Heavy workload is often cited as a major cause of dissatisfaction and stress among GPs.

1The issue was addressed in a 10point plan announced by the government in April aimed at reducing GPs' administrative and routine work to allow them to concentrate on patient care.

2The measures included delegation of duties to pharmacists, community nurses, other practice therapists and receptionists. The proposals have been welcomed by representatives of general practice.

3But questions remain about how they will affect job satisfaction and work-related stress among GPs and the rest of the general practice workforce.

Other studies have tended to look at GPs in isolation, but strategies for tackling work stress would be enhanced by a greater understanding of how general practice functions as an organisation, and the complex network of relationships between members of the primary care team and between staff and patients. Despite this, the workforce perspective adopted in a recent study of hospital trusts has not been replicated in primary care.

4Our study examined the prevalence and causes of work stress among the general-practice workforce.

5Random selection

The research comprised a postal survey and follow-up face-to-face interviews. Out of 100 randomly selected general practices from the NHS Executive South East region,81 agreed to participate. Questionnaires went to GPs, practice managers, receptionists and clerical staff, practice and district nurses and health visitors. The aggregate response rate was 70 per cent (n=1,545), and all occupational groups had a response rate of over 60 per cent. Follow-up interviews were carried out with all staff who were willing to participate at 10 practices (n=87).

Nearly a quarter (23 per cent) of all respondents were classified as suffering from mental distress according to the GHQ-12 methodology - scoring four or more.

4The rate among hospital staff is 27 per cent, and surveys of the general population have thrown up a rate between 14 per cent and 18 per cent.

4The study also found marked differences between occupations (see bar chart), with practice managers and doctors reporting the highest rate of stress (30 per cent), and the lowest rates found among receptionists and clerical staff.

The GHQ case rate for practice managers was slightly lower than their counterparts in hospital (33 per cent), but 4Ten of the 81 practices had at least 40 per cent of their staff reporting mental distress, while at the other end of the continuum 10 practices had less than 10 per cent of their staff in this category. Statistical analysis suggested that these differences could not be entirely explained by the occupational composition of the practice, but appeared to be linked to other structural and organisational characteristics which were identified through the follow-up interviews.

Both the quantitative and qualitative analyses showed that, as in other employment sectors, heavy workload and intensity of work, coupled with low job control and lack of social support, were associated with elevated levels of mental distress. However, the qualitative analysis also identified a number of other causes of stress that may be specific to general practice or the caring professions.

Relationships between staff could be just as stressful as the relationship between staff and patients. Two relationships were particularly significant - doctor-nurse and senior partner practice manager. The role of community nurses is expanding, with many beginning to take on some of the clinical responsibilities previously held by doctors. Some of the GPs welcomed this development as a means of sharing a heavy workload. Others lacked trust in the nurse's competence or felt that their status and income were threatened.

'We don't want them taking over our jobs and money and position and all the rest of it, but otherwise I think it's a good thing. Triaging is something we're going to have to do much more, and the nurses are going to have to deal with the trivial stuff. But these highly trained GPs should be more specialist and you should get the nurses to do the ordinary mundane stuff.'

In some practices doctors were eager to offload work on to nurses who were reluctant to take on additional duties.

But in others, well-trained and highly motivated nurses, eager to expand their remit, were frustrated by doctors who refused to let them do so.

Similar tensions were found in the relationship between some senior partners and their practice managers. In some practices the manager acted like the chief executive of a small company, taking responsibility for most of the financial and operational management and freeing the doctors to concentrate on clinical matters. More often, though, the practice manager was little more than a senior receptionist or administrative assistant, with the doctors doing most of the management.

'These GPs have been bleating about how stressed they are and then they want to hang on to this power. There are people who are skilled in. . . managing situations, organisations and money who would probably do a hell of a lot better than the GPs who are playing at it.'

