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Executive summary
The Medical Protection Society (MPS) welcomes the opportunity to submit evidence to the Health and Social Care Select Committee inquiry into workforce burnout and resilience in the NHS and Social Care.
Healthcare can be incredibly rewarding. There are few other professions with so many possibilities to improve people’s lives. However, the increasing levels of burnout MPS has encountered in healthcare professionals is extremely troubling.
When healthcare professionals feel burnt out and disillusioned it is not only bad for the professional concerned but also for patients and the wider healthcare team. Those who are happy and engaged are much more likely to be compassionate and provide safer care.
MPS published the report, Breaking the burnout campaign, in September 2019 which outlines the different factors that lead to burnout. The report detailed what healthcare professionals in the UK were telling us about their experiences of burnout through a member survey[1], and we put forward proposals for how healthcare professionals could be better supported. This was part of an international programme where we also produced further reports on burnout in Ireland, South Africa, Australia and New Zealand.
The prevalence of burnout in the workforce can only be exacerbated by the Coronavirus crisis and action is needed to ensure that we do not let the environment we work in reduce the sense of value that healthcare professionals get from their work. Everyone in healthcare has a role in identifying signs of burnout in themselves and others and in working together to develop strategies to enhance personal resilience. MPS has a role to play; we support healthcare professionals dealing with burnout around the world through workshops on “Building Resilience and Managing Burnout, which receives incredibly positive feedback. We have also launched a wellbeing app as well as an extension to our counselling service for those experiencing work-related stress due to the challenging circumstances. But while such support is invaluable, it is only a part of the solution.
As we prepare for what is to come next, a firm commitment is needed from healthcare providers and government to improve the working environment for all healthcare workers and to truly begin to tackle the endemic of burnout in the sector. We set out a range of proposals for consideration.
We would be keen to provide oral evidence to the Committee on this vital issue.
How resilient was the NHS and social care workforce under pre-COVID-19 operating conditions, and how might that resilience be strengthened in the future?
The healthcare sector is highly stressful and while the workforce is known to be extremely robust the system lacks resilience. It is well documented that the presence of high levels of burnout among healthcare professionals was already a significant problem prior to Covid-19.
In June 2019, we surveyed MPS members to better understand the impact work was having on their wellbeing. This found that:
- 45% had considered leaving the profession for reasons of personal wellbeing
- 44% do not feel encourage by their line manager or practice partner to discuss wellbeing issues
- 47% do not or not at all feel supported by practice or hospital management
- 50% do not or not at all feel supported by the regulator
- 42% always or often starting the day tired
- 40% feeling unable to take a break during the working day to eat/drink.
These results are based on the responses from 275 UK based MPS members between 11 and 25 June 2019. These numbers are alarming and show the level of burnout amongst the profession pre-Covid-19, and the high level of dissatisfaction amongst healthcare workers in the UK.
What has the impact of the COVID-19 pandemic been on resilience, levels of workforce stress, and burnout across the NHS and social care sectors?
The Covid-19 pandemic has had a huge impact on an already stretched workforce suffering from high levels of burnout. We believe that adrenaline has carried healthcare workers during the pandemic and helping them to cope despite the exhaustion and tragedy they may be facing, showing an incredible resilience and the willingness to help patients now more than ever.
However, it is when the crisis truly recedes and there is time to reflect that the accumulated stress and trauma may surface - this is the time doctors will be most at risk of burnout and need support.
A survey of 717 MPS UK members conducted from 18-29 May 2020 revealed the areas having the most concerning impact on doctors’ mental wellbeing:
- 50% said concern for the health of family and friends was having the most impact on their mental wellbeing
- 33% cited the health of patients
- 30 cited concerns for their own health
- 30% cited worries about family responsibilities
- 17% cited fear of regulatory or criminal investigation arising from difficult decisions made during the pandemic
Furthermore, over a third (35%) said they felt pessimistic about the future.
We believe that even after the worst has passed, Covid-19 will continue to bring pressures and complications, compounded by a significant referral backlog to deal with. The last thing we want is huge swathes of doctors leaving the profession after Covid-19. In order to avoid this, MPS has previously called on the Government, NHS and private healthcare providers to put a plan in place to support the mental wellbeing of healthcare workers as well as a strategy to ensure the system has capacity so that those needing treatment or time to recuperate can take that time without fearing staff shortages.
What is the current scale of workforce burnout across NHS and social care? How does it manifest, how is it assessed, and what are its causes and contributing factors? To what extent are NHS and care staff able to balance their working and personal lives?
In order to assess and understand burnout, we support the six areas identified by Christina Maslach, Professor Emerita of Psychology at the University of California at Berkeley[2]. These are workload, control, reward, community, fairness and values. In addition, we also highlight three further key areas: presenteeism, incivility at work and wellbeing oversight in the workplace.
