Written evidence submitted by NHS Providers (WBR0007)

NHS Providers is the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS trusts and foundation trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate.

NHS Providers has all trusts in voluntary membership, collectively accounting for £84bn of annual expenditure and employing more than one million staff.

Key messages

Trusts and other health and care organisations have prioritised support for their staff during challenging times, offering a range of local wellbeing initiatives. However, in a survey conducted by NHS Providers in June, 9 out of 10 trust leaders (93%) were concerned about staff wellbeing, stress and burnout following the pandemic.

The NHS and social care workforces were under extreme pressure and facing grave workforce shortages prior to COVID-19. The pandemic has exacerbated these pressures with a negative impact on staff wellbeing.

The question of resilience and burnout is particularly pressing as staff face winter pressures directly following the exhausting experience of the pandemic alongside the potential for further, local peaks of COVID-19.

It is no longer sustainable for the NHS to rely on the additional, discretionary effort from its dedicated and committed staff to meet rising demand for care across all services. The NHS requires an appropriately funded, well co-ordinated approach to supporting staff to underpin recruitment and retention and to complement local workforce initiatives.

The NHS People Plan 2020/21 puts much needed momentum behind steps to create more inclusive and compassionate cultures within the NHS. It also makes welcome commitments around equality and diversity and ensuring that staff from Black, Asian and minority ethnic communities feel supported. Government must therefore prioritise a multi-year funding package in the forthcoming comprehensive spending review to ensure the measures in the People Plan can be delivered.

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?

Before the pandemic, both the NHS and social care were under significant pressures, with demand for health and care services increasing year-on-year in the context of constrained finances and workforce shortages.

After the longest and deepest financial squeeze in NHS history, the service entered the pandemic with over 100,000 workforce vacancies. Research has shown that workload is the single greatest determinant of stress at work. Only 22.9% of respondents to the 2019 NHS staff survey reported that they ‘never’ or ‘rarely’ suffered from unrealistic time pressures in their jobs. [1] Over two thirds of respondents in 2018 felt there was not enough staff at their organisation to enable them to do their jobs properly. [2]

Discretionary effort from staff, and local wellbeing initiatives led employers including trusts, have been essential to sustain services in the face of these pressures. However, this is no longer sustainable. It is therefore unsurprising that under pre-COVID-19 operating conditions, the NHS Staff Survey has repeatedly returned unfavourable results around workforce stress and resilience in the NHS.

The People Plan has the potential to put much needed momentum behind the drive for a more inclusive and compassionate culture within the NHS. Government must therefore support the aspirations of the People Plan with a multi-year settlement in the forthcoming spending review to provide an adequately funded national framework and local resources to implement recruitment, retention, and wellbeing schemes for their staff.

Similar challenges in social care have been well documented, with the Association of Directors of Adult Social Services estimating the sector has had to make £7 billion of savings since 2010 [3].

There is a growing workforce gap in social care due to low pay, working conditions and lack of job security. Prior to COVID-19, the Health Foundation determined that the social care sector had 122,000 workforce shortages, and an annual leaver rate close to a third.[4] A study by the Institute for Public Policy Research (IPPR) think tank in 2018 found that half the social care workforce was paid below the real living wage. The IPPR warned that if the situation remains unchanged, there will be a shortage of 350,000 social care workers by 2028 – this could rise to 400,000 with the end of freedom of movement.[5] Continuing uncertainty over Brexit has also had an impact. European nationals make up a significant proportion of the social care workforce, and many have chosen to leave the workforce as questions over their status after Brexit remain unanswered.

To begin to strengthen the resilience of the social care workforce in future, these factors should be addressed as a priority by:

solving the funding crisis in social care
reform to increase pay and recognition for the workforce
a nationally coordinated approach to address both national and international recruitment to social care in the wake of Brexit.

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?

Frontline NHS staff need time to recover following the first wave of the pandemic and while it is vital to ensure patients can access the care they need, this must be balanced with a need to support an exhausted healthcare workforce. The British Psychological Society has published guidance [6] on the psychological needs of healthcare staff, anticipating a surge in these needs as a direct result of the Coronavirus pandemic. Among other things, this guidance highlights the importance of rest in staff’s psychological wellbeing. It has been, and remains, a consistent challenge for trusts to ensure that work patterns are not too burdensome on staff, given overwhelming workforce shortages. Many staff with frontline experience of tackling COVID-19 will have experienced the deaths of colleagues and patients they cared for, sometimes in distressing circumstances. The long-term impact for those affected by their experiences of healthcare during the pandemic cannot be under-estimated.

