Written evidence submitted by the Royal College of Surgeons of Edinburgh (WBR0035)
- The NHS has been ‘running hot’ with severe staff shortages and issues with staff recruitment, retention and burnout for several years before the pandemic hit.
- NHS budgets have not kept pace with increasing demand leading to resilience issues. The NHS’s obsolete IT infrastructure is a particular example.
- Proper resourcing of backroom functions, including a thorough upgrading of the NHS’s shockingly poor IT infrastructure would strengthen resilience greatly.
- Logistical improvements which have positively benefitted the mental wellbeing of NHS staff such as wobble rooms, a focus on staff mental health, free parking and better catering should be made permanent.
- The pandemic has had very negative impacts but also some positive ones. The deaths of so many patients, including colleagues, has traumatised the workforce. At the same time staff feel more unified and valued than they did before the virus and measures put in place to support mental health in response have been positive.
- NHS staff need respite. Holiday leave entitlements should be allowed to be transferred to new trusts and rotations and staff should be encouraged to take leave wherever possible. Those unable to take their leave entitlement should be compensated in some form.
- Staff retention issues and the failure to meet rota guidelines are clear manifestations of workforce burnout, as well as contributing factors to it. The latter largely stems from severe staff shortages.
- The NHS requires a recruitment drive for doctors which will need both more medical qualification study places in the UK and the recruitment of overseas doctors. This is the only way to have enough staff to both deliver round the clock care and allow clinicians to maintain a healthy work/life balance.
Introduction to the Royal College of Surgeons of Edinburgh.
- The Royal College of Surgeons of Edinburgh is the oldest and largest of the UK’s four surgical Royal Colleges, and one of the largest of all the UK medical Royal Colleges. First incorporated as the Barber Surgeons of Edinburgh in 1505 it has almost 30,000 members worldwide. Approximately half of our membership are based in the UK with 80% of that in England and Wales.
- The RCSEd is committed to representing the views of our members and fellows, to lobbying to improve outcomes for clinicians and patients and to providing expertise and information from the frontline to policymakers. We are committed to protecting, promoting and championing the highest professional standards of surgical and dental practice in Westminster and the devolved administrations.
- The RCSEd submits the following with regards to the National Health Service and in particular to those areas of the NHS which affects our members and fellows; that is those involved in surgery, perioperative care and dentistry. This includes surgical consultants, trainees, theatre nurses, medical students and dentists.
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?
What are the impacts of workforce burnout on service delivery, staff, patients and service users across the NHS and social care sectors?
- Resilience can be defined as the capacity to thrive in situations of high demand and ongoing pressure, and the ability to recover from significant challenges, difficulties and setbacks. In terms of our NHS it has two aspects, the resilience of the systems and structures of the NHS and the resilience of members of staff to cope with the stress and mental wellbeing issues presented by high demand and ongoing pressure.
- The NHS has been ‘running hot’ for many years prior to the pandemic, with little or no spare capacity in the system to cope even with the annual increased pressures caused by the winter weather. In December 2019 every single A&E in England and Wales missed its waiting times targets as a result of this.
- The NHS is facing a severe staff shortage with recruitment and retention being a major concern. Whilst absolute numbers of staff have increased in many areas this does not keep up with the demands caused by our aging population. As of February 2019, the Health Foundation found 41,000 registered nursing places were unfilled due to a lack of qualified applicants and that FTE numbers of GPs had dropped by 1.6% since 2016. A survey of the Royal College of Midwives in the same year found that 79% of Trusts had vacancies for midwives and 48% reported they did not have the funding to adequately staff those units. Research by the British Medical Association showed that over 70% of hospitals have gaps in their rotas caused by insufficient numbers of hospital doctors. This causes severe extra strain on the existing staff, leading to burnout and a high number of clinicians leaving the NHS.
- NHS budgets have not increased in line with the rising costs of an aging population and new medical advances in treatments. When resources are tight the frontline and clinicians are prioritised, often leading to cuts to backroom functions such as IT, administration and management teams. This has stripped much of the system capacity out and means that clinicians are often unable to utilise contemporary best practice or adapt. A good example of this is the shockingly backwards state of the NHS’s IT infrastructure which has meant most trusts were unable, during the pandemic, to perform virtual surgical consultations – often through simple issues such as a lack of webcams and poor WiFi connectivity.