These are summarised below along with some of the most relevant findings from our survey published in September 2019.
- Workload
Predisposing factors for burnout are often related to job demands such as workload, time pressure, and long hours without sufficient time to rest and recover. Workload is expected to have a direct relation to exhaustion.
Our survey results revealed that 25% of doctors rarely or never take a break at work, and 68% responded that regular rest/ recovery periods are not the norm during work sessions. Furthermore, 40% feel unable to take a break during the working day to eat/drink. The link between a failure to meet physiological needs (food, water, sleep, rest) and patient safety is evident.
- Control
Control refers to having a sense that we are in control of the tasks in hand and their outcomes. A lack of control can lead to a job that is in direct conflict with the values. Like workload, control reflects the demand-control model of job stress. Doctors are more likely to burnout if they lack control over their work. Low autonomy and not being able to say “no” scored high in our survey.
65% of respondents agreed or strongly agreed that it’s difficult to say no when asked to undertake additional tasks. 57% feel unable to take a short break in between two clinically demanding procedures. These figures highlight the need for training in ‘Saying No for Safety’ which is also a key BRAB workshop message. Almost 25% of respondents to our survey said they do not feel able to practise to the standard they’re capable of.
Ineffective, inefficient, unsafe systems and repeated reorganisations can also make a working environment stressful to work in and interfere with effective team functioning and professional relationships. In our BRAB workshops members often tell us that failing IT systems, for example, could have a serious impact on a doctor’s wellbeing.
- Reward
Reward can involve anything that makes the day-to-day flow of work more satisfying. This could certainly be financial rewards (high pay, good benefits), but can also be social rewards (recognition from those around you) and intrinsic rewards (the feeling that you’re doing a good job). Evidence suggests that burnout is more likely when your rewards do not match your expectations.
More than 50% of respondents to our survey said that their line manager/GP partner understands the value of celebrating success. However, for many doctors the job doesn’t match with the dynamic and exciting work life that they had expected. 47% of responding doctors feel often or always like they are on a treadmill. And a disturbing number of doctors, almost 30%, do not feel appreciated for the work that they do. These figures highlight the room for improvement around an appreciative culture/leadership in healthcare.
- Community
Support from colleagues and feeling part of an effective team are fundamental to the mental health of doctors. Such support not only improves professional effectiveness but can also foster a psychological safe environment where doctors feel they belong. Mutually supportive working relationship can help doctors manage the emotional labour of the job and also reduce the stigma of disclosing work-related stress and mental wellbeing problems and seeking help.
This was supported by the findings from our survey which found that 64% of respondents feel supported by their peers, while 74% agree or strongly agree that they would be prepared to cover a colleague’s work for a short period, so that they may take a break. These results highlight doctors’ desire for the sense of belonging and community in the workplace.
- Fairness
It is vital that employers not only treat people fairly in their work, but that that fairness is recognised. A perceived lack of fairness can lead to feelings of being disrespected or powerless.
Our survey results reveal that doctors are not confident that their managers are doing their best to maintain a fair and equitable workplace. 37% of respondents feel there is no fair and equal approach to work/life balance policies such as flexible working. 47% believe that the workload in their practice/organisation is not equally distributed among colleagues.
More than half of the respondents would be supported to learn from an error if they made one, 16% say they would be blamed. This raises concerns about the continuing presence of a blame culture in the NHS. It highlights a system where the emphasis can be on punishment and even criminalisation, while neglecting to nurture a system where mistakes – sadly sometimes catastrophic – can be learned from and avoided in the future. Patient safety suffers when healthcare professionals are not supported to learn from mistakes, which is why we encourage the use of standardised tools, scales and procedures to ensure sense of fairness in the workplace.
- Values
A disconnect in values can lead to a strong sense of moral distress. This conflict in values occurs when your personal values and goals are not in line with those of the organisation.
More than 30% of respondents said they too often or always feel disillusioned in their work. When asked how frequently systemic factors compromise ethical standards, 43% of respondents say they experience this once or twice a week or more. They indicated that time pressure 54%, workload 64% and lack of resources 34% were the top three factors that most contribute to this.
Presenteeism is the opposite of absenteeism and is defined as turning up to work when too unwell, fatigued or stressed to be productive. Doctors are notoriously reluctant to take time off when they are sick, and this can result in a number of issues including not performing efficiently. Both issues can have greater repercussions than if the doctor had sought advice from their own doctor and stayed off work[3].
72% of doctors responded that they will always come into work, even when they’re not feeling well or resilient enough to work safely. Working while sick has serious implications for mental wellbeing. Presenteeism increases the risk of long-term sickness absence as well as future mental health problems such as burnout. Research has found that healthcare employees who continue to work while sick are more likely to make errors leading to adverse patient outcomes. We have identified that doctors that find themselves in the ‘superdoctor’ trap expect the unachievable of themselves.
