Written evidence submitted by The Academy Trainee Doctors’ Group (WBR0058)

Who we are:

The Academy Trainee Doctors’ Group (ATDG), a committee of the Academy of Medical Royal Colleges, brings together the Junior Doctor representatives of the Medical Royal Colleges and Faculties and provides a collective informed, balanced, representative voice on issues affecting Trainees. All members of the group have been elected by their respective College or Faculty. Officers are elected from amongst the Group membership.

Trainee doctors, those who are not Consultants or Staff Grade/Associate Specialists, constitute around half of the medical workforce in hospitals and around a third of the NHS medical workforce overall.

This statement is further to the submission from the Academy of Medical Royal Colleges. Our submission focuses on trainees rather than the medical profession as a whole.

Key Points

• Even prior to the pandemic trainees were increasingly looking at ways of working both more flexibly and fewer hours because of workplace stressors
• This had been recognised as an increasing need by multiple key stakeholders looking to make flexible working throughout medicine a reality
• The pandemic has affected trainees in numerous ways including with increased levels of burnout, moral injury, PTSD, anxiety and depression. These issues, coupled with a number of other surrounding changes, all significantly negatively impact wellbeing
• Prior to the pandemic trainee wellbeing was significantly lower than that of consultant colleagues and consultant wellbeing was significantly below that of the wider population
• 66% of physician trainees have considered working less than full time[i], the vast majority would be expected reducing their working hours by 20% - this would require an increase in workforce of more than 10% purely to maintain the current whole-time equivalent
• Trainees are working significantly beyond their rostered and paid hours - despite there technically being systems in place for these hours to be paid this isn’t widely happening
• A number of trainees, especially those in more junior grades, wouldn’t recommend their jobs to prospective colleagues
• Enhanced decision-making support, especially out of hours, should become routine for complex decisions
• Time to ‘decompress’ needs to be built into working patterns including during and after the working day
• The relationship between trainee and trainer is one of the key factors influencing trainee satisfaction and the last decade has seen a significant decline in protected time for trainers to provide this role. Unsurprisingly trainees regularly report feeling unsupported, poorly trained and inadequately supervised – see GMC National Training Surveys
• Trainees have generally been consulted well at a national level but local levels of engagement have been hugely variable with significant numbers of trainees feeling decisions about them are being made without their involvement
• There is marked variation from specialty to specialty regarding how training and trainees have been affected by COVID
• Some trainees, particularly those at critical career progression points, needing exams, shielding or working in unfamiliar environments have been markedly adversely affected by COVID
• Local rostering should try and maintain consistent teams, which builds integral support, as much as possible

Reason for submitting evidence:

As representatives of a large proportion of the medical workforce from across the range of medical specialties we are well-placed to provide evidence to the committee on workforce burnout and resilience in the NHS. During the pandemic we have had academic work on Moral Injury published in both the BMJ and Occupational Medicine and our documents on trainee redeployment[ii] and subsequently returning the NHS to normal[iii] placed trainee wellbeing at their centre.

Submission:

The ATDG is concerned about the longer-term prospects for the medical workforce in terms of burnout and believes that the emergence of the current pandemic raises considerable concerns for the wellbeing and sustainability of the NHS workforce whilst also providing, in these awful circumstances, an opportunity for collective effort to resolve longstanding problems.

The language around psychological distress in the NHS workforce has evolved over time. We fear that terms like burnout - and particularly resilience when applied to individuals as opposed to systems - can attribute the problem to internal failings of individual health workers. We prefer the term “moral injury” as it more accurately frames the problem as being driven predominantly by external factors.

We have expressed our concerns previously about moral injury among doctors.[iv],[v] Moral injury arises from the moral distress that individuals feel when constrained from doing what they believe is the right thing by external factors, such as resource availability. Resource limitations cause unsatisfactory choices to have to be made – leading to moral distress upon moral distress, with limited time to process what has happened. This reduces tolerance for further moral dilemmas. This build-up of ‘moral residue’, those niggling doubts about the finely balanced decisions made, can result in moral injury.

Moral injury leads to some of the symptoms which have been called burnout. Doctors, who have generally entered the profession for altruistic reasons, are at risk of becoming cynical, emotionally distant and easily fatigued by the constant demand on their empathy.

Moral injury is not the only work-related cause of such symptoms. Being constantly overworked and stressed increases the risk of depression, anxiety disorders and can, put simply, cause poor performance and sickness absence. The NHS needs staff that are well and at work to deliver effective, quality care for patients. Rota gaps are endemic throughout the NHS which makes it difficult to provide a safe service. They also, importantly, prevent the feeling of being in a secure, supported environment in which to train to become a Consultant. Increases in the numbers of medical students are welcome, but will take at least 5 years to result in increased workforce availability and even longer than that to increase the Consultant workforce.

