Written evidence submitted by Our Frontline (WBR0057)

This evidence is being submitted on behalf of Our Frontline. Our Frontline is a collaborative partnership and campaign led by Mind, Samaritans, Hospice UK and Shout 85258, with support from The Royal Foundation of the Duke and Duchess of Cambridge. The campaign launched in April 2020 to provide 24hr mental health support for those working on the frontline against the Coronavirus (COVID-19). The campaign will run until Sep 2021.

Summary

1. Prior to COVID-19, there was a wealth of data and research highlighting both the drivers and impact of poor mental health on the health and social care workforce, who were already facing high levels of pressure and burn out.

2. There is no doubt that the impact of COVID-19 has increased this pressure, the risk of burn out and the risk of frontline workers experiencing long term mental health problems such as Post Traumatic Stress Disorder (PTSD).  Therefore we welcome this timely inquiry from the Health and Social Care Committee looking at workforce burnout.

3. While we understand the need to focus on and build the resilience of the workforce, much of our evidence points towards poor working cultures and organisational factors being the biggest drivers of poor mental health for those working on the frontline. These factors, and the root causes of poor mental health across the workforce, need to be tackled as a priority if we want to see a truly resilient health and social care sector.

4. Along with poor working cultures and organisational factors driving poor mental health, there are also on going challenges with recruitment and retention which lead to additional pressures on frontline staff. Ensuring there are the right numbers of staff in place across the health and social care workforce is critical for minimising the risk of burnout and the UK Government must set out a clear plan for the recruitment, training and retention of the NHS and social care workforce, with corresponding investment.

Question 1: 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? 

5. The NHS and social care workforce spend their days saving lives, helping people in distress, dealing with difficult cases, sometimes experiencing violence and aggression. In most cases, frontline health and social care workers return to work with an even deeper resolve to make a difference. These people are resilient.

6. And while it is important to focus on continuing to strengthen the resilience of the NHS and social care workforce, particularly in the wake of COVID-19, we know that more often than not that it is organisational factors (such as long working hours, poor physical workspaces, and lack of management support) that have the most negative impact on staff mental health and wellbeing. This needs to be focused on as a priority, if we truly want to see strengthened wellbeing across the workforce.

7. For many workers these organisational factors often feel completely outside of their control, so to hear the word ‘resilience’ can often leave them feeling as though the responsibility is solely on them to look after their own mental health and wellbeing. While undoubtably all workers have a role in this, they can only do this effectively if the operating conditions they work within are conducive to promoting good mental health and wellbeing.

Organisational factors:

8. Evidence from Health Education England’s NHS Staff and Learners Mental Wellbeing Commission highlighted a range of factors impacting on the mental health and wellbeing of NHS staff, many of which were organisational factors with a big focus on culture.[1] Some of the key themes and discussions that emerged during the commission included:

• Taking a break - often under pressure from colleagues or the accepted workplace culture, staff can feel pressurised to work long shifts without breaks, come to work when ill (presenteeism) and even skip annual leave, particularly where staffing is under-resourced.
• The simple things - wellbeing at work needs to be addressed strategically across the NHS but often it is the simple things in the workplace that can make a real difference: staff lockers, showers, a quiet room, the availability of nutritious food, a good coffee, a psychologically safe space to get together with others to talk and debrief, or just a colleague taking the time to say ‘thank you’.
• Need for self-care - if a person is intolerant of their own distress, they may not be able to tolerate the distress of others. We need to support a learning and workplace culture which encourages compassion to oneself, where self-care is ‘normalised’.
• Being human beings - some clinicians may feel a need to adopt a ‘superhero complex’ to help deal with the pressure of their role, but we need to acknowledge in healthcare that being a human being and high performing are not mutually exclusive.