In a survey of trust chairs and chief executives conducted by NHS Providers in June, we found that 9 out of 10 trust leaders (93%) are concerned about staff wellbeing, stress and burnout following the pandemic. 70% of trust leaders agreed or strongly agreed with the statement ‘there has been a much higher rate of staff absence’ during the pandemic. Several respondents were very concerned about the impact on staff should there be a second and third wave and levels of resilience, and staffing levels are also an ongoing concern.

This is particularly concerning as we approach the winter months in which the pressures on the NHS increase. This year trusts and their partners are particularly concerned about the impact another exhausting winter may have on their staff, straight after dealing with the first peak of the pandemic, and alongside the risk of flu and further peaks of COVID-19.

It is unrealistic and unfair to expect healthcare workers to go from coping with one crisis to working flat out to manage the backlog of care that has arisen during the pandemic. Steps must be taken to ensure, protect, and maintain staff resilience. Trust leaders are doing all they can to ensure support is available for staff and have set up wellbeing offers within their organisations, but additional funding is necessary to maintain these offers and to employ staff in sufficient numbers to offer colleagues flexible working options, and fair access to their leave entitlements.

The pandemic has also highlighted the need to address structural inequities for black, Asian and minority ethnic (BAME) groups as well as other vulnerable groups, including care home residents and people with learning disabilities who have suffered disproportionately during the pandemic. The effect which this will have had on staff who are themselves vulnerable to COVID-19, or who have seen colleagues, friends and family suffer cannot be underestimated and must be addressed.

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?

The clearest national assessment of NHS staff burnout is found in the annual NHS Staff Survey. The most recent was conducted between September and November 2019, prior to the COVID-19 outbreak, and published in February 2020. The 2019 NHS Staff Survey showed that:

A significant proportion of staff experience work-related stress. 40.3% of staff reported feeling unwell due to work-related stress in the past year. The five-year trend presents greater concern, with an increase from 36.8% in 2015. Additionally, 56.6% had gone to work while not feeling well enough to perform their duties (no improvement since 2015).
Too many staff are stretched beyond a reasonable limit. Only 22.9% of respondents said they “never” or “rarely” experienced unrealistic time pressures in their jobs (a 0.7% increase following 2018’s initial finding on this measure) while 32.3% said there are enough staff in their organisation to allow them to do their job (0.6% increase from 2018 and a 2%rise since 2015). 55.9% report working unpaid hours in 2019 (down 2% since 2018, and a 4.9% decrease since 2015, though this figure is still very high).

Flexible working patterns, which support work life balance, are available to just over half of NHS staff. 54% of staff say they are satisfied with opportunities available for them to take on flexible working patterns (0.8% increase since 2018, and a 3.7% rise since 2015). This is positive, though there is considerably more work to be done to increase these opportunities.[7]

The impact of working during the COVID-19 pandemic, as assessed by NHS staff, will not be fully known until the 2020 NHS Staff Survey is published. The 2020 survey is scheduled to use the same methodology and timings as previous years, so can be expected to be conducted from September – November 2020, and to be published in February 2021. In the interim, NHS Providers have consistently heard from trust leaders that staff wellbeing has been hugely impacted by the pandemic, as detailed in points 9 and 15 of this document.

What are the impacts of workforce burnout on service delivery, staff, patients and service users across the NHS and social care sectors?

NHS Providers’ member survey in June found that 86% of trust leaders agree or strongly agree with the statement, ‘I have concerns about staff wellbeing’ in terms of returning to a level of service where trusts can meet the needs of all the patients and service users they normally provide care for (following reduced service provision during the peak of the COVID-19 outbreak). It is noteworthy that this was the 3rd biggest concern for service provision, after social distancing measures reducing capacity (92%), and the increased backlog of care (89%).

Under pre-COVID-19 operating conditions, concerns over staffing and provision of care were also reflected in trust leaders’ responses to our survey in 2019.[8] Only 29% of survey respondents were confident that their trust currently had the right numbers, quality and mix of staff in place to deliver high quality healthcare to patients and service users, and almost six in 10 (59%) were worried that they did not have this in place. Levels of confidence decreased as respondents were asked to look forward to future years, with only 18% saying they were confident of the right numbers, quality and staff mix in two years’ time.

