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Stressing the risks: managing the pressure

28 August 2009

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Independent Consultant in Practice Management

Fiona is an experienced primary care trainer and facilitator. She is the national RCGP QPA Adviser and has advised on both the original and the review of the Quality and Outcomes Framework of the 2004 GP contract

General practice is a highly rewarding and challenging working environment. In many practices, staff are so loyal and committed to the practice that they stay for years and it’s not for the money. While acknowledging that, there must only be a handful of practice managers throughout the UK – if any – who would not say that working in general practice can also be highly stressful.

In November 2007, People Management, the magazine of the Chartered Institute of Personnel and Development, said that 25% of fulltime workers were “generally stressed”, and 23% of fulltime workers never take a break.(1)

By November 2008, a report commissioned by Friends Provident stated that 25% of the people surveyed were planning to work more hours in the next six months, 61% were more stressed and 11% said that the source of the majority of their stress was work, principally caused by colleagues and bosses.(2)

Add to the equation the continuing pressures on general practice to measure performance, take part in government initiatives such as practice-based commissioning, maintain profits, cope with swine flu and deliver a population-wide additional immunisation programme, and we have a potent mixture capable of producing significantly increased levels of stress for GPs, practice managers and their teams.

The Health and Safety Executive’s (HSE) new website giving guidance on managing stress in the workplace defines stress as “the adverse reaction people have to excessive pressures or other types of demand placed on them” – and clearly this has the potential to cause harm to workers.3 Stress that lasts for an exceedingly long period of time, or which is in itself excessive, can cause mental and physical illnesses to develop.

Symptoms of stressed staff may include:

  • Difficulty sleeping.
  • Being tired all the time.
  • Headaches.
  • Being indecisive.
  • Being irritable.
  • Feeling anxious.
  • Being hypersensitive.

The HSE website also identifies contributing factors such as:

  • Eating on the run.
  • Rushing.
  • Being available to everyone.
  • Doing several jobs at once.
  • Missing breaks.
  • Taking work home with you.
  • Not taking time for exercise or to relax.(3)

Significant numbers of staff in general practice will recognise these factors in their own behaviour or that of colleagues, including GPs.

Clearly, there is significant risk of detriment to the practice. Absence rates may rise, performance may suffer and conflict between team members may start to develop.

Under the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1999, employers have a legal responsibility to ensure the health of their employees while at work, and this includes being responsible for minimising the risk of stress-related illness.

What should be happening in practices to try to mitigate the effects of the particularly stressful period we are working through at present?

What should the GPs be considering?
GPs are ultimately responsible for the safety of their staff, and at partner level in a practice the following issues could be considered:

  • What are we doing to monitor factors that might suggest high levels of stress? This would include the areas mentioned above, as well as absence, performance, conflict and high turnover.
  • Does our Health and Safety Policy include a Stress Policy and/or other mechanisms for dealing with stress in team members?
  • Have adequate risk assessments been undertaken, recorded if necessary, and have actions to reduce the risk of harm been identified/introduced?

What action should managers take?
In most practices, the manager has responsibility for implementing the Health and Safety Policy, and in many practices the manager would work with the GPs to ensure that the points above are actioned. But what should managers be doing in addition?

  • Ensure your risk assessments are adequate, using the HSE’s risk assessment checklist (see Resources), and that these assessments are reviewed and updated if necessary in accordance with the guidance.
  • Monitor and address sources of stress.
  • Discuss the symptoms of stress with staff.
  • Remind staff that they are responsible for informing you of any risks they encounter at work.
  • Review staff absences/turnover to see if stress is an increasing/significant factor.
  • Make reasonable adjustments if a member of staff is considered to have a disability under the Disability Discrimination Act (see Resources).

What action should staff take?
Staff also have responsibilities under Health and Safety legislation. They should take reasonable care of their own health and safety and the health and safety of others likely to be affected by their actions. Staff should:

  • Be aware of their responsibilities.
  • Inform the manager if they feel that conditions in the practice are causing the risk of harm.
  • Contribute to finding solutions.
  • Inform the manager if they have a condition or illness that might be considered to be a disability (physical or mental), and whether this may be long-term and may have an effect on their ability to carry out day-to-day tasks.
  • Work with the manager to identify reasonable adjustments that could be made to help them do their job.

Additional guidance
Helpfully, the HSE has also developed a set of management standards for work-related stress (see Resources). These are straightforward and simply reflect good practice, but could be extremely useful in supporting a systematic approach to this risk area.

These standards do not purport to eliminate stress in the workplace, but rather help organisations effectively control and manage it. The standards examine ways that work is designed in order to identify ways of minimising resultant illness, poor performance, sickness absence, turnover and other harmful consequences of stress in an organisation.

Additionally, they help employers to demonstrate good health and safety management practice by taking a stepwise approach to risk management. This involves:

  • Identifying the risks of workplace stress.
  • Focusing on underlying causes.
  • Finding ways of measuring success.

They also suggest ways in which employers can work with staff to support and encourage them in suggesting improvements that could be made in the workplace to reduce stress.

Areas covered by the HSE standards
The HSE’s management standards identify the following six areas of work design that are known to be potential causes of stress and related ill-health:

  • Demands. This covers areas such as workload, the working environment and working patterns such as rotas.
  • Control. This standard covers how much say or control the worker has over the way they do their job.
  • Support. This standard covers support, encouragement, feedback and information from management for staff and also how staff can provide support for colleagues.
  • Relationships. This standard focuses on working to avoid conflict and deal with unacceptable behaviour. This includes positive behaviours (such as assertiveness), managing bullying and effectively dealing with conflict.
  • Role. This standard helps managers to examine whether staff understand their role within the organisation and to identify conflicting roles. This covers job descriptions, clear objectives and performance standards and mechanisms to raise problems.
  • Change. This focuses on how change is managed in the organisation from the point of view of managing related stress. This includes engaging and consulting staff about organisational change, providing information and a chance to influence proposed changes, explaining the potential impact of the change on a person’s job, when the changes will occur and what support will be available.

The HSE Stress website (see Resources) also gives examples, including a health service example, of how organisations have applied the Stress Management Standards. The benefits to the organisation and to individuals of effective stress management include the following:

  • Improved customer care.
  • Less sickness absence, sickness cover and recruitment.
  • Higher morale.
  • Improved performance.
  • Improved team relationships.
  • Lower staff turnover.
  • Better staff understanding of others.

Undoubtedly, launching into a new management project at a time like this just looks like a bridge too far for many of us. However, GPs and their managers have a responsibility to take action to minimise the risk of stress-related illness in the team, and at the very least we should be undertaking risk assessments and putting into place action plans to minimise risk. Also, GPs need to remember to consider what they can do to support their managers!

1. Soriano K. A quarter of UK workforce are stressed. People Management November 2007. Available from:…
2. Friends Provident. Britain under Pressure. Wiltshire: Friends Provident; 2008.
3. Health and Safety Executive. Dealing with my stress [homepage on internet]. Available from:


Disability Discrimination Act

HSE Management Standards

HSE – Work-related stress

HSE Risk Assessment checklist