limited, and preference differences between principals and sessional GPs (previously called non-principals) are insufficiently explored. AIM: To elicit GP principals' and sessional GPs' preferences for alternative jobs in general practice, and to identify the most important work attributes. Design of study: A discrete choice experiment. SETTING: National Health Service (NHS) general practices throughout Scotland. METHOD: A postal questionnaire was sent to 1862 principals and 712 sessional GPs. The questionnaire contained a discrete choice experiment to quantify GPs' preferences for different job attributes. RESULTS: A response rate of 49% (904/1862) was achieved for principals and 54% (388/712) for sessional GPs. Of responders, most principals were male (60%), and sessional GPs female (75%), with the average age being 42 years. All GPs preferred a job with longer consultations, no increase in working hours, but an increase in earnings. A job with outside commitments (for example, a health board or hospital) was preferable; one with additional out-of-hours work was less preferable. Sessional GPs placed a lower value on consultation length, were less worried about hours of work, and a job offering sufficient continuing professional development was less important. CONCLUSION: The differences in preferences between principals and sessional GPs, and also between different personal characteristics, suggests that a general contract could fail to cater for all GPs. Recruitment and retention of GPs may improve if the least preferred aspects of their jobs are changed. However, the long-term success of contractual reform will require enhancement of the positive aspects of working, such as patient contact.     

A survey of access to medical services in nursing and residential homes in England.

BACKGROUND: Residential and nursing homes make major demands on NHS services. AIM: To investigate patterns of access to medical services for residents in homes for older people. DESIGN OF STUDY: Telephone survey. SETTING: All nursing and dual registered homes and one in four residential homes located in a stratified random sample of 72 English primary care group/trust (PCG/T) areas. METHOD: A structured questionnaire investigating home characteristics, numbers of general practitioners (GPs) or practices per home, homes' policies for registering new residents with GPs, existence of payments to GPs, GP services provided to homes, and access to specialist medical care. RESULTS: There were wide variations in the numbers of GPs providing services to individual homes; this was not entirely dependent on home size. Eight percent of homes paid local GPs for their services to residents; these were more likely to be nursing homes (33%) than residential homes (odds ratio [OR] = 10.82, [95% CI = 4.48 to 26.13], P<0.001) and larger homes (OR for a ten-bed increase = 1.51 [95% CI = 1.28 to 1.79], P<0.001). Larger homes were more likely to encourage residents to register with a 'home' GP (OR for a ten-bed increase = 1.16 [95% CI = 1.04 to 1.31], P = 0.009). Homes paying local GPs were more likely to receive one or more additional services, over and above GPs' core contractual obligations. Few homes had direct access to specialist clinicians. CONCLUSION: Extensive variations in homes' policies and local GP services raise serious questions about patient choice, levels of GP services and, above all, about equity between residents within homes, between homes and between those in homes and in the community.     

Do GPs working in practice with high or low prescribing costs have different views on prescribing cost issues?

BACKGROUND: In a previous study we found that a minority of general practitioners (GPs) had different views to health authority advisers on a number of prescribing cost issues. However, there were few differences between subgroups of GPs. We hypothesised that subgroups that might show differences were GPs from practices with either high or low prescribing costs. AIM: To assess differences in views on prescribing cost issues between GPs working in practices with either high or low prescribing costs. METHOD: Using PACTLINE data, prescribing costs were obtained for general practices within the Trent Region for the financial year 1996 to 1997. A questionnaire was sent anonymously to 340 GPs working in those practices with high prescribing costs, and to 322 GPs working in practices with the lowest prescribing costs. RESULTS: A total of 216 (63.5%) GPs from high-cost practices and 194 (60.2%) from low-cost practices responded. There were statistically significant differences between the two groups on seven out of 22 statements. However, when the confounding effect of fundholding was taken into account, significant differences were found for just three statements and each of these related to substitution with comparable but cheaper drugs. CONCLUSIONS: GPs working in practices with either high or low prescribing costs had different views on a number of statements concerning substitution with comparable but cheaper drugs. When encouraging GPs to control their prescribing costs, a different approach may be required for doctors in some high-cost practices.     

