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Wednesday 17 July 2019
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At breaking point?

The rising workload in general practice means stress levels have reached a new high. Can practice managers cope with the pressure?

It won’t be a surprise that most people working in primary care find it stressful. However, many will be shocked by the scale of the problem revealed in a recent survey of

primary care staff by the mental health charity Mind.

Nearly nine in 10 (88%) of the 1,000 GPs, practice nurses, practice managers and colleagues interviewed for the study said their work causes them to feel either fairly or very stressed. To put that into context, that’s almost double the levels of stress reported by working people across all occupations in England.

This high-stress environment in practices and other primary care settings is taking its toll. Two in five staff (43%) either resign or consider leaving their jobs. Over half (54%) have experienced physical health issues. The vast majority report that they are losing sleep over worries at work (83%). Just

under half (43%) are self-medicating with alcohol to cope at least once a week. And nearly a third (31%) have developed mental health problems as a result of stress at work.

So what’s going on? Why are NHS primary care staff so stressed and what can be done about it?

For Amanda Sayer, practice manager and business partner at Eastbourne’s Lighthouse Medical Practice, it was a sense of wider isolation that began to cause intolerable stress levels.

She says that the level of change in recent years has meant her job has “changed beyond all recognition”, and a huge leap in regional and central reporting requirements have led to “rising” levels of stress.

However, she says she could have coped with all of this if the work involved dealing with ‘real people’, as in the “olden days of primary care trusts”.

“Now we’re just asked to send endless information to nameless, faceless people at generic email addresses, who often don’t reply for weeks, and it’s very isolating,” she says.

The stress problem for practice managers can be particularly acute because their role is to “look after everybody’s needs”, explains Sayer. “We are all having to deal with trying to operate in an environment where resources are being cut as patients’ expectations are being raised by Government rhetoric and media hype,” she says.

“We work really hard, but we’re having to do so much more for less.” Fiona Dalziel, co-lead for the RCGP’s General Practice Foundation for Practice Managers, agrees that practice managers feel there is little help for them, while the workload is forever increasing.

“There is little support for practice managers. Practice managers have seen an increase in regulatory management workload. There is the stress of managing a small business which feels besieged and there is a strong sense of responsibility for keeping the wheels on the wagon.”

Practice managers aren’t alone. GPs are also feeling the strain, which means added pressures in the general running of practices.

Dr Zoe Norris, a GP in East Yorkshire, ditched her life as a partner in a busy practice and began working as a locum two years ago, after she finally realised she could no longer cope with the enormous stress of her excessive workload.

The final straw came on a Friday, well into the evening. Shorthanded as ever at the end of the week, Dr Norris was trying to finish her non-stop day
- which was now topping 12 hours long - when an additional hour’s work suddenly became unavoidable.

“ I just lost it,” says Dr Norris.

“I started crying and I couldn’t stop.
I thought ‘I just can’t do this any more’. I didn’t want to be a GP any more. I just wanted to leave it all behind.”

Dr Norris says she is lucky to have a very supportive family and friends, who helped her to find a way to survive on the day she says she felt she “failed as a GP”.

She left her partnership role and went to work for a locum chambers - and has never looked back.

She says the comprehensive support and mentoring from her new colleagues has made her realise that feeling isolated as a partner was at the heart of the problem.

“In a practice, everyone is operating on the edge to stay on top of their workloads, and there is no time to talk,” says Dr Norris. “They are practising beyond safety in some cases,” she adds.

Part of the problem is the feeling that everyone is in the same boat; no one wants to admit they aren’t coping for fear of letting colleagues down or being perceived as weak and not up to the job.

Nearly a third (31%) of primary care staff say they can’t talk to colleagues for fear of being “seen as less capable than other colleagues”, according to the Mind research.

Dr Norris says that ministers are making matters worse with their drive to shift more care out of hospitals at a time of a national GP shortage and drastic social care cuts.

She says that it has got to a point where increased workload is creating an unsafe environment for patients, and there is “no goodwill left” among GPs and colleagues.

“People are now starting to say ‘this job is not worth my health and happiness’, and is forcing me to act in a way that is unsafe for patients,” says Dr Norris.

“GPs don’t want to be in a position where they are resenting a patient when they say ‘just one more thing’. And they know their stress levels won’t be taken into account when they’re in front of the GMC for making a mistake. So they conclude it’s not worth it,” she adds.

In terms of reducing stress overall, GPs and colleagues in primary care must get better at communicating with the wider world, says Dr Norris.

She says the British Medical Association (BMA) and the Royal College of GPs (RCGP) need to “stand up” for their members and shout that patients will come to harm if the current pressures aren’t dealt with.

She adds that health secretary Jeremy Hunt and his colleagues should stop making stage-managed tours of leafy GP practices and instead go to the sharp end - for example, a practice in inner-city Hull operating with half the staff it needs.

“It goes without saying that a service that relies on sick and fatigued GPs is not good for patient safety,” she adds.

For Sayer, she was lucky enough to have a supportive GP senior partner who was keen to listen and fnd answers for her stress.

However, she has also found solace and support among an external peer group and she urges practice managers to form local groups, if they haven’t already, that meet regularly to support

each other, share problems and feel less isolated.

She also stresses the importance of taking breaks and “time for yourself”, and resilience training.

For GPs, the BMA says it is well aware of the issues facing practices and is pushing for measures to address stress. “This [Mind] poll reinforces the BMA findings that GPs and their staff are under unsustainable pressure because they are having to work long, intense hours on dwindling resources against a backdrop of rocketing patient demand,” says GPC chair Dr Chaand Nagpaul.

“The inevitable side-effect is rising levels of burnout and stress. Many GPs are now considering cutting their working hours and one in three told
a recent BMA survey they were considering retiring in the next five years,” he adds.

Dr Nagpaul says the Government has recently announced a new service for GPs suffering from stress following BMA lobbying, but it needs to be widened to support all the primary care workforce.

Dr Maureen Baker, chair of the RCGP, also welcomes measures in NHS England’s recently published GP Forward View, which pledges £16 million to “support GPs suffering from burnout and stress” as a “lifeline for general practice”.

Dr Baker called for it to be implemented urgently so “we can keep our profession strong ... for the benefit of the wider NHS and our patients”.

Mind policy and campaigns manager Geoff Heyes says the research shows that the NHS needs to take the mental health and wellbeing of its staff much more seriously.

For instance, he says there is clearly work to be done to address the stigma of admitting to mental health problems.

Heyes echoes Dr Norris’s concern about the impact on patient care. “Somebody experiencing high levels of stress is unable to perform their job to the best of their ability,” he says. “If someone works in an environment where they feel they can’t talk about stress, that impacts how they deal with patients.” 

Mary-Louise Clews, freelance journalist