9. We need to understand what progress is being made against the 33 recommendations from the Commission and who is accountable for these recommendations.
10. In association with the Royal College of Nursing Foundation, the Society of Occupational Medicine published a report on the Mental Health and Wellbeing of Nurses and Midwives in the United Kingdom in July 2020.[2] This report also highlighted a range of factors impacting on the mental health and wellbeing of midwives and nurses working within the NHS. Again, many of the factors were organisational factors with a big focus on culture.
11. There were 45 recommendations made in total, with eight being a priority. The first priority set out in the report is: Action is needed to address the organisational factors found to underpin poor mental health and wellbeing in nurses and midwives (e.g. high work demands, poor leadership, lack of resourcing and workplace bullying). Others recommendations include:

• All organisations should have a mental health strategy that is fully implemented, demonstrating their commitment to improving the wellbeing of all nurses and midwives with holistic interventions in place to address prevention, treatment and rehabilitation.
• Managers and shift coordinators need a better understanding of the impact of shift-work on health and how this can be mitigated.

12. We need to understand what progress is being made against these recommendations and who is accountable for driving them forward.

13. In a survey conducted by Mind with 5,081 ambulance staff in 2019, only 22.7% of ambulance personnel said they would seek support from their managers for a mental health problem. Just over half (50.7%) of ambulance service staff and volunteers said they felt confident that attitudes towards mental health in their organisation were changing for the better. When asked what aspects of their role could cause them to feel low, depressed, stressed or mentally unwell, experience of distressing or traumatic events came first, closely followed by long hours and excessive workload.[3]

14. Mind also carried out research to understand more about the pressures faced in Emergency Departments that impact on mental health, and what kinds of interventions are most effective.[4] The findings highlighted:

• Emergency departments (ED) have a powerful performance culture that affects the way people do their jobs and how they think about and act in relation to their mental health. Staff don’t associate ‘self-care’ with better performance.
• ED staff tend to think of mental health in binary terms. They appear to think of themselves – and others – as either mentally fit or unfit, seeing nothing in between.
• At particularly busy times, relentless caseloads leave little or no time for staff to mentally ‘warm up’ before dealing with a situation. Staff across all the trusts described how they and others were “thrown in at the deep end”. One GP trainee reflected on not having time in between cases, and how when these cases were complex, this added to the feeling of pressure.
• Staff often don’t know where to go for support at work and worries about confidentiality put them off seeking help. They lack informal coping strategies and don’t generally share the techniques they do have. Senior staff do not see looking after the mental wellbeing of their staff as part of their role.
• Staff faced significant barriers accessing formal support. Commonly staff didn’t know where to go for support at work.
• Whatever else was going on in the ED, or in an individual’s professional or personal life, there was a pervasive narrative that patients came first. Shabby and untidy staff areas, and culture or policies that downplayed staff members’ own needs reinforced this narrative. It was common to see piles of coats and bags in staff rooms, over the floor and across the tables. Facilities were often out of order. One consultant commented on a ban on staff drinking water in the ED. Rather than this being for hygiene reasons, he was told this was to “make the patients feel less uncomfortable” if they were going into surgery and couldn’t have anything to drink themselves.
• Staff frequently seemed anxious about making mistakes or a lack of loss control, which negatively impacted on their mental health.

15. The above highlights the extensive evidence and research that supports the need to focus on improving both the organisational factors and the poor working cultures that are impacting on staff mental health and wellbeing across the NHS workforce. These need to be tackled as a precursor to talking about strengthening the resilience of the workforce, given the fact that workers continue to perform and produce results despite these factors and at significant personal risk to their own mental health and wellbeing.

• We recommend all employers across NHS and social care settings adopt the Mental Health at Work Commitment: www.mentalhealthatwork.org.uk/commitment 
• We recommend that the recommendations set out in Health Education England’s NHS Staff and Learners’ Mental Wellbeing Commission are adopted as a priority.
• We recommend that the recommendations set out in the Mental Health and Wellbeing of Nurses and Midwives in the United Kingdom report are adopted as a priority.

Individual resilience:

16. Responding to the COVID-19 pandemic is just one example of the resilience of the NHS and social care workforce. However the impact of the pandemic may mean we need a different approach to strengthening individual resilience in the future because of the trauma many will have experienced during the pandemic.

