Written evidence submitted by the Chair of the Association of Clinical Psychologists UK (WBR0042)

 

Evidence to the Health and Social Care Select Panel:

Workforce burnout and resilience in the NHS and social care

 

Summary

Overall, although initial signs suggest NHS staff have weathered the pandemic storm remarkably well, it is too early to evaluate: many effects are only just emerging and the period over which we can expect to see the overall impact will run into years rather than months.

While in our opinion, NHS England has in general made a good start in organising staff support, some provision has been poorly resourced and there has been a failure to organise existing high calibre psychological support such as that offered by clinical psychologists.

The pandemic has highlighted again the lack of representation of psychological professions at senior level resulting in poor management of the existing staff resource. There is urgent need for a Chief Psychological Professions Officer and to recognise the potential value of the clinical psychology profession as a national resource.

Emergency arrangements for the provision of clinical psychology support for frontline staff should now be embedded into the infrastructure and organisation of the NHS acute sector.

The NHS People Plan includes impressive expansion of the workforce, but mainly in terms of the intake of new trainees. In order to help reduce the prevalence of burnout over the next five years there also needs to be concurrent expansion of senior posts to supervise and manage the trainees and newly qualified staff.


Introduction

  1. I write on behalf of the Association of Clinical Psychologists UK  (ACP-UK).
  2. The Association of Clinical Psychologists U.K. is the professional body for registered Clinical Psychologists. We promote, publicise, support and develop the contributions of clinical psychologists, a well-established and highly trained NHS postgraduate profession, to improving the health, social care and well-being of the population of the United Kingdom. Clinical psychologists are substantially employed in the NHS in both mental health and acute physical health services.
  3. We have been actively involved in the NHS staff support response to the pandemic in a number of ways:

3.1. We have been included in expert working groups and panels by NHS England from an early stage and we have provided expert advice;

3.2. We have heard throughout from our Nation Directors about the response to the pandemic across the four nations and have been in the position to compare approaches to staff support;

3.3. We have provided a support scheme for ICU consultants, hospital managers and NHS senior executives in which respondents have access to senior and consultant clinical psychologists for one-to-one support, advice and treatment;

3.4. We have provided a one-to-one support system for our own profession;

3.5. We have provided high-quality webinars on specific psychological support interventions, designed for frontline staff and aimed at improving organisational resilience as well as reducing stress and burnout at the individual level;

3.6. We have provided high-quality webinars on how to manage psychological problems arising from the pandemic in both frontline staff and Covid-19 patients for our members.

  1. All of this work up to this point has been funded by ourselves and the voluntary support of our members.

The reaction and condition of health and social care staff

  1. The collective knowledge of experts (including clinical psychologists) has informed a model of the response of frontline staff to the pressures created by the pandemic (Lowell et al., 2018; Kiseley et al., 2020; Kahani, 2020). This model predicts a triphasic reaction in which, in the acute phase, the vast majority of frontline staff will be operating at their peak, consumed by the national importance of the task and fuelled by adrenaline of the unrelenting clinical demands of frontline work. Although pressure and stress are immense, staff are operating “on autopilot” and implementing their acute clinical training.
  2. It is only once the peak stress has begun to decline that we begin to see burnout and PTSD-type problems emerging, and we are only just entering this phase (Murphy et al., 2020).
  3. Overall NHS staff have performed remarkably well during the acute phase, with little evidence of widespread psychological difficulty (but this is not to say there has been no difficulty). This has been partly because of generally good clinical leadership locally in acute services, generally strong clinical team cohesion and not least, broad and well publicised public support for frontline staff (e.g. weekly “street claps”).
  4. Reaction to the “clap” is complicated because of a sense of the gap between the reality of an understaffed and resourced NHS, in which staff often feel unsupported and as if they must not admit to weakness of vulnerability, and the rhetoric of heroism.
  5. Many staff are low and exhausted. There have been examples of striking personal sacrifices which staff have made during the acute phase, for example not seeing loved ones in order to protect them from infection, which cannot be sustained in the long-term. There is now a risk of increased numbers of staff going off sick, with the risk of absenteeism.
  6. Some clinical psychologists have been poorly supported and have concerns about not being consulted about their workloads and the balance of staff support and patient work - and some were moved into staff support roles without direction. Basic infrastructure essentials such as IT provision have not been in place in several trusts to allow clinical psychologists to work from home.
  7. People are now expected to return to their former roles, but also to deal with the backlog of work and in some cases patients whose care has now become urgent or their situations palliative or terminal.