Historically efforts to manage the NHS workforce have felt more reactive than proactive, more about treatment than prevention. This, alongside our understanding of the mechanism of moral injury and of work-related mental ill health and distress, brings us to suggest 3 preventative approaches.

The first is that trainee doctors should have better support with their decision making, particularly in the complex cases which are likely to present themselves this winter. Decision making in medicine, as in life, lies on a spectrum of complexity. Simpler decisions can be made quickly, reliably and without significant psychological stress by most doctors. However, as the complexity of the decision increases, the need for involvement, be that remotely or in person, of senior staff with both the experience and expertise to make decisions rises in proportion. There is a risk during the pandemic, if resources are again stretched this winter, that the most complex decisions such as resource-constrained escalation to intensive care will occur more than they ever have before. These decisions are less typical of usual practice and will carry a burden of not being able to deliver the most satisfactory care and treatment for individuals. Such decisions are therefore highly morally distressing.

Sharing moral responsibility with other clinicians should reduce the intensity of dilemmas and the build-up of moral residue. A degree of moral disengagement and diffusion of responsibility is likely to be protective to the person’s wellbeing in situations where difficult choices sometimes have to be made. We believe that there should be processes in place for the rapid review of the most ethically challenging decisions and there may be a role for local clinical ethics committees, their members or for lecturers in medical ethics in providing this.

We are aware that efforts have been made across the UK to increase capacity and resource to reduce the need for decisions to be made on the basis of resource allocation alone but, in the longer term, we need more senior doctors to be able to support the most complex decision making which will always happen in medicine. Given the inbuilt delay in training new doctors in the UK, we would suggest that we need to make the NHS desirable to work in so that it is competitive with other world health systems in attracting senior medical talent.

The second approach is to improve the underlying psychological health of the workforce. Trainees need to feel supported and valued by their colleagues and employers. We need to give healthcare professionals time and a safe space to rest, and to be able to talk about their experiences, if they wish to do so. A lack of time to process events is key to the build-up of moral residue and the development of moral injury. Time to ‘decompress’ should reduce the risk. We must recognise that repeated long, intense shifts, and making decisions overnight, whilst being expected to work the next day, are not conducive to this. We believe that a better job needs to be done of balancing and varying the intensity of working environments for individuals. The experience of our members in Psychiatry suggests that we explore the principles of Acceptance and Commitment Therapy, several of which would seem to be relevant and could be utilized pre-emptively to promote psychological good health. These principles are:

• cognitive defusion - seeing thoughts as they are, not as what they say they are - with alternatives to rumination on events which can otherwise lead to concrete, but false, beliefs developing
• acceptance of challenging situations and noticing the emotions that come with them
• increasing contact with the present moment and having common core values as a team.

These require time and space to “decompress” to be built into our working patterns. As things stand, we are aware that Trainees often use routes such as Less Than Full Time (LTFT) working to achieve the sort of respite that should be available to all NHS workers. At present, 15% of the Trainee workforce is LTFT. Just prior to the pandemic around 50% of Trainees wanted to take up expanding opportunities for LTFT – in the past this was only open to Trainees on health or family grounds, but there is a commitment in England in the People Plan that there will no longer be such requirements to accessing LTFT working. The vast majority of that 50% want to work 80% (4-day week). This has the potential to reduce the Trainee whole time equivalent by around 10%. Even to stand still therefore a 10% increase in medical student, and ultimately junior doctor, numbers would be required. Consultants have been shown to have lower levels of wellbeing than the wider population and trainees have lower levels of wellbeing again. If we cannot boost the number of Trainees in the NHS, then it will simply be impossible to provide a psychologically safe and secure workplace for Trainees to work in, and the brain drain with long term sickness absence and doctors leaving the UK will continue – compounding the problem further.

The pandemic will undoubtedly have had a significant negative impact on the psychological wellbeing of Trainees. We have already seen great uncertainty and distress brought about by the cancellation of Trainee interviews and major changes to the process of appointment to training posts and to high-stakes postgraduate examinations. Training opportunities, already challenging for many to access reliably, have been reduced further by the loss of a lot of face to face teaching and by major reductions in elective work – especially in surgical specialties. Those opportunities are vital for Trainees to be able to progress in their chosen profession, and increased difficulty in obtaining them will only serve to compound work-related stress yet further.

The final approach that we suggest is that, as far as possible, people work consistently within the same team. Doctors are much better at identifying others’ distress than they are their own and we need colleagues who know us and how we work to be able to recognise that we are struggling. Working and sharing breaks with the same team means working with colleagues you know, can rely on, and allows development of mutual support and reduction of emotional and moral distress particularly if difficult decisions have to be made quickly. Especially for the most junior doctors, having a clear team structure lets people know who to call when help is needed, and that it is always OK to call for help. This increases the resilience of both the individual and the system in which they are working.