17. In a study commissioned by Mind and carried out by the University of Oxford (Wild et al., 2016), rumination, low resilience appraisals and unhelpful thought patterns were all identified as predictors of mental health problems within emergency service workers, including paramedics. In 2017 Mind and the University of Oxford then developed and delivered a resilience intervention to modify these predictors and the results saw significant improvements over time in resilience, wellbeing, social capital, psychological distress, mental health awareness and confidence to manage mental health.[5]

18. Results from the intervention showed that initial higher scores on measures of depression, anxiety, PTSD, depressive attributions, rumination and wishful thinking were linked to greater changes in outcome. This suggested that the participants most likely to benefit from the training may be those who were more vulnerable at the outset.

19. Given the impact of COVID-19 and the increased likelihood of remuneration, moral injury, mental health problems, including anxiety and PTSD, it is important that staff are given adequate training and tools to strengthen their resilience. We know that resilience can be trained and with treatment, people can become more resilient (i.e., Connor & Davidson, 2003). And we know that research suggests that resilient people are less likely to experience mental health problems (e.g., Foresight, 2008). Staff also need to be given time to carry out this training and to put it into practice.

Resilience in the face of growing demand:

20. Prior to the COVID-19 outbreak, the health and social care workforce were operating in an environment of growing demand and reducing resource. At the turn of the year NHS England providers were reporting a shortage of over 100,000 FTE staff while in social care the gap has been reported at 122,000 FTE vacancies.[6] The number of GPs and nurses in particular have failed to keep pace with rises in the population.

21. At the same time, demand is growing at a rapid rate, largely fueled by an ageing population. The number of hospital admissions in England rose 15% between 2010/11 and 2018/19 and waiting lists increased from 2.5million to 4.6million people.[7] Each year the number of deaths continues to grow, reaching more than 616,000 in the UK in 2018.[8] With around three quarters of people approaching end of life anticipated to benefit from palliative care, it is no surprise demand on end of life and palliative care services has continued to grow.

22. Further issues exist that will still require attention in order to build future resilience in the workforce. Challenges around terms and conditions (including disparity between health and care and the proportion of minimum wage roles in the social care sector), job recognition, training and development and access to appropriate equipment to do the role, are all long standing problems.

23. Before the outbreak of COVID-19, plans to address workforce challenges in health and social care had somewhat stalled. Issues in the NHS, such as improving leadership culture and prioritising action on nursing shortages, had been identified but have still reached no further than an ‘interim’ People Plan. In social care, despite commitments from decision makers to look at the workforces in an integrated way, a plan is yet to materialize. In the meantime the challenges highlighted in this submission have become more stark due to the pandemic.

• We recommend that all employers across NHS and social care settings promote the Our Frontline campaign to their staff: www.ourfrontline.org.uk.

• We recommend that employees across the NHS and social care are given adequate evidence-based training and tools to strengthen their resilience.

Question 2: 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? 

24. The full impact of the COVID-19 pandemic on resilience, levels of workforce stress, and burnout across the NHS and social care sectors is not likely to be realised fully for some time. We know that the effects of trauma can often take months, even years, to surface, as highlighted by learning from incidents like the Grenfell Tower fire and Manchester and London bombings.

25. However we do know that the COVID-19 pandemic has put health and social care professionals in an unprecedented situation. People on the front line have been working under extreme pressure, having to make impossible decisions that have included how to allocate scant resources to equally needy patients, and how to provide care for all severely unwell patients with constrained or inadequate resources. Workers have also been needing to provide support to a disproportionate number of grieving families, dealing with the added difficulty of not being able to allow them to see loved ones who are dying from COVID-19.

26. In addition to the extraordinary challenges of the day job, health and social care workers would have had equally challenging decisions to make around how to balance their own physical and mental healthcare needs with those of patients and how to align their desire and duty to patients with those to family and friends. Workers who live alone may find themselves feeling isolated, with the pace of work meaning there’s little time to connect with colleagues or engage in informal peer support during shift, and no one to connect with once they return to their domestic situation.

27. The combination of the above, in addition to an already stressful job, will no doubt have had an impact on the resilience levels of the workforce. The paragraphs below highlight some of the main themes we have heard through our work with frontline staff.

28. Self-stigma: The hero narrative promoted by the media has proved to be a double-edged sword: intended to communicate the value with which we hold health care professionals, it has unintentionally added to the pressure individuals feel to rise to the present challenge, continually going above and beyond their duty of care, putting their mental health at risk. The impact of this may cause workers not to reach out for support in the months to come, leading to greater burnout in the long-term.