The importance of civility in the workplace, especially in the context of burnout, cannot be overestimated. Creating a culture of respect is the essential first step in a health care organisation’s journey to becoming a safe, high-reliability organization that provides a supportive and nurturing environment and a workplace that enables staff to engage wholeheartedly in their work[4].
Feeling psychologically safe at work is essential but bullying and harassment are both still sadly present in healthcare. The ability to speak up for safety and a Just Culture have yet to be embedded in many organisations. Almost 30% of respondents experience behaviour from colleagues that undermines respect 36% of respondents witness disrespectful behaviour among colleagues more than once or twice a week When they witness disrespectful behaviour, almost 50% of respondents say they are not sure if they feel comfortable speaking up, and almost 20% would not feel comfortable at all.
It is essential for doctors to have the skills to manage disagreements with colleagues whilst remaining respectful, and to know how to manage themselves well in difficult situations. In healthcare, speaking up is about raising a concern before an act of commission or omission that may lead to unintentional harm, rather than after it has occurred, as happens when reporting sentinel events or whistleblowing.
Medical Protection is also playing its part in this area. Our Cognitive Institute[5] has set up “Speaking Up for Safety”. This is an organisation-wide programme helping healthcare organisations overcome entrenched hierarchical behaviours that can contribute to unintended patient harm. We partner with hospital groups across the world to build and embed a culture of safety and quality by normalising collegiate two-way communication between staff to support each other and speak up any time there is a concern for patient safety.
- Wellbeing oversight in the workplace
The environment within which a doctor works is crucial to wellbeing – hence the need for change at an organisational level to allow professionals to thrive.
Our survey results reveal some interesting data about the way doctors feel treated. Almost 40% of respondents do not always get the support they need from their employer to do their job well, 44% do not feel encouraged by their line manager/GP partner to discuss wellbeing issues, and 58% do not feel like their personal wellbeing is a priority of their line manager/GP partner In the context of wellbeing. 93% of respondents say they do not have someone at work solely responsible for staff wellbeing. These figures highlight the need for a role to be filled which is dedicated to staff wellbeing.
We believe, based on what our members told us in our survey 2019, the inability to obtain a work/life balance is one of the causes of disillusionment among the profession. 52% of respondents at that time said the were not or not at all satisfied with their work/life balance.
What are the impacts of workforce burnout on service delivery, staff, patients and service users across the NHS and social care sectors?
Evidence suggests a significant correlation between healthcare staff wellbeing and patient safety[6].7 Burnout directly and indirectly affects medicolegal risk, with the poor wellbeing of doctors having major implications for patient outcomes and the overall performance of healthcare organisations.
Doctors with burnout are more likely to subjectively rate patient safety lower in their organisations and to admit to having made mistakes or delivered substandard care at work; they are less empathic, less able cognitively and can have a negative impact on colleagues, teams and the organisation[7].
This can jeopardise patient care and lead to complaints or a negligence claim, leaving clinicians even more vulnerable to burnout. Victims of burnout also suffer from poorer health and strained private lives. To put it simply, happy staff are more compassionate and provide safer care – which of course will come as little surprise. It is not surprising, therefore, that wellness of doctors is increasingly proposed as a quality indicator in healthcare delivery[8].
Analysis from the NHS Staff survey found that opportunities for employees to recover from work demands can have a strong influence on organisational and patient outcomes. Greater satisfaction with work/life balance was linked with better financial performance and lower absenteeism, as well as higher patient satisfaction and lower risk of infection rates in hospitals. Such findings further highlight the need for evidence-informed initiatives to promote work/life balance and recovery from work[9].
Will the measures announced in the People Plan so far be enough to increase resilience, improve working life and productivity, and reduce the risk of workforce burnout across the NHS, both now and in the future?
MPS believes that the NHS People Plan is a step in the right direction as it promotes looking after each other and promotes quality health and wellbeing for everyone, as well as tackling discrimination and looking into the effective use of people’s skills.
We particularly welcome the NHS England and NHS Improvement initiative which has started during Covid-19 and allows all NHS staff on people.nhs.uk to access a dedicated health and care staff support service, including confidential support via phone and text messages, specialist bereavement support and free access to mental health and wellbeing apps; among other services. We also support the NHS England and NHS Improvement pilot approach to improve staff mental health by establishing resilience hubs working in partnership with occupational health programmes to undertake proactive outreach and assessment, and co-ordinate referrals to appropriate treatment and support for a range of needs.
MPS also welcomes the initiative of providing safe spaces for staff to rest and recuperate for staff, so they can manage and process the physical and psychological demands of the work, on their own or with colleagues. However, these initiatives should not be only available during the current pandemic, even if they are a response to it. These should be extended post Covid-19.
