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General Practice is the foundation the National Health Service is built on.
We depend on our (approximately) 42,000 GPs to provide frontline care to most patients seen every day in the NHS, rapidly assessing, diagnosing, treating, and referring on those who need it.
GPs make hundreds of judgments every day, rapidly shifting gears from deciding whether the child in front of them has a minor viral illness or the early signs of sepsis; to considering the multiple complex factors which may have led someone to present with aches and pains.
In appointments lasting just 10 minutes, GPs consider complicated physical, mental, and social factors, while making complex judgments about risk, and appropriate resource use. It’s a highly skilled, demanding, stressful, often under-appreciated role and, like every aspect of the NHS, is currently under intense pressure.
Those who choose healthcare as a career are often those who willingly sacrifice from themselves to give the best care to the patients in front of them. When pressures are relentlessly high, this often means working long, extended periods without stopping for even a teabreak, let alone for lunch.
Across the NHS we have forgotten that to look after our patients it is essential that we also look after ourselves. Maintaining function and performance for hours on end without a break simply isn’t possible. It’s well recognised in other fields – the Highway Code tells us we shouldn’t drive for longer than two hours without stopping for a break; airlines will ground a plane rather than allow their crew to fly without having had sufficient rest – but in medicine, we tend to think that ‘the patient is the priority’ means that we are not.
When working out of hours shifts, or when doing sessional work, these issues can be amplified. We are less used to thinking about GPs as night-shift workers compared to other areas of the NHS, but overnight Out-of-Hours GP services are a key part of 24 hour healthcare provision. Out-of-Hours services are often staffed by GPs working on a locum basis, meaning they can be less well protected to be able to take regular breaks. In the middle of the night, our body clocks tell us we should be asleep. Working against that is the same as working while severely jet lagged, and further affects our ability to sustain good performance – so ensuring staff get breaks is even more important when working at night. OOH Provider employers should have clear, robust policies to make sure GPs working at night get regular rest, to protect both their health and also the patients under their care.
Daytime pressures and stress in turn affects night-time sleep, leading to chronic sleep deprivation – making us feel even more irritable, anxious and lacking in concentration the next day. Over time, this can lead to significant physical and mental health problems.
As part of winter preparedness, GPs have an essential role in providing influenza vaccination to those most likely to benefit. This includes vaccinating healthcare staff, both to directly protect our patients, but also so that we are more likely to be able to carry on providing essential care during the busiest time of the year.
When we are fatigued and sleep deprived, we become more vulnerable to viral infection – up to three times more likely to develop symptoms after exposure to a virus than if we’ve had the right amount of sleep. If we are sleep-deprived when we receive the influenza vaccination, it takes longer to be optimally protective – 10 days after vaccination, healthy but sleep-deprived volunteers have 50% of circulating antibody compared to those who had had the right amount of sleep before they were vaccinated.
We rightly recognise staff influenza vaccination as a key plank of winter preparedness to the extent that the question of whether it should be mandatory often comes up. We are less good at recognising that self-care extends far wider than just staff vaccination. When we are fatigued and sleep-deprived, our brains and bodies suffer – and that affects our patients as well as ourselves.
It’s difficult to stop, to allow ourselves to take a break and have a cup of tea instead of seeing the 14th patient in a row, with the waiting room bursting at the seams. But, when we don’t, we’re compromising not only our own health but, by affecting our performance and ability, the care we deliver to our patients. When pressures are high, it is more important, not less, to ensure that we look after ourselves – the same principle as making sure you put your own oxygen mask on first in an aircraft emergency before helping others.
Looking after ourselves isn’t a sign of weakness, or lack of commitment to patient care, but the exact opposite – an essential part of the overall care we deliver.
General Practitioners are adept at thinking about early prevention to prevent later problems for their patients. It’s essential that they also allow themselves to do carry out the basics of simple preventive care for themselves – having a cup of tea, going to the toilet, stopping for lunch – and recognise that doing so isn’t a luxury, but a key part of being able to provide high quality clinical care to our patients, safely, effectively and efficiently.
Find out more about our work on fatigue and sleep deprivation
Dr Michael Farquhar is a Consultant in Sleep Medicine at Evelina London Children’s Hospital
BMJ piece on Night Working http://blogs.bmj.com/bmj/2017/10/06/michael-farquhar-we-must-recognise-the-health-effects-associated-with-shift-working/
For Nature Cannot Be Fooled: Why We Need To Talk About Fatigue http://onlinelibrary.wiley.com/doi/10.1111/anae.13982/full
Farquhar M. Fifteen minute consultation: problems in the healthy paediatrician – managing the effects of shift work on your health. Archives of Disease in Childhood: Education and Practice 2017; 102: 3. http://ep.bmj.com/content/102/3/127
Fatigue in the NHS Youtube video for RCoA: https://www.youtube.com/watch?v=_SLWD9uXeNw
Excellent, exellent paper Michael- thanks.
I cannot remember the last time I had a lunch break at work or completed my days work even after 14hrs. I now leave documents unread as I have no time to do them then have to do them from home on days off. After Jan 4th when I had personally 187 patient contacts in one day I was unable to sleep for the whole weekend and dreaded returning to work- where is the duty of care to GP’s to provide a safe place of work or longer consultations to provide a safe place in work? How can 10 mins be safe anymore and then everything else is done as a “hobby” eg unpaid and in our spare time? The BMA is too expensive for salaried GP’s on low incomes paying for their own phones, cars and indemnity costs and working huge unpaid hours. Reduce the costs and then we can start to be counted as well. At the moment we are disenfranchised. Is it the gender pay gap?
It is well known that when a doctor becomes a patient, it is customary not to self diagnose and self prescribe because his or her judgement would be diminished. It is obvious that a doctor who becomes overworked, fatigued and insomniac, he or she becomes a Patient. It is a common sense that when a doctor becomes a patient, their management of patients would be far less than average. Patients would not only suffer but also they do officially and legally complain against the doctor. After two patients' complaints, even a normal doctor becomes an abnormal patient. Currently, a doctor in Accident & Emergency Department works 9 hours a day shift e.g. 2 pm to 11 pm or 11 pm to 8 am for 3 or 4 days a week. "A & E Departments" have become "Urgent Care Clinics" run by GPs. There are no home visits by their own GPs anymore. Obviously, patient care in Britain is at a greater risk than ever before. I urge the decision maker politicians, administrators and senior doctors, who themselves may become patients, please do listen to the doctors and their sole trade Union the BMA; it is the time to save doctors who in fact save lives as many as they can. Please protect the protectors who are under enormous pressure now. Dr Bashir Qureshi FRCGP, FRCPCH, AFOM,RCP, MICGP, Hon FFSRH-RCOG, Hon FRSPH, Hon MAPHA-USA. Life Member of the BMA since 2014; its supportive Member since 1964.
Such an important topic, thank you!
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Of course, the constant deprivation of sleep will negatively affect your health. When I worked in WriterCheap - written service, I also had to work night shifts. Because of this, my sleep regime was often violated, and sometimes I felt bad because of this. But in fact, this is half the problem. The main difficulty is to return to normal sleep. After you are transferred to regular day shifts, your body has to rebuild its sleep mode again. What is accompanied by stress. But after a few weeks, it all goes away, and you can work normally again.
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Thanks for sharing! Amazing article.
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