29. Moral distress and moral injury: Moral injury has been defined as the psychological distress caused by actions, or inactions, which violate an individual’s moral code. Whilse moral injury is not in itself a mental disorder it is a risk factor for a range of mental health problems including depression, PTSD and increased suicidal ideation. It is very likely that the nature of the decisions that healthcare professionals have had to make in the last 6-months months will expose them to high risk of moral injury.

30. However, whether someone develops a psychological injury or experiences psychological growth is likely to be influenced by the way that they are supported before, during, and after a challenging incident. Some people who have to contend with significant challenges, moral or traumatic, experience a degree of post-traumatic growth - a term used to describe a bolstering of psychological resilience, esteem, outlook, and values after exposure to highly challenging situations. Despite the huge physical and psychological demands being placed on staff, supporting people’s natural coping mechanisms, enhancing a feeling of connectedness between colleagues, and acknowledging that in the current crisis many people’s usual coping mechanisms and outlets for stress are limited, will help more people cope and reduce the level of harm.

31. Increased risk of PTSD: Exposure to traumatic incidents can be a trigger for somebody experiencing PTSD. Trauma symptoms can often persist long after the traumatising event and have a significant impact on a person’s day to day functioning and it’s likely in the case of COVID-19, that we will start to see the impact on workers in the coming 6-months and beyond.

32. It can also be said that a person experiencing trauma, or the effects of intense pressure, may not recognise the symptoms so continual assessment of the mental wellbeing of frontline staff could be highly beneficial. We know that frontline workers can wait up to three years before taking up the offer of trauma support. Recovery from a traumatic or stressful event or period can be defined as being able to enjoy day-to-day life unaffected by the trauma and to be equipped to cope well with difficult and stressful situations in life and work.

33. Helplessness and loss are two strong risk factors for crises such as suicide, so crisis intervention is crucial to stabilise and address someone’s immediate safety. Therefore, there must be a way to identify health and social care staff that might be experiencing trauma following COVID-19.

34. Early career staff: It’s important to acknowledge that people who chose to work in these professions have usually developed resilience to the demands of their work over their careers, and that these positive experiences should be harnessed. However, we know that people who are early on in their careers and are less experienced, including student nurses and more junior doctors, may be at increased risk of stress, distress and PTSD.

35. Safety: The pandemic has increased workforce anxieties around their own health and safety. These anxieties have been amplified through issues relating to access and support around Personal Protective Equipment (PPE). As the crisis worsened, many hospices and social care providers found access to PPE very challenging, relying on private purchases where prices were significantly inflated and community support – including provision of equipment from local schools – to keep workers safe and continue providing services. Efforts from Hospice UK, alongside NHS England, have since resulted in hospices being included in a weekly shipment of PPE, with 29,000 units being sent to regional hubs for distribution every week. Confidence both in ongoing supply but also in the effectiveness of equipment and support in how to use PPE appropriately is key to reducing anxiety and stress.

36. Initial difficulties in accessing testing for staff contributed to additional stress and anxiety. The delay in rolling out mass testing led to doubts and concerns and had a knock-on effect to the number of people needing to self-isolate just in case they were carrying the virus. Skills for Care found that in March and April 2020, days lost to staff sickness in adult social care increased to 8% instead of the 3% found before the pandemic. Moving forwards, community-based health and care providers such as hospices and care homes must be provided with immediate and on demand supplies of testing that can be carried out on site. This can help to provide reassurance and confidence to staff.

37. Dealing with new challenges Guidance designed to enable the workforce to operate most effectively has been ever changing. Health and care staff have faced additional stresses in trying to deliver best practice in a constantly evolving environment, often taking on unfamiliar roles or additional responsibilities to keep services going. In some hospices, entire teams were redeployed from their usual roles, sometimes adding to the volume of care delivered in the community. Normal ways of working have been rewritten, and the workforce has been expected to negotiate different routines, different models of care and communication, as well as use a raft of new technologies. Risks both to themselves and those they care for, have often been unknown.