- Proper resourcing of the NHS and a focus on upgrading its systemic capacity such as with up-to-date IT infrastructure are vital to strengthen the NHS’s resilience. This includes allowing remote access to systems to allow access from home where appropriate.
- This ‘running hot’ has also had a deleterious effect on the wellbeing of NHS staff by creating a pressure cooker atmosphere, with a study performed in 2017 finding that a quarter of NHS clinical staff reported that they had experienced bullying, harassment or abuse from colleagues in the last 12 months. This costs the NHS £2.3billlion a year in sickness absence, employee turnover, productivity and employment relations in England alone. Further a study in the US attributed 67% of adverse events, 71% of medical errors and 27% of perioperative deaths to the the disruptive behavioural responses associated with a high-pressure environment. Put simply, stressed out doctors make mistakes. Staff mental wellbeing is therefore a key component of strengthening resilience.
- Staff need both appropriate levels of respite and self-care – currently unavailable due the continuous high-pressure environment – and the correct tools and support to deal with high-pressure environments when they occur. This means that proper levels of resource need to also be allocated to the clinical sector of the NHS, to allow them to cope with the demands of an aging population. It also means the provision of ‘wobble rooms’ – safe spaces staff can retreat to for respite breaks during their shifts – adequate holiday provision, easy access to counselling and mental wellbeing support and an encouragement of a culture whereby all staff to keep an eye on each other for signs of mental fatigue or stress.
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 pandemic has had both positive and negative impacts on staff stress and burnout. It has been acknowledged that this has been a traumatic time for the health care. Dealing with the deaths of so many patients – especially the deaths of fellow clinicians – has had an obvious and extremely negative impact on individual staff members. Some health car staff have families abroad and have not been able to see them due to restrictions on travelling abroad. The NHS workforce had to cancel annual leave, and many have been working every other weekend on call on a COVID rota. They have then been left unable to take leave or to transfer their leave entitlement to their next trust or rotation. This is unsustainable in anything except the very short term as staff are already beginning to burnout.
- Clinicians have, however, in their feedback to the RCSEd, reported that they have never felt more supported by colleagues and peers. Many have also felt more valued than they were previously, in particular following the response of the public to ‘clap for carers’ and other gestures of solidarity with key workers.
- NHS staff need some respite. They should be allowed to transfer their leave entitlement to their next trust or rotation where applicable and encouraged by managers to take as much time off as is consistent with the needs of the hospital. We recognise that this may mean that many staff cannot take their full leave entitlement, especially given the severe staff shortages in many NHS roles, so some alternative should be offered such as money in lieu or a voucher scheme for something like ‘red letter days’ or restaurant meals.
- The pandemic resulted in a series of measures to protect the mental wellbeing of staff, such as the availability of ‘wobble rooms’, improved availability of psychological support and a much-needed emphasis on the safeguarding of mental health. There have also been wider logistical improvements that have made a real practical difference to the wellbeing and resilience of NHS staff such as free parking and better catering. These improvements should be preserved and made a permanent fixture of the NHS.
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 manifestations of burnout are the staff retention crisis discussed above and the failure to meet shift pattern guidance due to a lack of adequate numbers of staff. NHS guidance states that a doctor should not work more than one in three weekends. Research amongst RCSEd members and fellows indicates that this is often not the case due to the shortage of doctors. The need to maintain round the clock care and the reality of doctors working every other weekend means that it is very difficult for clinicians to maintain a healthy work/life balance.
- The government should take steps to increase the number of places on relevant degrees for NHS staff shortage areas and expand or create bursary schemes to make them attractive to all students.
- However, the reality of the time it takes to train doctors and the urgency with which they are required means that a significant number will have to be recruited from overseas. Therefore, it is imperative that the removal of the cap on visas for NHS staff is maintained and that there is no cap placed on the new NHS visas currently being proposed, and that other action is taken to remove impediments to the NHS recruiting from overseas. The scrapping of the immigration health surcharge for health and care staff is a good example of doing this.