We have recommended the implementation of a strategy that support doctors’ mental wellbeing in order to avoid huge numbers either leaving the profession or suffering in silence with psychological injuries. This needs to be properly funded and we have suggested that this could be funded by new funding or by part of £3 billion funds announced for the NHS to prepare for a second wave of the virus.
Moreover, we do not think this is enough to reduce the risk of workforce burnout across the NHS, since the level of burnout within the sector was already high pre-Covid-19 and further measures are needed to tackle the burnout of healthcare workers. We have provided details of those answering the next question.
What further measures will be required to tackle and mitigate the causes of workforce stress and burnout, and what should be put in place to achieve parity for the social care workforce?
In order to address the issue of burnout facing the profession, MPS believes there are important lines of action that need to be taken by healthcare workers- the individuals-, the healthcare team and the wider healthcare system. The focus should not solely be on interventions that help the individual doctor to cope with their work environment. A move towards prevention is needed with much more emphasis placed on the improvement of underlying working conditions that impact on the wellbeing of clinicians.
We are calling for the following actions:
- Healthcare organisations should have clear policies and procedures in place to ensure healthcare professionals feel able to take breaks and to take time off when ill. These should include:
- KPIs/corporate objectives should include wellbeing as part of the staff survey.
- Optimal rotas should be implemented to ensure adequate recovery time is embedded for individual doctors with adequate staffing, policies and procedures to ensure doctors can be absent when needed.
- All staff, including managers, to be educated on the importance of putting policies and procedures in place to prevent burnout. Resilience of individuals and teams must be seen as a priority at all times.
- Doctors and medical students should receive training in building resilience and be supported and rewarded for developing good individual coping strategies in the workplace.
- Occupational health teams should be involved in the planning and support of psychological safety in the workplace, proactive involvement rather than just being involved when burnout has occurred.
- Organisations must offer appropriate spaces for doctors to rest and meet during breaks.
- NHS organisations in England should fully commit to the implementation of NHS Staff and Learners’ Mental Wellbeing Commission’s recommendation to establish Workforce Wellbeing Guardians in every NHS organisation and GP partnership. Given that the role of board-level leadership is central to the wellbeing of staff, in particular to the culture of the NHS, we are calling for Wellbeing Guardians to be put in place in every NHS organisation and GP partnership by 2022, and to report to the board. We would support similar actions in Scotland, Wales and Northern Ireland.
- Private sector healthcare providers should mirror the recommendations for NHS employers, and commit to the implementation of and access to Wellbeing Guardians, preferably one guardian per group or cluster of clinics/practices.
- The Department for Health and Social Care and/or NHS England should develop and implement a strategy that support doctors’ mental wellbeing in order to avoid huge numbers either leaving the profession or suffering in silence with psychological injuries.
- The CQC should, as part of inspections once they resume, assess the extent to which healthcare providers look after the wellbeing of their doctors and other healthcare professionals. Whilst this is already a publicly reported criterion as part of the ‘well led’ domain, it could be made more specific and it should also be made a key line of enquiry. Questions can be expanded such as whether there is a Guardian appointed, whether staff have regular breaks, feel supported by management etc.
Organisations that are assessed to be requiring improvement in this area should develop a strategy in consultation with their workforce and publish this on their website. System regulators in Scotland, Wales and Northern Ireland should consider similar actions.
Our work with doctors and the key findings from the survey have helped to identify these concrete recommendations which, if taken seriously, would mitigate the risks of burnout in the profession.
[1] https://www.medicalprotection.org/uk/hub/breaking-the-burnout-cycle-keeping-doctors-and-patients-safe
[2] C. Maslach and M. Leiter, (1999) Six areas of worklife: A model of the organisational context of burnout, Journal of health and human services administration 21(4): 471-489
[3] T. Shanafelt et al, (2018) Physician burnout: contributors, consequences and solutions, Journal of Internal Medicine, 283 (6): 516-529
[4] L. Leape (2012) A Culture of Respect: The Nature and Causes of Disrespectful Behaviour by Physicians, Academic Medicine, 87(7): 845-858
[5] Cognitive Institute is part of the not-for-profit MPS Group, the world’s leading protection organisation for doctors, dentists and healthcare professionals with more than 300,000 members globally
[6] 46 studies were identified. 16 out of the 27 studies that measured wellbeing found a significant correlation between poor wellbeing of staff and worse patient safety, with six additional studies finding an association with some but not all scales used, and one study finding a significant association but in the opposite direction to the majority of studies. 21 out of the 30 studies that measured burnout found a significant association between burnout and patient safety, whilst a further four studies found an association between one or more (but not all) subscales of the burnout measures, and patient safety.
[7] L. Hall et al, (2016) Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review
[8] M. Panagioti, (2017) Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis, JAMA Internal Medicine, Physician work environment and wellbeing; 177 (2):196
[9] Health Education England, (2019) NHS Staff and Learners’ Mental Wellbeing Commission