38. Health and care professionals working in palliative and end of life care already have very challenging roles, where delivering care that is human, compassionate and tailored to the individual is of utmost importance to the experience of patients and their families. COVID-19 has made giving the same standard of holistic care, maintaining humanity in the last days or weeks of life, incredibly difficult. Offering comfort or holding challenging conversations while wearing PPE or observing social distancing has been a daily headache, while hospices have reported to Hospice UK the distress of staff as well as the patients and families at the visiting restrictions that had to be in place at the height of the outbreak, with limitations remaining now. For care provided in patients’ own homes, staff have understandably faced difficulties in administering care where families are concerned about infection risks associated with entering the property.

39. Death and dying has been at the epicentre of the pandemic, often occurring quite suddenly and in ways that no advanced care plan could reflect. Health and care staff, including hospice staff, are among those who need extended support around bereavement and loss. Work must be done to understand the psychological impact of operating in new ways during the pandemic. For example, surrounding concerns that have been raised in the increased number of Do Not Attempt Resuscitation (DNAR) notices or the increased flexibility under the Coronavirus Act 2020 around who can certify death.

40. Hospice UK believe the risk of not swiftly analyzing and responding to the impact of the pandemic on staff would be significant. In a question responded to by 71 hospice chief executives and leaders, three fifths (59%) told Hospice UK they were concerned clinical staff will consider leaving the workforce due to stress or exhaustion should there be a second wave of COVID-19. In children’s hospices there is already a nursing vacancy of 12%, while there are just 15 children’s palliative care consultants in the UK when there should be 40-60.[9]

• We recommend that employers across health and social care settings promote anti-stigma messaging encouraging people to reach out if they need support. It is important that staff are encouraged to not ‘just carry on’ if they are feeling burnt out, as over time this could lead to them experiencing mental health problems. 

• We recommend that all employers across NHS and social care settings promote the Our Frontline campaign to their staff: www.ourfrontline.org.uk.

• We recommend investment in mental health services specifically for NHS and social care staff who may be experiencing trauma following COVID-19. These staff need access to this support as soon as the need is identified.

• We recommend that mental health training is embedded as a core part of new staff members induction, including adequate evidence-based training and tools to strengthen their resilience.

• Community-based health and care providers such as hospices and care homes must be provided with immediate and on demand supplies of testing that can be carried out on site.

Question 3: 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?

Please see response to Questions 1 and 2 above.

Question 4: What are the impacts of workforce burnout on service delivery, staff, patients and service users across the NHS and social care sectors? 

Please see response to Questions 1 and 2 above.

Question 5: 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?

41. Ensuring there is the right workforce in place is critical for enabling the effective delivery of health and social care services and for minimising the risk of burnout for those working on the frontline. The UK Government and NHS England must set out a clear strategy for the recruitment and retention of health and social care staff and corresponding investment to enable the delivery of that strategy.

42. Effective recruitment and retention is critical for ensuring that staff have manageable workloads, which enable them to deliver the care that we would all hope to receive when unwell. For example, a survey of mental health staff by the British Medical Association, published in January, highlighted that four in ten found their workload “unmanageable” or “mostly unmanageable” and over 50% said they were too busy to provide the care they would have liked to on their last shift.[10] These pressures will have been exacerbated during the COVID-19 pandemic.

43. As part of the recruitment strategy, the UK Government and Health Education England must focus on areas of the workforce which are currently facing the greatest challenges, such as mental health services. Recent workforce forecasts from Health Education England indicate that only 71 additional consultant psychiatrists will be added to the mental health NHS workforce by 2023/24 against a requirement of 1040, while only 257 mental health nurses will be added to the NHS workforce by 2023/24 against a requirement of 7,000.[11] If the Government fails to address workforce shortages in these areas, they will leave some parts of the workforce at greater risk of burnout.

44. We would also encourage a focus on primary care. The Nuffield Trust report that last year across the UK, the number of GPs relative to the size of the population has fallen in a sustained way for the first time since the 1960s. They report this fall reflects insufficient numbers of GPs previously being trained and going on to join the NHS; failure to recruit enough from abroad; and more practitioners leaving for early retirement.[12] Pressures on the primary care workforce will have been further exacerbated by COVID-19, making it even more important to ensure there is a clear plan in place for recruitment and retention of staff.