The barriers to effective management of heart failure in general practice.

BACKGROUND: Several studies have shown that most patients with heart failure are not investigated and treated according to published guidelines. More effective management could reduce both mortality and morbidity from heart failure. AIM: To identify the reasons for gaps between recommended and actual management of heart failure in general practice. DESIGN OF STUDY: A nominal group technique was used to elicit general practitioners' (GPs') perceptions of the reasons for differences between observed and recommended practice. SETTING: Ten Medical Research Council General Practice Framework practices in the North Thames region. METHOD: Data were collected on the investigation and treatment of heart failure in the 10 participating practices and presented to 49 GPs and 10 practice nurses from those practices. RESULTS: Of the 674 patients requiring echocardiograms, 226 were referred for echocardiography (34%), and 183/391 (47%) with probable heart failure were prescribed angiotensin-converting enzyme inhibitors. A wide variety of barriers were elicited. The main barrier to the use of echocardiograms in the diagnosis of heart failure was lack of open access. The main barrier to the use of angiotensin-converting enzyme inhibitors in treating heart failure was GPs' concerns about their possible adverse effects. CONCLUSION: The barriers to the effective management of heart failure in general practice are complex. We recommend further research to establish whether multifaceted intervention programmes based on our findings can improve the management of heart failure in primary care.     

Addressing the problems associated with general practitioners'' workload in nursing and residential homes: findings from a qualitative study.

BACKGROUND: Caring for older people in residential and nursing homes makes major demands on general practitioners (GPs). AIM: To investigate the perceptions and experiences of home managers and GPs of the provision of general medical services for older residents. DESIGN OF STUDY: In-depth qualitative study. SETTING: Forty-two nursing and residential homes in five locations in England, interviewing home managers and eight of their residents' GPs. METHOD: Semi-structured face-to-face and telephone interviews. RESULTS: Most homes endorse principles of continuity of care and patient choice. Although many homes therefore deal with a large number of GPs, with the inherent difficulties of coordinating care and duplication of GP effort, limitations in residents' choice of GP result in the majority of residents in many homes being registered with only one or two practices. Contracts between homes and GPs may provide opportunities for improving medical care but do not guarantee additional services and have implications for patient choice and residents' fees. Visits on request form the bulk of GPs' workload in homes but can be hard to obtain for residents and may not be appropriate. Regular weekly surgeries are preferred by many homes but may have additional workload implications for GPs. CONCLUSION: The assumption that patient choice and continuity in medical care are paramount for older people in nursing and residential homes is questioned. While recognition of the additional workload for GPs working in these settings is necessary, this should be accompanied by additional NHS remuneration. Further research is urgently required to identify which models of GP provision would most benefit both residents and GPs.     

Online data on opening hours of general practices in England: a comparison with telephone survey data

Background

The NHS Choices website (www.nhs.uk) provides data on the opening hours of general practices in England. If the data are accurate, they could be used to examine the benefits of extended hours.

Aim

To determine whether online data on the opening times of general practices in England are accurate regarding the number of hours in which GPs provide face-to-face consultations.

Design and setting

Cross-sectional comparison of data from NHS Choices and telephone survey data reported by general practice staff, for a nationally representative sample of 320 general practices (December 2013 to September 2014).

Method

GP face-to-face consultation times were collected by telephone for each sampled practice for each day of the week. NHS Choices data on surgery times were available online. Analysis was based on differences in the number of surgery hours (accounting for breaks) and the times of the first and last consultations of the day only between the two data sources.

Results

The NHS Choices data recorded 8.8 more hours per week than the survey data on average (40.1 versus 31.2; 95% confidence interval [CI] = 7.4 to 10.3). This was largely accounted for by differences in the recording of breaks between sessions. The data were more similar when only the first and last consultation times were considered (mean difference = 1.6 hours; 95% CI = 0.9 to 2.3).

Conclusion

NHS Choices data do not accurately measure the number of hours in which GPs provide face-to-face consultations. They better record the hours between the first and last consultations of the day.     

