Written evidence submitted by The Nuffield Trust (WBR0064)
The Nuffield Trust is an independent health think tank. We aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis and informing and generating debate.
This brief submission aims to support the Committee’s inquiry by surveying the limited data available to shed light on staff burnout and resilience before and during the coronavirus pandemic, and by assessing the measures in the 2020 People Plan as a response to these issues. It does not address the question of how this plays out for individuals or in specific workplaces: members of staff, representative bodies, and NHS trusts will be well placed to offer responses shedding light on these important questions.
We show that there is evidence of significant workforce problems associated with what might be seen as burnout, and some evidence of it worsening during and before the pandemic. While the recent People Plan does signal a positive direction, there remains a great deal to be done to address this issue.
1. Evidence and indicators for resilience and burnout
1.1. Objective evidence for patterns of burnout and staff mental and physical wellbeing is limited. Along with the staff survey collecting NHS workers’ views on specific aspects of their experiences, data is nationally collected and published on sickness absence, and on staff leaving the service.
1.2. The 2019 NHS Long Term Plan included an ambition to reduce sickness absence in the NHS to that of the public sector average (2.9% in 2016).[1] However, even before Covid-19, absence rates in the NHS were still exceeding this, and showing little sign of improvement.
The staff absence rate in the NHS in April 2020 was the highest since records began[2]: 2.1 percentage points higher than the same month last year, and exceeding even winter peaks of sickness absence over the last 11 years. Many clinicians were exposed to patients with Covid-19 in this period, and those experiencing symptoms of coronavirus were required to self-isolate. There were also concerns about staff wellbeing relating to the significant shortages in personal protective equipment (PPE). 
1.3. Regionally, the pattern largely follows the national picture. However, as the chart above shows, staff in London, who historically have had the lowest rate of sickness absence, saw a 3.9 percentage point increase since the same time last year, and had the highest absence rates in the country. This parallels evidence that London experienced a higher rate of coronavirus than other regions in the general population.[3] All other regions also experienced large increases in staff absence. The exception was the South West, which also had the lowest number of Covid-19 cases among the general population.
The reasons for sickness that were recorded further support a direct link to the pandemic[4] – with over 40% of absences in April attributed to either ‘cold, cough or flu’, ‘chest and respiratory problems’ and ‘infectious diseases’. The psychological wellbeing of staff also contributed to high levels of absence: this was the reason for over a fifth of sickness days taken.
1.4. There is now data available covering January to March 2020 which details the reasons for staff leaving their role altogether, although not yet for the peak of the pandemic.[5] Although around 13% of those recorded leaving do not have a reason specified, once these unknowns are excluded, 15.1% of NHS professionals cite work-life balance; incompatible working relationships; voluntary early retirement; health or having adult or child dependents as reasons for leaving. The proportion leaving for these reasons has increased over the last decade, from typically below 10% between 2011 and 2013. The total in the last financial year, 2019/20, exceeded 28,000. In the last two quarters, more people were recorded leaving NHS roles for reasons of work/life balance than because they reached retirement age.
Whilst there is not a category which explicitly states an individual has left because of burnout, these groups may be used as a proxy for this. Leavers for these reasons tend to be less prevalent during the summer, suggesting a link with pressure on the service.
1.5. Over half of professionals leaving their role resigned voluntarily. This may be because this includes staff moving between NHS organisations, rather than just those leaving the NHS entirely. However, excluding this category may underestimate the true number of those leaving due to burnout, since it is plausible that some staff choose to move organisations for this reason.
2. The NHS people plan and possible future actions
2.1. There is much to be welcomed in the People Plan for 2020/21[6]. The recommendations are grounded in existing good practice across the NHS. There is real focus on the physical and psychological wellness of staff, and on addressing systemic inequalities.
But there are two factors which mean that this plan on its own is unlikely to address the issues of resilience and burnout sufficiently in the short term.
2.2. Firstly, ahead of the Spending Review, it explicitly excludes discussion on plans to expand the workforce significantly, and to ensure that education and training is fit for the long term. This means that staff are continuing to work in an environment where there are significant levels of vacancies, which is stressful in itself. There is also a need for a clear and costed plan to address the serious staff shortages in the NHS in the long term. Although that will not directly help staff coping with those shortfalls now, it would provide a sense of hope, which is often one of the most important factors underpinning resilience.
2.3. In addition, the People Plan was published in the same week as the 'Phase 3 letter' from NHS England setting out expectations for service delivery for the next 6-12 months[7]. Although the drivers of the ambitious targets set out in that letter are understandable, we and others have already written extensively about the challenges the NHS will face in a return to anything like normal levels of activity due to the demands of infection control.[8] As a result, there is a risk that staff who are already weary feel that the standards to which they are being held are unrealistic. This could mean that recent successes in recruitment and retention are lost, both by staff actively choosing to leave the service, and via increased levels of sickness absence in those who remain.
There is a real need for a realistic assessment of the levels of activity which can be delivered over the coming months, and an honest and open conversation with the public about this at both local and national levels.
2.4. The direct impact of coronavirus should also be taken into account. Just as reasonable adjustments are made for staff with long-term conditions (such as musculoskeletal disorders), there must also be concerted action taken to support staff who have experienced stress and trauma due to the additional work they took on during the pandemic. The People Plan mentions the establishment of resilience hubs to ensure staff are well-supported.
2.5 As the People Plan acknowledges[9], there has been a long term concern in the NHS about bullying, the problems of creating working environments where staff feel safe (both psychologically and physically), and the difficulties of helping staff deal with the often emotionally challenging nature of their work. The plan does acknowledge these issues and has a number of concrete ideas for addressing them.
But this is not the first time that many of these sort of proposals have been made and the persistence of the problem suggests that there are more fundamental causes that have not been properly addressed. It is likely that some of these are inherent to the nature of healthcare, such as the stress associated with caring for people. The adoption of measures such as Schwartz rounds[10] are a helpful recognition of this.
Others causes may be associated with the way the NHS is managed, and addressing them would requires changes in culture at all levels. This is more difficult to achieve particularly given the long standing preference for top-down performance management. Progress will require us to look at the way policies of all sorts are implemented in the service, rather than narrowly at those explicitly relating to staff wellbeing.
Sept 2020