45. Any workforce plan should consider not only statutory services, but also the voluntary and community sector who play a critical role in the delivery of health and care services. Mind’s Local Mind Network alone supported almost 400,000 people across England and Wales in 2018- 19. In the hospice sector an estimated 125,000 volunteers provide millions of hours a year, covering a range of key roles that frees professional capacity elsewhere and which enables hospices to reach everyone who needs them. Their value is estimated to be worth over £200million to hospices in the UK a year. During COVID-19, volunteering has been badly affected in the hospice sector. Many volunteers are in the age group initially asked to shield by the UK Government, while measures around infection control and social distancing have meant many volunteering roles have had to be paused or reconfigured. Often the additional workload this creates will fall on professional hospice staff, and consideration will be required across health and social care as to how volunteers will be supported to safely reintegrate into roles, both pre-existing and new.

• The UK Government must publish the full NHS People Plan as a matter of urgency, setting out plans for the recruitment of health and social care staff and set out a long-term strategy for investing in the health and social care workforce in the forthcoming Comprehensive Spending Review. These plans must also incorporate the role of the voluntary and community sector.

Question 6: To what extent are there sufficient numbers of NHS and social care professionals in training for service and resilience planning? On what basis are decisions made about the supply and demand for professionals in training? 

46. Any workforce plan should also have a significant focus on looking ahead to assess what staff will be needed to deliver health and care services in the future. This includes significantly expanding medical school places to deliver a sustainable supply of doctors. For example, as highlighted above, one area where there is a need to increase the supply of training places is primary care and the Conservative Manifesto pledged to increase the GP workforce by 6,000 by 2024/25.[13] While this is a commendable aim, the Royal College of GPs argue for this target to be met then 5,000 GPs need to be trained a year, as opposed to the 3,500 training places currently available.[14]

47. The Royal College of Psychiatry is calling on the UK Government to use the Spending Review to double the number of medical school places in England, at an estimated cost of £3.942bn by 2028/29. Building on the need to focus on the areas of the workforce where there are the greatest challenges, they are also calling for those places to be allocated to medical schools that have a clear plan to encourage more students to choose a shortage specialty, including psychiatry.[15]

48. There also needs to be a rapid expansion of training places for mental health nurses, social workers, occupational therapists and psychological professionals as well as the new roles set out in the Long Term Plan, such as peer support workers, nursing associates, physician associates, primary care mental health practitioners and social prescribing link workers.

• As part of workforce planning, the UK Government must ensure there are sufficient numbers of NHS and social care professionals in training and particularly prioritise areas of the workforce which are currently facing the greatest shortages.

Question 7: 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? 

49. Many of the measures under the ‘invest in our physical and mental health and wellbeing’ section of the 2021/21 interim People Plan, don’t go far enough in explaining ‘how’ employers could implement the measures. They also don’t go far enough in tackling some of the root causes of poor mental health and wellbeing across the health and social care sector such as high levels of stigma (including self-stigma), lack of trust, poor workplace culture etc. (see answer to question 1).

• As highlighted above, we recommend all employers across NHS and social care settings adopt the Mental Health at Work Commitment: www.mentalhealthatwork.org.uk/commitment 

50. We are pleased to see that every trust is required to have a Wellbeing Guardian, but seek further clarity on what this role entails, who is responsible for deciding the selected guardians are and how the success of this role will be measured. There should be a better understanding of how accountability will be measured and what success will look like across the NHS in terms of staff mental health and wellbeing.

51. We are also pleased to see that every member of the NHS should have a health and wellbeing conversation and develop a personalised plan. However, currently it states that the plans should be reviewed annually. Conversations about mental health and wellbeing need to happen much more regularly than once every year. They should be embedded and ongoing, not a one-off tick box conversation. This should be mandatory.

• We recommend all NHS and social care staff complete a Wellbeing Action Plan, which is reviewed at a minimum on a quarterly basis.[16] 

52. We appreciate the acknowledgement that employers should make sure line managers and teams actively encourage wellbeing to decrease work-related stress and burnout. And to do this, they must make sure staff understand that they are expected to take breaks, manage their work demands together and take regular time away from the workplace but do not feel reassured that this will happen in practice if workload is not tackled. Simply asking employers to do this, without tackling the root cause effectively, will only lead to higher stress and burnout for line managers.

