At the age of 32, Amy Small, a GP in East Lothian, realised that she had more years left to work than she had lived on the planet; it was a thought that filled her with horror.
‘I realised there was no way I could continue at this pace for the next two years, let alone the next 35,’ she says. ‘I think general practice, as it stands, has become totally unsustainable as a full-time job. When you give a little piece of you to every patient you see, there isn’t much left at the end of the day for you, your partners, or your family.’
Dr Small’s experiences are far from unique; doctors in all branches of practice are warning that the increased pressure and intensity of work in the NHS is not sustainable in the long term.
Tales of stress and burnout cropped up in debates at the BMA annual representative meeting in Edinburgh this week time and time again, and not just in the discussions specifically addressing these issues. Here, three doctors — a GP, junior doctor, and consultant — share their experiences.
Nikki Thompson, consultant anaesthetist, Dundee
‘I graduated in 1989 and have been working in the NHS for more than 20 years.
‘Things have changed a lot in that time. Patients can now expect to receive higher standards of care. New technologies and advances in medicine mean that we can treat patients who, 10 years ago, wouldn’t have had any options, and in the last four to five years I’ve noticed a big difference in how quickly patients are being treated. ‘The downside of this progress is that work is much more pressurised. We have many more older and sicker patients with more complex care needs and making sure that they get the right care at the right time means that the workload is more demanding and there is no down time.
‘The constant pressure of the intense workload makes me feel that, while still worthwhile and useful, my work is not anything like as enjoyable as it used to be. I personally feel under pressure and I can see that the system is under a huge amount of pressure, so I have to be constantly on the top of my game to make sure I’m 100 per cent focused all of the time.
‘This intensity of my work is not sustainable and there’s no way I would be able to continue to work like this until I retire. The changes to the pension age means that I will probably have another 20 years of working at this pace.
‘I can’t see the health service getting any easier, especially as we see more and more older patients with complex medical problems. Certainly the out-of-hours work, which is increasingly demanding, will be more difficult to deal with as I get older and I become more tired after a night or weekend on call; I just can’t see myself doing that in my late 60s.’
Tom Berry, specialty trainee in surgery, Airdrie
‘I am told repeatedly by my senior colleagues that the intensity of work has increased in the 21st century. The majority of junior doctor shifts are now full shift rather than on call and many more patients have complex presentations of intertwining co-morbidities. Too many doctors in training are still on rotas with fixed annual leave, often apportioned piecemeal across the months of their posts so never affording any real break from work. Too many long runs of successive long days or nights build up a sleep debt and fatigue that can be of no benefit to doctor or patient.
‘You cannot train, you cannot learn, you cannot be at your best, if you are too tired to remember your own name. The deep, bone-weary tiredness I have experienced during, and at the end of, some of the shifts I have undertaken is not a badge of honour to be worn proudly but simply stark evidence that best practice of rota design and training is still not being shared across the NHS.
‘Stress manifests itself in and out of the workplace. As a general rule, I have a relatively placid temperament, but I have lost my temper quite spectacularly at work.
‘I have argued and ended personal relationships where work has undoubtedly played a part. I have suffered insomnia. I don’t believe I’m unique. I don’t believe that the problems are unique to doctors. I do believe that things will only get worse and the situation is unacceptable.
‘I want to be well rested and well trained. I want to be able to promise my patients I’ll be well rested and attentive when operating. I want the stories of the doctors who’ve left the profession, taken to drink, grown ill or left the country owing to the stresses and demands of working in our NHS to be stories of a past generation. If our working lives were to be assessed, the report cards would say: “Must do better.” We owe it to ourselves and to our patients to do just that.’
Amy Small, GP principal, East Lothian
‘Over the last five years I’ve noticed a constant and incessant rise in the demands placed on GPs but we are expected simply to get on with it; no resources are put in place to help manage this extra work.
‘I found this incredibly stressful. I would arrive at work at 8am every day and often not leave before 7.30pm or later. I dreaded going into work. I felt like I was constantly treading water and keeping my head afloat. The more stressed I got the more detached I became from my patients. I started to cut them off while they were talking, trying desperately to ignore little cues that they dropped indicating they had things they really needed to talk about. I would deal with the matter in hand but perish the thought they wanted to talk about other things. I would get more and more frustrated with patients who brought in lists of problems. I would be ratty with them and tell them off.
‘I stopped sleeping well. I often woke in the night and remembered things that I had forgotten to do. I also felt incredibly guilty. I wasn’t the doctor I wanted or aspired to be. I wasn’t the compassionate, empathetic person that I used to be. I joined a fitness class but rarely made it on time during the week and was left with only being able to attend at weekends, which decreased my ability to de-stress further.
‘After talking at length with colleagues and my husband, I was lucky that they agreed to support me and I decided to drop to three days a week. I’m six months into my new working life and I feel great. I’m taking my time with patients. I don’t mind if I run late now, I don’t mind if they need to talk.
‘I think general practice, as it stands, has become totally unsustainable as a full-time job. When you give a little piece of you to every patient you see, there isn’t much left at the end of the day for you, your partners, or your family. We need to strip out the non-evidence based parts of the quality and outcomes framework. We need to get back to basics and be doctors that look after patients who are sick. We need to stop chasing meaningless targets. We need to stop filling out meaningless forms. Our infrastructure needs to be adequately invested in, so that we can go and get on with our jobs. We’ll do a great job, I have no fear of that, just leave us be.’