Primary care group commissioning of services: the differing priorities of general practitioners and district nurses for palliative care services.

BACKGROUND: General practitioners (GPs) have become more responsible for budget allocation over the years. The 1997 White Paper has signalled major changes in GPs' roles in commissioning. In general, palliative care is ranked as a high priority, and such services are therefore likely to be early candidates for commissioning. AIM: To examine the different commissioning priorities within the primary health care team (PHCT) by ascertaining the views of GPs and district nurses (DNs) concerning their priorities for the future planning of local palliative care services and the adequacy of services as currently provided. METHOD: A postal questionnaire survey was sent to 167 GP principals and 96 registered DNs in the Cambridge area to ascertain ratings of service development priority and service adequacy, for which written comments were received. RESULTS: Replies were received from 141 (84.4%) GPs and 86 (90%) DNs. Both professional groups agreed that the most important service developments were urgent hospice admission for symptom control or terminal care, and Marie Curie nurses. GPs gave greater priority than DNs to specialist doctor home visits and Macmillan nurses. DNs gave greater priority than GPs to Marie Curie nurses, hospital-at-home, non-cancer patients' urgent hospice admission, day care, and hospice outpatients. For each of the eight services where significant differences were found in perceptions of service adequacy, DNs rated the service to be less adequate than GPs. CONCLUSION: The 1997 White Paper, The New NHS, has indicated that the various forms of GP purchasing are to be replaced by primary care groups (PCGs), in which both GPs and DNs are to be involved in commissioning decisions. For many palliative care services, DNs' views of service adequacy and priorities for future development differ significantly from their GP colleagues; resolution of these differences will need to be attained within PCGs. Both professional groups give high priority to the further development of quick-response clinical services, especially urgent hospice admission and Marie Curie nurses.     

Research general practices: what, who and why?

BACKGROUND: By the autumn of 1995, 14 research general practices had been funded. These are service NHS general medical practices that are supportive of primary care research and have a lead GP who has research experience as evidenced by publication in peer-reviewed journals. AIM: To ascertain the characteristics of those who have been successful in securing the first 14 grants, the effect the process has had on them, and the practical advice they would offer to future applicants and to future funding bodies. METHOD: A confidential postal survey of research general practices. RESULTS: They are atypical practices (high level of research and teaching involvement, mostly non-urban) with atypical lead GPs (male, research degrees, possess MRCGP, publications and grants obtained). Practices contemplating applying for future research practice grants should consider planning ahead, use of grant monies, protection of research time, involving the primary health care team, and sources of both internal and external support. Funding bodies need to make adequate funding available for capital expenditure and running costs as well as staff and lead GP time. CONCLUSION: Research general practices are ideal for integrating the core values of the medical profession, providing clinical care by medical generalists, teaching the discipline and researching its basis. Such practices should be funded on a rolling basis and throughout the United Kingdom. Future evaluation of funding such practices is needed and should confirm their utility both to the discipline and to patient care within the NHS.     

An exploration of the value of the personal doctor-patient relationship in general practice.

BACKGROUND: Within the context of general practice, continuity of care creates an opportunity for a personal doctor-patient relationship to develop which has been associated with significant benefits for patients and general practitioners (GPs). Continuity of care is, however, threatened by trends in the organisational development of primary health care in the United Kingdom and its intrinsic role within general practice is currently the subject of debate. AIMS: To determine how many patients report having a personal doctor and when this is most valued, to compare the value of a personal doctor-patient relationship with that of convenience, and to relate these findings to a range of patient, GP, and practice variables. DESIGN OF STUDY: Cross sectional postal questionnaire study. SETTING: Nine hundred and ninety-six randomly selected adult patients from a stratified random sample of 18 practices and 284 GP principals in Oxfordshire. METHOD: Qualitative interviews with patients and GPs were conducted and used to derive a parallel patient and GP questionnaire. Each patient (100 from each practice) was invited to complete a questionnaire to evaluate their experience and views concerning personal care. All GP principals currently practising in Oxfordshire were sent a similar questionnaire, which also included demographic variables. RESULTS: Overall, 75% of patients reported having at least one personal GP. The number of patients reporting a personal GP in each practice varied from 53% to 92%. Having a personal doctor-patient relationship was highly valued by patients and GPs, in particular for more serious, psychological and family issues when 77-88% of patients and 80-98% of GPs valued a personal relationship more than a convenient appointment. For minor illness it had much less value. CONCLUSIONS: Patients and GPs particularly value a personal doctor-patient relationship for more serious or for psychological problems. Whether a patient has a personal GP is associated with their perception of its importance and with factors which create an opportunity for a relationship to evolve.     

