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Practice management today: ‘the stress is mentally and physically breaking me’

by Costanza Pearce
7 May 2019

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Low morale, a desire to quit the job and abuse from patients are some of the biggest challenges for practice managers, a new report reveals. Costanza Pearce finds out more
Looking at the results of Management in Practice publisher Cogora’s annual report on the primary care sector, primary care emerges as an unforgiving place to work for many practice managers. Primary Concerns 2018 – The State of Primary Care, published in March, surveyed more than 2,300 primary care professionals at the end of last year. 
In addition to more than 400 practice manager respondents, it also gathered responses from GPs, nurses, healthcare assistants and pharmacists across the UK. The report found that if working conditions do not improve, the sector may face a drain of practice managers.
One standout fi gure is that as many as 47% of practice managers said they may leave the profession in the next 12 months, with 30% contemplating leaving for reasons other than retirement.
This was the highest percentage of any of the primary care professions surveyed. Practice managers were revealed to be a high-risk group for all types of abuse from patients, with eight in 10 experiencing verbal abuse and twice as many reporting written abuse compared with the survey average (41% versus 18%).
We are pleased to see that for the fi rst time in three years, the proportion of practice managers reporting written, verbal and physical abuse has decreased. 

However, it should be noted that this year’s survey sample was much larger than last year’s: 2,386 respondents compared with 1,897.
Low morale was common, with 42% of practice managers rating their morale as ‘low’ or ‘very low’, and a third, 35%, saying they had taken time off for stress or burnout in the last year, or expected to in the next 12 months.
This was unsurprising in light of the long hours practice managers reported, with 52% stating they work overtime on a daily basis. Equalled only by salaried GPs, this was the highest overtime figure in the report.
Pay and conditions

It may not come as a surprise that more than  half of practice managers, 52%, said they work unpaid overtime on a daily basis, while a third, 36%, do so at least once a week. 
Because of practice demands and heavy workloads, just 4% never work beyond their contracted hours, placing practice managers second only to GPs, of whom just 2% said they never work unpaid overtime.
No other profession surveyed worked long hours to the same extent as these two groups, who seem to bear the brunt of the squeeze on general practice. However, our question on pay rises paints a more positive picture of practice managers’ situation.
Nearly two-thirds, 60%, said they had requested a salary increase or improved terms and conditions while in their current role, and some three-quarters, 76%, were successful in receiving a pay rise.

As for the extent of the increase, practice managers received an average pay rise of 7%, while the fi gure was 10% for GPs. Interestingly, a third of practice managers, 33%, said they had not asked for a pay rise or requested better terms.
What you said…

‘The pressures are unbelievable. I work 10 hours beyond my contract every week’
Work morale
Almost half of practice managers struggle with motivation, with 42% reporting ‘low’ or ‘very low’ morale. More than a third, 35%, said they felt so stressed and burnt out that they had taken time o in the previous year, or expected to need time o in the coming 12 months.
Some of those who had not taken time off  sought counselling or medication for stress and anxiety. An alarming 47% of practice managers said they are contemplating quitting in the next year. 
Nearly a third, 30%, are thinking of leaving, but not to retire – the highest figure of all the professions surveyed. Practice managers described feeling anxious and depressed, saying they ‘can’t carry on’ because ‘every day is a battle’.
There were fi ve main factors damaging the morale of practice managers: unrealistic demands from patients, which was ‘very influential’ for 55%; too much bureaucracy, of which 49% said the same; workload ‘dumping’ from other sectors, 39%; unfair criticism from the media at 34%; and unfair criticism from politicians at 33%.
Positively, workplace bullying was ‘not at all’ influential on low morale for 70% of practice managers, compared with 56% of salaried GPs.
What you said…
‘The stress is mentally and physically breaking me’
Abuse from patients

Practice managers are among the primary care professions most likely to experience abuse from patients. A staggering eight in 10 practice managers, 79%, said they had been subjected to verbal abuse in the 12 months leading up to the survey, along with 79% of pharmacists, 60% of nurses and 57% of GPs.
Almost half of practice managers, 45%, cited the impact of verbal abuse from patients as ‘influential’ or ‘very infl uential’ on low morale; that figure was only higher for healthcare assistants, at 50%.
While fewer practice managers had received written abuse from patients, they were still the group most likely to experience it, with 41% reporting written abuse in the past year.
This was more than double the proportion of respondents across all the professions, for whom the figure was 18%. Only 4% of practice managers reported physical abuse in the 12 months leading up to the survey, but this still represents 15 individuals.
Because of the small number involved, it’s not surprising that 62% of practice managers said physical abuse had no impact on morale.
The report also examined levels of sexual abuse by patients. Although rates were low, 1% across all the professions, that still equates to five practice managers.
What you said…
‘I’m verbally abused by patients several times a day and am going home drained’
Brexit and the NHS