There were several reasons why GPs were reluctant to delegate managerial responsibility, including the long history of independent-contractor status in which singlehanded GPs traditionally managed their own affairs, often with the administrative support of their spouse. The growth of group practice and the fundholding initiative enabled the role of practice manager to develop, but in small practices where funding for managerial pay is limited it is difficult to recruit well-trained and experienced managers. It was often the case that the practice manager had limited managerial expertise and little credibility, still being seen as the doctor's administrative assistant rather than an autonomous manager. As well as causing a degree of antagonism between doctor and manager, the scarcity of fully empowered and competent managers often meant that practices relied on 'muddling through'. In some instances this undermined the cohesion of the practice, causing problems for many of the staff.

Essential skills Well-developed managerial skills were perceived as essential for a supportive organisational culture. Many informants spoke favourably about a 'family atmosphere' in the workplace. Where this existed, relations between staff appeared to be less antagonistic and more supportive. It appeared to be particularly strong in small practices where staff had developed their working relationships over a number of years.

There was no evidence to suggest that the promotion of a 'family atmosphere' was compromised by formal managerial devices, such as detailed contracts. In fact, relations between staff appeared to be strengthened by clarity about expectations, responsibilities and entitlements. The key factor appeared to be that such formal mechanisms should be introduced and administered flexibly and with sensitivity. Where managers and partners were able to empathise with their staff, value their contribution and relate to them in ways which enhanced motivation, performance, flexibility and cohesion, there appeared to be greater job satisfaction and increased resilience in the face of a heavy workload and other causes of stress.

This finding raises questions about the government's 10-point plan for improving general practice. It suggests that the subjective experiences of work stress and low job satisfaction are not a simple function of workload, but are also shaped by factors such as the presence or absence of a supportive organisational culture. Similarly, the assumption that the burden of paperwork and routine procedures can be eased easily by delegation to other practice staff is also questionable. The government needs to ensure that the new proposals are acceptable to both professions, and that work stress is not simply displaced from doctor to nurse.

The government's proposals fail to address properly tensions in the doctor-patient relationship. More time for patient care is desirable, but other factors to do with patients' expectations and behaviour also have an impact on job stress.

Most importantly, the proposals do not address the practice manager's role in reducing GPs' administrative burden and developing a supportive organisational culture.

This study shows that practice managers are as likely as GPs to suffer stress, and the development of their role may be impeded by poor funding and an unclear division of managerial responsibilities between doctors and managers.

Key points

A survey of 1,545 staff in general practices in South East region found that GPs and practice managers were the most stressed.

GPs believed that dealing with difficult patients was particularly stressful.

The relationships between the senior partner and practice manager and the GP-nurse relationship were seen as crucial.

The relationship between GPs and nurses is characterised by ambivalence and uncertainty.

The division of labour between GPs and practice managers needs clarification if the government's proposals for improving general practice are to succeed.

Losing patience with the patients

Dealing with difficult patients was a commonly reported cause of stress, not just for doctors and nurses, but for receptionists and managers, too.

Usually, this was simply verbal abuse, but instances were reported of physical assaults on staff. One practice even installed panic buttons and surveillance cameras to improve safety.

Inappropriate demands for treatment were also felt by many to be a cause of stress. More specifically, doctors (particularly women) were often presented with social and emotional problems which they felt lay beyond their remit.

It was widely held that the relationship between health workers and their patients had deteriorated over time. Patients were seen as less concerned about wasting the doctor's time, more assertive in demanding their rights, more likely to present with social or relationship problems, and more likely to be abusive if their needs were not promptly met.

The emotional demands of caring for the seriously and terminally ill were also a potential cause of stress. But many informants reported mechanisms that enabled them to cope with such demands.

REFERENCES

1 Howie J, Porter M. Stress and interventions for stress in general practice .In Firt-Cozens J, Payne RL (eds). Stress in health professionals . Chichester: John Wiley & Sons. 1999

2 Department of Health. Prime Minister wants GPs to spend less time on bureaucracy, more on patients .Press release, 11 April 2000.

3 British Medical Association. GP leader says Blair's 10 point plan could help workload .Press release, 11 April 2000.

4 McManus IC, Winder BC, Gordon D. Are UK doctors particularly stressed? Lancet , 1999, 354, 1358-9.