NHS England support for frontline staff

  1. The response of NHS England in support of frontline staff has been sophisticated, multi-layered and developed with relevant psychological expertise. Key clinical psychologists already employed in senior management and advisory positions within NHS England were appointed to leadership roles in the staff support response early in the pandemic. Clinical psychology experts with experience of previous national emergencies and incidents causing acute pressure on the NHS were enrolled in expert advisory groups.
  2. ACP-UK applauds NHS England for its general approach.
  3. The NHS England Staff Wellbeing support programme has involved a “stepped care” approach:

14.1.                      Excellent health and wellbeing apps, webinars for teams and self-guided online mental health resources have been provided free of charge (without recipients being identified);

14.2.                      “Common Rooms” in which healthcare staff can meet online in groups with a healthcare professional with some psychological training chairing and facilitating have also been offered;

14.3.                      Confidential and anonymous telephone listening support, provided primarily by the Samaritans, has been offered;

14.4.                      If further one-to-one support involving specific psychological interventions is needed, staff self-referral to IAPT services offering evidence-based psychological treatments has been made possible.

  1. The take-up of these various forms of psychological support has been remarkably low thus far (Murphy et al., 2020). This may be because of the acute phase effect described below, or it may also be because the various offers are not seen as likely to be effective, or if they are, the risk and professional consequences of admitting to psychological difficulty may outweigh the advantages of their access. It may be that people cannot be released from other work or domestic responsibilities to take up the opportunities offered; that they want to devote their time away from work to their families or self-care such as getting some sleep. Research is needed into the reasons for both take-up and non-engagement with these offers.
  2. While the regulatory bodies have eased some of their requirements to enable retired and previously unregistered doctors, nurses and allied staff to return to frontline working as their response to the pandemic, they have not provided any reassurance that existing registrants admitting to mental health or psychological difficulties will be sanctioned any differently than in the past, causing healthcare staff to be reluctant to access support in case they are identified and reported.
  3. ACP-UK considers the reliance on an already oversubscribed IAPT service for the provision of high intensity psychological support for frontline staff without consideration of existing psychological professions such as clinical psychology, a strategic mistake. No additional resources or funding has been made available in practice for IAPT services, and it is no surprise we see little evidence of a significant increase in uptake for frontline staff.
  4. NHS England is presently in negotiation with ACP-UK for a funded one-to-one support scheme for NHS and social care senior executives, who may be reluctant to access more widely available forms of support: this is a welcome development.
  5. It is also important to note that local clinical psychology services have organised their own staff support schemes (outwith and in addition to those of NHS England), and these may have been accessed more readily by local frontline staff, although we know that many prefer not to receive services from local colleagues because of the sensitivity of their issues and situations. It is unclear whether data on local provision uptake is being recorded.
  6. NHS England is now developing multiple regional “resilience hubs” with specific provisions for the emerging mental health needs of staff during the post-acute phase of the pandemic. These include appropriate mental health expertise and clinical leadership and should be an effective solution providing they are properly funded.

