Written evidence submitted by The Royal College of Physicians (WBR0023)
The Royal College of Physicians (RCP) welcomes the Health and Social Care Select Committee’s inquiry on Workforce burnout and resilience in the NHS and social care, which will consider increased pressures brought by COVID-19 and the resilience of services to cope with high levels of staff stress.
As part of our work to track the impact of COVID-19 on the workforce, to date, we have conducted several surveys on members and fellows 1–2 April, 22–23 April, 13-14 May, 3-4 June and 21-22 July. Our surveys asked a range of questions in order to monitor changes in working patterns as a result of the pandemic. Separately, in February 2020 we surveyed consultant physicians in the UK about their wellbeing during the previous year (yet to be published). Together, the surveys demonstrate the longstanding challenges on wellbeing as a result of increased pressures from the system, exacerbated by the pandemic.
The RCP welcomed proposals outlined in the new NHS People Plan – with the stated aim of putting ‘NHS staff wellbeing at its heart’ and placing new focuses on recruitment and retention as well as safe spaces for rest and recuperation, the introduction of wellbeing guardians and support to keep staff fit and healthy. However, what is important now is delivering these plans in a timely manner so that these long-overdue aspirations become a reality.
The pandemic has exacerbated challenges associated with shortages in the workforce, resulting in doctors being exhausted and pressured to work under intensified capacity constraints. We therefore urge that the government provides greater clarity on the scale of plans to expand the workforce to ensure that this goes far enough to address the historic levels of understaffing in the health service.
COVID-19 survey findings
Our COVID-19 surveys asked members a range of questions in order to monitor changes in wellbeing as a result increased pressures and changes to working patterns.
Clinicians have worked incredibly flexibly during the pandemic. Our fourth survey (3-4 June) found that during the pandemic, 59% of respondents reported working on an emergency rota. 49% reported informal changes to their job plan, and 11% reported that their job plan had been formally altered. 45% of clinicians said they wanted to return to their previous working patterns, with 26% saying that they want to work the same number of PAs but more flexibly. 14% also responded that they wish to work fewer PAs in the future.
During the peak of the pandemic, our second survey (22-23 April) found that 29% of respondents were working in a clinical area different from their normal practice. However, only 59% said they had access to psychological/emotional support and 51.5% received mentoring. Meanwhile, our third survey (13-14 May) found that 48% said they were either concerned or very concerned about their health. This rose to 76% for respondents from black, Asian, and minority ethnic (BAME) backgrounds.
We have been told time and again by our membership that morale is low and continues to fall. The main reason for this pressure is workload, which forces doctors to act down and doctors in training to take on more than they should. As demand continues to outstrip supply of doctors, to ease pressures created by increased workload we must adopt the notion that patient safety is everyone’s responsibility.
Just before the pandemic began, the Medical Workforce Unit - on behalf of RCP London, RCP Edinburgh and RCPS Glasgow - surveyed UK consultant physicians in February 2020 about their wellbeing during the previous year. 2,644 consultants responded to the survey which revealed:
Workload and morale
High workload pressures continue to be common:
Based on the Maslach Burnout Inventory, women and consultants of white ethnicity appeared at higher burnout risk than men and consultants from black, Asian and minority ethnic backgrounds. Working less than full time carried a lower burnout risk. Consultants who are disabled or have a long-term health condition had a higher burnout risk.
Separately, the RCP has highlighted the challenges with using the term ‘burnout’ in relation to doctors as it implies a failure of the individual. Instead, we must encourage the use of the term ‘moral injury’ to make it clear that healthcare staff are ‘injured’ by the overstretched system.
Mental wellbeing scores using the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) [© NHS Health Scotland, University of Warwick and University of Edinburgh, 2006, all rights reserved] revealed a similar picture. Consultant physicians had lower (worse) mean scores (men 47.5, women 46.2) than the background UK population (men 50.1, women 49.6). Lower mean scores were particularly found among full time consultants and specialties such as gastroenterology, haematology, infectious diseases and medical oncology.
The RCP recently published a mental health and wellbeing resource, to help physicians spot the signs of deteriorating mental health, and know where to look when they need to seek help. Our mental health resources on the RCP website have been viewed over 8000 times since February with notably higher activity during the peak of the pandemic between March and June.
Burnout, work-related stress, mental illness and suicide are increasingly recognised within the physician workforce. Doctors are not good at seeking help; often denying there is a problem, not recognising there is a problem, being fearful of any stigma, having anxieties and guilt about burdening others with our own difficulties or even possibly losing their job.
Areas of work affecting wellbeing
The following work areas most commonly adversely affected wellbeing:
The same number of consultants at high and low burnout risk had received a complaint in the past year. However, those at high burnout risk were more likely to have been the subject of a serious incident investigation and four times more likely to have undergone a disciplinary investigation. 73% felt supported by colleagues during their complaint or investigation and but only 47% by their organisation.
Moving between career stage is an important milestone for doctors. 16% of respondents had become a consultant in the past five years. 39% reported that this had adversely affected their wellbeing. 53% of consultants had undertaken a medical leadership role in the past five years. 54% reported that this had adversely affected their wellbeing.
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?
The RCP welcomed the government’s recent announcement to lift the cap on medical schools. In response to the announcement, Professor Andrew Goddard, RCP president, said:
"[The] decision is really welcome news for many hardworking A-level students who could see their dream of medical school fading away through no fault of their own. In tandem it is vital that universities and the NHS receive the resources they need to ensure that these students receive the full experience they deserve.
“This situation also acts as a reminder that we need to plan for a large phased expansion of places which will help place the NHS workforce on a more sustainable footing. If we don't we are setting ourselves up for another decade of workforce shortages which is totally avoidable.
“Ahead of the comprehensive spending review, we urge the Government to make clear its commitment to double the number of medical school places. We will soon be publishing a new report which we hope will act as a catalyst for significant expansion.”
The RCP has long called for the need to double the number of medical school places to 15,000 per year, with the aim of a moving towards a small surplus of supply. The interim NHS people plan likewise refers to the need to consider a potential expansion in places.
While there will be many opinions and analysis on how large a future expansion should be, we know that this will require careful consideration. We believe that the principles of expansion should focus on; attracting talent by urgently improving prospects for students considering a career in medicine from a diverse background; the challenges with recruiting doctors in rural areas and the significant regional disparities in the doctor to patient ratio across the country; and revisiting how medical education is delivered to best equip our future doctors in a forever changing landscape.
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?
The government must ensure and support employers to focus on effective job planning and facilitating flexible working, including keeping consultants working later in their careers. Employers should also be supported with:
The COVID-19 crisis has once again shone a light on the importance of health and social care working in
equal partnership. We remain concerned that Brexit will exacerbate shortages in the social care workforce, adding further pressures on capacity, morale and subsequently the quality of patient care. The Migration Advisory Committee’s (MAC) report highlights that EEA migrants contribute significantly to social care services, which hospitals heavily rely on for adequate transfers to care. This is why we are also calling for the new fast-track health and care visa to be extended to the social care workforce. The decision to exclude them is just the latest example of the inequities between our health and social care systems.
About the RCP
The RCP plays a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the UK and overseas with education, training and support throughout their careers. As an independent body representing over 37,000 fellows and members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare. Our primary interest is in building a health system that delivers high-quality care for patients.