Diagnosis of somatisation: effect of an educational intervention in a cluster randomised controlled trial.

BACKGROUND: Somatisation is highly prevalent in primary care (present in 25% of visiting patients) but often goes unrecognised. Non-recognition may lead to ineffective treatment, risk of iatrogenic harm, and excessive use of healthcare services. AIM: To examine the effect of training on diagnosis of somatisation in routine clinical practice by general practitioners (GPs). DESIGN OF STUDY: Cluster randomised controlled trial, with practices as the randomisation unit. SETTING: Twenty-seven general practices (with a total of 43 GPs) in Vejle County, Denmark. METHOD: Intervention consisted of a multifaceted training programme (the TERM [The Extended Reattribution and Management] model). Patients were enrolled consecutively over a period of 13 working days. Psychiatric morbidity was assessed by means of a screening questionnaire. GPs categorised their diagnoses in another questionnaire. The primary outcome was GP diagnosis of somatisation and agreement with the screening questionnaire. RESULTS: GPs diagnosed somatisation less frequently than had previously been observed, but there was substantial variation between GPs. The difference between groups in the number of diagnoses of somatisation failed to reach the 5% significance (P = 0.094). However, the rate of diagnoses of medically unexplained physical symptoms was twice as high in the intervention group as in the control group (7.7% and 3.9%, respectively, P = 0.007). Examination of the agreement between GPs' diagnoses and the screening questionnaire revealed no significant difference between groups. CONCLUSION: Brief training increased GPs' awareness of medically unexplained physical symptoms. Diagnostic accuracy according to a screening questionnaire remained unaffected but was difficult to evaluate, as there is no agreement on a gold standard for somatisation in general practice.     

General practitioners' attitudes to the development of midwifery group practices.

BACKGROUND: The report Changing childbirth (1993) has led to the development of midwifery-led schemes that aim to increase the continuity of maternity care. AIM: To determine the impact of midwifery group practices on the work of general practitioners (GPs) and their perceptions of midwifery group practice care. METHOD: Postal questionnaires were sent to 58 GPs referring women to the care of midwifery group practices (group-practice GPs), and a shorter questionnaire was sent to the remaining 67 GPs (non-group-practice GPs) within the same postcode area as a comparison group. In-depth interviews were conducted with 12 GPs. RESULTS: Questionnaires were returned by 71% of group-practice GPs and 81% of non-group practice GPs. One third of the group practice GPs felt that they were seeing group practice women too few times, and 50% thought midwives discouraged women from visiting their GP for antenatal checks. Over 80% of group practice GPs believed that midwives had the skills to detect deviation from the normal, and 66% would confidently refer women to their care. However, only 14% of group practice GPs believed that their own role was clear, while 64% agreed that communication with group practice midwives was poor, and concerns were expressed about the level of consultation before establishing schemes. Of the non-group practice GPs, 87% said they would consider referring women to the care of a midwifery group practice in the future. CONCLUSIONS: General practitioners were generally positive about the quality of care provided by midwifery group practices but identified issues that require addressing in developing this model of care.     

Psychological morbidity in general practice managers: a descriptive and explanatory study.