Burnout

  1. From a human resources standpoint, burnout is a very serious problem, not just because it often represents the end of an employee’s career but because it is essentially hidden and unpredictable to the employing organisation. Indications from previous incidents suggest that those in most danger of burnout are the last to seek help, hence the covert nature of the problem. Often it is those in the most senior leadership and management positions that are most vulnerable, and yet these are the last to admit their need and seek help.
  2. Another pernicious outcome is “presenteeism” or simply going through the motions at work: loss of interest and motivation for work activity and compassion fatigue (Dewa et al., 2017; Figley, 1995; West & Chowla, 2017). These effects damage the whole organisation and quality of care delivery.
  3. This is very difficult to assess short of distributing burnout questionnaires to the whole workforce (Maslach & Jackson, 1981), but it is likely that there will be burnout casualties who end up resigning, often left with chronic mental health problems, as well as those who although continuing to work, cease to be able to engage with their vocation with their previous level of enthusiasm and aspiration.
  4. Some of the factors explaining why some succumb and others do not, include the perception of overwhelming demand along with insufficient resources to meet this. Perceptions of the degree of control over situations are also important as well as personality factors and personal history.
  5. Resilience is often seen as a characteristic of the individual, with the implication that help-seeking represents a weakness of the individual. Clinical psychologists have experience of organisational development and service consultancy and recommend building resilience at the organisational level, and promoting psychologically-minded work cultures in which staff support and the recognition of the impact of work are built into the way services are run from the ground up.

Improving resilience for the future

  1. The Select Committee has asked what lessons can be learned and how the resilience of the health and social care workforce might be improved. One example would be to integrate some currently NHS employed clinical psychologists into Occupational Health Departments (alongside existing clinical roles) and to have the support arrangements that were rapidly created in response to the pandemic more securely embedded into acute healthcare staff support.
  2. Psychological support interventions, such as Compassion Circles, Reflective Practice Groups and The Schwarz Round, should also become more routine and widespread, and we should build on the existing evidence base in evaluating and developing these.

Increasing NHS healthcare staff numbers

  1. The People Plan and implementation of the NHS Long Term Plan propose impressive expansion of the whole NHS workforce, which if implemented in full, is long overdue and will make a substantial improvement in the ability of the NHS to manage future emergencies and reduce burnout. A 25% increase in clinical psychology trainees has been implemented for the autumn with further year-on-year expanded intakes expected. However at present there is no arrangement for increasing senior grades who will be needed to supervise and manage more junior, newly qualified clinical psychologists.

Professor Mike Wang
Chair, ACP-UK
September 2020

References

Dewa CS, Loong D, Bonato S, et alThe relationship between physician burnout and quality of healthcare in terms of safety and acceptability: a systematic review
BMJ Open 2017;7:e015141. doi: 10.1136/bmjopen-2016-015141

Figley, C. R. (1995). Compassion fatigue: Toward a new understanding of the costs of caring. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (p. 3–28). The Sidran Press.

Greenberg, N., Docherty, M., Gnanapragasam, S., Wessley, S. (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic, BMJ 2020;368:m1211

Kiseley, S., Warren, N., … (2020) Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis, BMJ 2020;369:m1642

Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., … Hu, S. (2020). Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Network Open, 3(3), e203976.

Lowell A, Suarez-Jimenez B, Helpman L, Zhu X, Durosky A, Hilburn A, Schneier F, Gross R, Neria Y. 9/11-related PTSD among highly exposed populations: a systematic review 15 years after the attack. Psychol Med. 2018; 48:537–553doi: 10.1017/S0033291717002033.

Maslach, C, Jackson,S. (1981). The Maslach Burnout Questionnaire. Palo Alto: Consulting Psychologists Press

Murphy, J., Spikol, E., …. (2020). The psychological wellbeing of frontline workers in the United Kingdom during the COVID-19 pandemic: First and second wave findings from the COVID-19 Psychological Research Consortium (C19PRC) Study

West MA, Chowla R (2017). ‘Compassionate leadership for compassionate healthcare’ in Gilbert P (ed), Compassion: concepts, research and applications, pp 237–57. London: Routledge.

Zhang, C., Yang, L., Liu, S., Ma, S., Wang, Y., Cai, Z., … Zhang, B. (2020). Survey of Insomnia and Related Social Psychological Factors Among Medical Staff Involved in the 2019 Novel Coronavirus Disease Outbreak. Frontiers in Psychiatry, 11.

 

Sept 2020