What long term projections for the future health and social care workforce are available, and how many more staff are required so that burnout and pressure on the frontline are reduced? To what extent are staff establishments in line with current and future resilience requirements?

Long term projections for the future health and social care workforce are available from:

The Health Foundation [9]
The Institute for Public Policy Research [10]
NHS England and NHS Improvement’s quarterly performance data [11]
The King’s Fund [12]

In order to reduce burnout and pressure on the frontline of health and social care, enough additional staff are needed not only to cover existing workforce gaps, but also to build flexibility into the system. Resilience is often spoken of at an individual staff level, but by building a resilient system, workforce wellbeing will be far better protected by realistic workloads, more regular and reliable breaks, opportunities for development and career progression, and better work life balance.

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?

The NHS People Plan for 2020-21 puts much needed momentum behind steps to create more inclusive and compassionate cultures within the NHS. We strongly support the commitment to prioritise staff health and wellbeing and to making the NHS a great place to work through actions which will make staff feel more valued, such as more flexible working patterns. The pandemic has also highlighted that there is still more to do on equality and diversity and ensuring that staff from Black, Asian and minority ethnic communities feel supported, safe, and valued. There are some welcome commitments in the plan which reflect the priorities of trust leaders.

However, although the plan has some vital investment attached to it, last year the Government made several manifesto commitments on workforce that will not be deliverable without significant funding. Growing the workforce takes time and international recruitment may also be problematic in the current climate. As part of the forthcoming Comprehensive Spending Review (CSR), the Government must provide certainty that its workforce commitments and the wider cultural aspirations of the People Plan, can be met through a multi-year funding package. Until NHS workforce supply is increased to match ever-growing demand, there will be considerable limitations on the impact that any reforms to staff wellbeing can have.

We also note that the national People Plan focusses on the NHS workforce as expected, and there remains a need for national policy makers to align their thinking on a coherent approach for health and social care together, reflecting the work now underway by local systems.

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?

NHS Providers has been clear that initiatives to improve staff wellbeing must be complemented by action to address persistent workforce shortages. At times, too much of the equation around staff burnout is out of an individual organisation’s control. Workforce shortages will take time to solve. The People Plan, and any other long term strategy implemented at national, system and local levels must address both keeping people within the NHS by improving culture and promoting development, but also ensuring we have the means to recruit and train the staff we need to meet growing demand, both domestically and internationally.

In order to reduce burnout and pressure on the frontline of health and social care, enough additional staff are needed not only to cover existing workforce gaps, but also to build flexibility into the system. Resilience is often spoken of at an individual staff level, but by building a resilient system, workforce wellbeing will be far better protected by realistic workloads, more regular and reliable breaks, and better work life balance.

Priority measures to mitigate the causes of workforce stress and burnout in the NHS increasing include:

early intervention and preventative measures among the population to reduce service demand
addressing the history of under-funding for NHS services
an appropriately funded national framework which supports recruitment and retention in the service including competitive pay and terms and conditions
giving trusts the resources to implement recruitment, retention, and wellbeing schemes for their staff.

One important short-term solution to help increase workforce supply (and thereby helping to reduce staff burnout) in social care would be to ensure immigration policy enables the recruitment of care staff from overseas, given that the care sector relies heavily on international recruitment. NHS Providers is deeply concerned that the new points-based immigration system will make it much harder to recruit social care staff internationally. Social care professionals are not on the shortage occupation list and will be in effect ruled out from gaining a visa through not meeting the essential criteria requirements and not meeting the salary threshold.

Public awareness of the fundamental role played by the social care sector during the COVID-19 response has drawn attention to the urgent need for a long-term funding settlement and accompanying reform to place the social care system on a sustainable footing more generally. Some local authorities have been unable to increase the fees paid to care providers in line with the rising costs of delivering care, and several wrote to providers in March 2020 to say they were unable to cover the rise in the National Living Wage from April 2020. In addition to solving the funding crisis in social care, accompanying reform should increase pay and recognition for the care workforce, improve access and quality of care, and facilitate integration between health and care services.

Priority measures to mitigate the causes of workforce stress and burnout in social care include:

solving the social care funding crisis
reform to increase pay and recognition for the social care workforce
a nationally coordinated approach to address both national and international recruitment to social care, particularly in the wake of Brexit.

Sept 2020