BACKGROUND: Proposals to establish an occupational health service for primary care should be informed by knowledge of the health needs of general practice employees. AIM: To determine the prevalence and occupational correlates of stress, anxiety, and depression among practice managers in two contrasting health authorities in England. METHOD: A postal questionnaire, soliciting information about stress induced by work-related activities, which contained the General Health Questionnaire (GHQ) and Hospital Anxiety and Depression Scale (HADS), was sent to all 149 practice managers in two health authorities areas of south-east England. RESULTS: Completed questionnaires were returned by 111 (75%) managers; 41/111 (37%) achieved GHQ case status with scores on HADS indicating that 49/111 (44%) classified themselves as anxious and 19/111 (17%) as depressed. The likelihood of being a case was found to be higher in managers from practices with larger numbers of GP partners (P = 0.02) and in managers from practices not in receipt of deprivation payments (P = 0.03). Multiple logistic regression showed that managers' perceived difficulties with general practice administration duties (relative ratio [RR] = 3.27, 95% confidence interval [CI] = 1.22-8.75) and dealings with GPs (RR = 1.86, 95% CI = 1.03-3.34) were the most powerful predictors of case status. CONCLUSION: The questionnaire uncovered high prevalences of self-reported stress, anxiety, and depression in general practice managers. Although the vast majority of National Health Service (NHS) employees have access to an occupational health service, no such source of support exists for those working in general practice. The NHS needs to establish an occupational health service that caters to the needs of clinical and non-clinical members of primary health care teams.     

Why do general practitioners from France choose to work in London practices? A qualitative study.

BACKGROUND: Growing concerns about the ability to maintain and increase the general practitioner (GP) workforce has led to active recruitment of GPs from overseas. However, little is known about why these GPs choose to leave their countries and come to work in London. AIM: To investigate the motivations and expectations of French GPs migrating to work in general practices in London. Design of study: A qualitative study using semi-structured interviews. SETTING: General practice induction programme in southeast London. METHOD: Individual interviews with 31 French GPs, who attended an induction programme for international recruits, were taped, transcribed, and analysed using a categorical approach. RESULTS: Three factors led to the process of migration: instigating factors, creating the stimulus for migration; activating factors, based on the perception that English general practice offered greater opportunities; and facilitating factors, which make migration possible. Particular emphasis was placed on personal and professional instigating factors, with a desire for new cultural experiences and a widespread discontent surrounding the infrastructure of French general practice, playing crucial roles in the stimulus to migrate. Ease of travel and a paid induction programme facilitated the move to their chosen destination. CONCLUSION: French GPs' decisions were part of a process of migration influenced by a series of integrated factors. Consideration of these factors will not only enhance recruitment to English general practice, but will also facilitate foreign GPs' transition to work in the National Health Service (NHS) and, ultimately, maximise their retention.     

The work hours of GPs: survey of English GPs

BACKGROUND: There is no current information about the hours worked by English GPs. AIM: To compare the reported hours worked by GPs with that of other professions and to explain the variation in GP hours worked and on call. Design of study: National postal survey of 1871 GPs in February 2004. SETTING: English general practice. METHOD: Multiple regression analyses of part-time versus full-time status, hours worked, and hours on call. RESULTS: Full-time male GPs report more hours worked (49.6; 95% CI [confidence interval] = 48.9 to 50.2) than males in other professional occupations (47.9; 95% CI = 47.6 to 48.1) and male managers (49.1; 95% CI = 48.8 to 49.5). Full-time female GPs report fewer hours (43.2; 95% CI = 42.0 to 44.3) than females in other professional occupations (44.7; 95% CI = 44.4 to 45.0) and female managers (44.1; 95% CI = 43.7 to 44.5). The number of hours worked decreased with practice list size, and increased with the number of patients per GP. GPs work longer hours in practices with older patients and with a higher proportion of patients in nursing homes. Fewer hours are worked in practices with higher 'additional needs' payments. Having children under 18 years of age increased the probability that female GPs work part-time but has no effect on the probability of male GPs working part-time. Given full-time/part-time status, having children under 18 years of age reduces the hours of male and female GPs. CONCLUSION: Male English GPs report longer hours worked than other professional groups and managers. The sex differences between GPs in hours worked are mostly attributable to the differential impact of family circumstances, particularly the number of children they have. Perversely, 'additional needs' payments are higher in practices where GPs work fewer hours.