You don’t have to be a psychiatrist to know that working in the NHS is stressful. It’s a strain not just for so-called frontline staff like nurses and doctors – who tend to attract all the public sympathy. It’s also difficult for those working in management and basically everywhere else, though the stress of administrative and other staff is much less often publicly acknowledged.

As a psychiatrist who sees a lot of NHS staff referred to me suffering from the psychological difficulties which result from the stress of working in this organisation, I have developed a somewhat maverick view over the years that the key reason why working here can be so awful for so many is actually fundamentally misunderstood.

My experience is that it’s not the level of stress you experience that determines whether you will end up touting for a season ticket to my clinic or not. There is a huge amount of individual variability in how we all deal with stress. Actually, it’s the coping responses we mount in the face of our predicaments that explain who will be sitting in my out-patient department, stalled, and who will be merrily progressing up the career ladder instead.

So when NHS staff come to see me complaining about the level of work stress they face, I explain that actually isn’t the real issue. Instead it’s the problems attached to their inadequate coping responses that determine their mental health. What is interesting is that some organisations develop a certain “culture” or cultural response to coping. If a strategy is adopted which isn’t all that helpful for the mental health of the workers  but is aligned with certain organisational objectives, then the seeds are sown for widespread upset.

There are basically only two coping responses we can mount as an effective rebuttal to a stressful life event. The first one is problem-solving and the second is emotionally-focused coping.
This conclusion was recently arrived at by the FBI’s Behavioral Sciences Unit in Virginia in the USA, where they studied the psychological reactions of those who have been taken hostage by armed gunmen in order to better plan rescue attempts. This may seem like stretching the point a bit, but in my experience working in the NHS increasingly resembles being taken hostage by armed gunmen.
Problem-solving according to the FBI, involves acting upon the world in some way to make it a less stressful place to be: if you are taken hostage, you try to escape. So if you work in an NHS unit where a bullying consultant is rendering your life a misery, a problem-solving approach would be to get a group of colleagues together to help persuade the consultant to change his or her behaviour. Problem-solving is all about changing the world to make it a better place to continue to live in.
The other key coping skill is called emotionally-focused coping (if your problem isn’t solvable or your consultant won’t change despite all your efforts). This means adjusting your internal emotional state so you are less upset by the bullying. If you were taken hostage, emotionally-focused coping is about sitting tight and waiting to be rescued, but passing the time in as pleasant a way as possible.
The relevance of this to the NHS is that, in my experience, health service staff keep trying problem-solving, when many of the problems they are faced with simply are not solvable. There is little or no consensus in this organisation as to what constitutes a solvable problem or not. It is this lack of agreement over where to draw the boundary as to what is possible and what isn’t, which leaves staff feeling they are on a treadmill where no matter how hard they labour, they don’t seem to get anywhere.
One of the most therapeutic things any meeting or group of colleagues can start a project off with, is a mutually agreed understanding of what is not expected of them. The high expectations of the public, politicians and those the staff have of themselves are actually, I believe, the core cause of the stress we all experience.
For example, recently I have attended several conferences where staff heatedly debate what to do about the high levels of teenage pregnancy. Yet teenagers will still be getting pregnant for many years to come, despite all our best efforts, so completely eradicating this may not be a solvable problem.
In contrast, reducing the levels of teenage pregnancy somewhat might be a solvable problem. Staff never seem to discuss what is solvable and what isn’t. I don’t know what is going to happen about teenage pregnancy in their areas, but I do know everyone seems to leave the meetings feeling terribly stressed.
One key aspect of the way private practice functions which is often ignored by those who remain in the NHS, is that there is a clearer setting out from the start of what you are buying. There is less of a mismatch between patient expectations and what the doctor can deliver. Implicit in the initial encounter between doctor and patient is a drawing of boundaries, as the private hospital is anxious not to be responsible expansively for the patient’s future health. 
 At the heart of the NHS is the sentiment of total care from cradle to grave – an amazing objective for a state-run service and undoubtedly born out of the optimism of the late 1940s when Labour was constructing a society “fit for heroes”. However, one consequence of this amazing ambition is a reluctance to address the key issue of what the health service, and therefore its staff, are not going to be held responsible for, and therefore what the patients and the population are going to have to do for themselves. If we don’t draw this boundary, then really we are saying that every problem faced by every member of staff in the NHS is solvable.
If this is the case and you work in the NHS, then you might as well book your season ticket to my clinic now.