53. We are also keen to see the interim people plan go further in outlining how it will support individuals to build their own resilience and what training/tools will be provided to do this. If we are assuming that individuals need to take some responsibility for their own resilience, then providing them with the tools and techniques to do this must be a priority. 

• As above, we recommend that employees across the NHS and social care are given adequate evidence-based training and tools to strengthen their resilience.

• We recommend that an employee mental health and wellbeing measures are revisited, and a new matrix is developed, across health and social care, which measures progress and improvements nationally.

Question 8: 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?

54. 40.3% of NHS staff who took the staff survey in 2019 reported feeling unwell as a result of work-related stress in the last 12 months. This proportion has been steadily increasing since 2016 (36.8%). Within this time there have been many programme, services and initiatives put into place to support staff, but things are not improving.

• As above, we recommend all employers across NHS and social care settings adopt the Mental Health at Work Commitment: www.mentalhealthatwork.org.uk/commitment to tackle the root causes of poor employee mental health.
• As above, we recommend that the recommendations set out in Health Education England’s NHS Staff and Learners’ Mental Wellbeing Commission are adopted as a priority.
• As above, we recommend that the recommendations set out in the Mental Health and Wellbeing of Nurses and Midwives in the United Kingdom report are adopted as a priority.
• We recommend NHS England consult with Our Frontline partners fully before publishing the full NHS People Plan to ensure that the section on mental health and wellbeing is guided by experts and focusses on tacking the drivers of poor mental health.

55. The staff survey also showed that 56.6% of staff said they had gone to work in the last three months, despite not feeling well enough to perform their duties. This puts both staff, and their patients at risk. Staff should be encouraged to take time off if they are feeling unwell, if we are to mitigate against workforce stress and burnout, This requires not only a culture which supports people to take time out, but also ensuring the workforce is properly resourced as otherwise staff may feel even greater pressure to come into work, to avoid their already over-stretched colleagues having to cover for them, impacting on them and their patients.
56. Commissioning services based on population need to reduce existing pressures: This submission has underlined the growing demand on health and care services. Supply is not keeping up with demand, and many of the associated stressed fall on the existing workforce. More must be done to gather relevant data and apply modelling based on population need both now and, in the future, and to ensure appropriate resource is available to back up commissioning of services that match identified requirements. This includes the supply of the number of workers needed, paid at a level which befits the skills required.
57. Parity of esteem and pay for care workers: The groundswell of public support and high opinion of care workers during the pandemic has been very positive. However, well wishes must be followed up with a more meaningful move from the UK Government to back those care workers with improved terms and conditions, providing greater parity with health service counterparts. In 2018/19 the average hourly rate for sales assistants in the retail sector of £8.20, is higher than the average rate for care workers.[17] Care worker pensions, maternity leave, training offer and holiday entitlements tend to lag far behind workers employed by the NHS. Plans for a recovery post COVID-19 must seek parity in these areas.
58. Availability of 24/7 support Moving forward health and care staff must have access to 24/7 support, such as the offer made through Our Frontline. Hospice UK is also providing a counselling and trauma telephone and email helpline during the crisis. This started at the beginning of the pandemic as a NHS funded helpline for NHS staff. It expanded in July 2020 thanks to funding from the Royal Foundation and is available nationally for any frontline staff who want to receive emotional support to deal with the impact of the crisis. It is now for all NHS, care sector staff and emergency service workers.
59. The free and confidential service provided by Hospice UK is delivered by Just ‘B’ who are located in North Yorkshire at St Michael’s Hospice.  It provides a network of specially trained staff and counsellors with bereavement, trauma and emotional support experience, working within the British Association for Counselling and Psychotherapy Ethical Framework for Good Practice. The service is responsive to faith, individuality, culture and community including providing a Tagalog speaking therapist service to support the large numbers of NHS and social care staff from the Philippines. Calls so far have tackled issues like anxiety, physical health concerns and feelings of isolation, as well as bereavement, stress and trauma.

Sept 2020