Practice managers fear Brexit will have a negative impact on primary care across areas such as staffing, patient numbers, drugs shortages and the NHS budget. More than two-thirds, 68%, thought Brexit will have a detrimental effect on the number of nurses working in the NHS; 10% said it would have no impact.
Similarly, 65% thought Brexit will have a negative effeect on GP numbers; 13% felt it would have no impact. More than half of practice managers, 54%, thought Brexit would cause a drop in the number of other primary care staff; 22%, did not think Brexit would have any effect.
Practice managers were divided on Brexit’s impact on the number of patients accessing NHS care: 34% said Brexit would have a negative impact; 29% felt it would have no impact; and 12% that it would be positive. More than half, 55%, said Brexit would lengthen the time spent assessing a patient’s eligibility for NHS care.
With respect to drugs availability, 56% believed Brexit will have an adverse effect, and 49% said it will lead pharmacists to stockpile medicines. Practice managers also had financial concerns: 44% felt Brexit would have a negative impact on the NHS budget.
What you said…

‘We are already seeing prices rising way above drug tariff costs, and this will only get worse’
The multidisciplinary primary care team
Practice managers were positive about the potential of easing pressures in primary care by incorporating a wider range of professions into the team, with nearly half, 45%, saying they currently employ a practice pharmacist and would continue to do so.
Almost as many, 41%, said they would consider employing one although they do not at the moment. Although practices are increasingly working with pharmacists, there has been slightly less uptake when it comes to mental health therapists and physician associates.
However, the report found that while only 7.5% of practice managers currently work with mental health therapists, those who did found it a positive experience, with 100% saying they would continue to employ them.
Of those who did not already employ mental health therapists, 84% said they would consider adding one to their team.

As many as 40% of practice managers said they would be open to hiring a physician associate for their practice in the future, although only 7% already employ one.
Those who currently work with one expressed a positive experience, with only 0.5% of practice managers saying they would not continue to employ a physician associate.

However, as many as a quarter, 25%, seemed unconvinced, saying they neither employed one at the moment, nor would consider doing so.

Following the opening of the Nursing and Midwifery Council’s nursing associate register in January this year, practice managers were also asked for their views on employing a nursing associate.
More than a third, 38%, said they would consider hiring one but had no plans to do so this year, while only 11% had plans to incorporate one into their practice in 2019.
Almost as many practice managers were unsure about nursing associates as about physician associates, with around a fifth, 19%, saying they would not employ one.
What you said…

‘Primary care is under pressure with limited resources. We need to reconfigure the workforce if we are to survive’
Transformation and working at scale

Practice managers provided a fairly damning assessment of recent attempts to remodel primary care. Two-thirds, 66%, said they had seen no improvement following NHS England’s recommendation that sustainability and transformation partnerships (STPs) earmark 15% of their fund allocations for general practice.

Practice managers were also unconvinced of the positive impact of STPs on patient care. As many as 40% said their implementation
had had a neutral effeect on the quality of patient care in the previous year.
Only 0.8% believed the impact of STPs had been ‘extremely positive’, and a quarter, 25%, said it had been ‘negative’ or ‘extremely negative’.
This lack of confidence in STPs comes at at a time when the NHS has decided that it needs to work more collaboratively. This was a focus both of the long-term plan and the new GP contract, with NHS England announcing plans for practices to join primary care networks across England by July – backed by £1.8bn of funding by 2023.
Nearly a third, 31%, of practice managers believed large-scale GP practice organisations and the upscaling of primary care had had a ‘negative’ or ‘extremely negative’ impact on the quality of patient care in the previous 12 months. GPs were even less enthusiastic, with 43% agreeing with this assessment.
The majority of practice managers and GPs, 58% and 69% respectively, believed the General Practice Forward View – which ‘commits to an extra £2.4bn a year to support general practice services by 2020/21’ – had brought no improvements to the sector, since its announcement in 2016.

Despite this, practice managers were the most enthusiastic profession surveyed, with 31% acknowledging that it had brought ‘some improvement’.
What you said…

‘I’ve simply had enough of the never-ending change. The NHS as a political football is not sustainable’