Written evidence submitted by The General Medical Council (WBR0072)
Our role
The GMC’s role is to protect patients and improve medical education and practice across the UK. As part of this, we decide which doctors are qualified to work in the UK, we oversee UK medical education and training, and we set the standards that doctors need to follow throughout their careers. We also take action where necessary to prevent a doctor from putting the safety of patients – or the public’s confidence in the profession – at risk.
Overview
We are very pleased that the Health and Social Care Committee has launched an inquiry into this important issue. We know that successfully managing and reducing levels of professional burnout is fundamental to patient safety, and it is now a key issue for the health service to address in order to retain its workforce. This is more important now than ever given the significant uncertainties around international recruitment during the current coronavirus pandemic and what our data tells us about how workload and burnout can drive doctors out of the workforce or force them to reduce their working hours.
In 2018 we asked Professor Michael West and Dame Denise Coia to carry out a UK-wide review into the factors which impact on the mental health and wellbeing of medical students and doctors. The subsequent report, Caring for Doctors, Caring for Patients, which they published last year noted that in two studies doctors who had high levels of burnout had “between 45% and 63% higher odds of making a major medical error
in the following three months, compared with those who had low levels”[*]. In order to bring about positive change on workforce burnout, it is vital that there is a renewed focus within the health service on the importance of doctors’ health and wellbeing, as well as fair and supportive working environments, teamworking and effective leadership.
The coronavirus pandemic has resulted in significant and sudden changes for our health service and in wider society. As the regulator of doctors in the UK, we have been doing everything in our power to support the health system, ease pressure on the profession and protect patients during this challenging period.
We are pleased that this inquiry will further contribute to the body of evidence around the various drivers of workforce burnout, and the ways that it may be mitigated or prevented in the future. We are hopeful that the inquiry will ultimately lead to a stronger emphasis on induction, which not only has an important role to play in supporting productivity but can also help to promote a supportive and inclusive workplace, particularly for black and minority ethnic (BME) doctors. We commissioned independent researchers, Community Research, to carry out a piece of work last year to help us better understand issues affecting doctors’ induction, including for those who were returning to practice. Some of the key findings from this research was that the impact of poor induction was often linked to the effect it has on doctors and their wellbeing, and that poor induction is also a possible contributing factor to poor patient safety as doctors who feel ‘out of their depth’ are more likely to make errors.
We also hope that the inquiry will strongly support the principle of greater regulatory alignment. Recent public inquiries such as the Paterson inquiry and the Independent Medicines and Medical Devices Safety Review have underlined the need for regulators to collaborate and to share information more effectively in the interests of patient safety and quality. We are working increasingly closely with both system and professional regulators with a shared ambition to align our views around leadership and enabling more supportive working environments. Collaboration of this kind needs to take place at both national level (developing joint approaches to policy questions) and locally (e.g. joint approaches to support a particular NHS trust or service).
Finally, we believe that having a more flexible legislative framework for professional regulators which enables fitness to practise cases to be faster, fairer and fewer would benefit morale in the NHS. It would allow regulators to focus on the highest risk cases, remove unnecessary stress from the workforce, and allow us to divert more resources to supporting doctors in other ways.
The state of medical education and practice in the UK report 2019
1 Each year the GMC publishes a report on The state of medical education and practice. This annual report gives us an in-depth understanding of the experiences of the medical workforce in any given year through detailed data and research. The report also gives us some insight into the prevalence and impact of workload pressures, stress and burnout for members of the medical profession.
2 Our report in 2019 for example noted that:
- Over a quarter (28%) of doctors reported feeling unable to cope with their workload at least once a week. There was also evidence of how these pressures have had an impact on patient care and safety.
- GPs are at particular risk of burnout due to these pressures and two thirds (65%) of GPs reported working beyond their rostered hours every day.
- Feelings of burnout are associated with doctors finding it difficult to provide patients with a sufficient level of care, and also with doctors taking hard steps toward leaving the profession.
- Two thirds (65%) of doctors at high risk of burnout said they’ve found it difficult to provide a patient with a sufficient level of care at least once a week over the previous year.
- Just over half (52%) of doctors with high burnout risk have taken hard steps toward leaving the profession, such as contacting a recruiter, applying for other roles outside medicine, or attended training for a new role.
3 Our 2019 report also noted that more flexible working patterns and training pathways can help to protect against burnout, and that being unprepared for postgraduate training early in a doctor’s career is associated with a higher risk of burnout for at least the subsequent six years. Other significant protective factors reported in the 2019 report included a good workplace culture of team working, support systems being in place at key points of a doctor’s training and career, supportive management, and effective leadership.
4 It is clear from all of this evidence that many doctors feel unable to strike the right balance between their own wellbeing and delivering the care they wish to.
5 It is crucial that doctors are practising in workplaces that support their wellbeing. The system must work together to better plan and resource clinical leadership, spread good practice in supporting the wellbeing of its diverse workforce, and improve induction and support for doctors who are new in a role or new to an organisation.
6 Good inductions to new roles, teams and employers, more time for training and more flexible opportunities for development can all be vital in achieving high standards of care and inclusive work environments, and these will be necessary in supporting an increasingly mobile and flexible workforce.
7 The UK-wide review of medical students’ and doctors’ wellbeing Caring for doctors Caring for patients has pressed for safe, nurturing environments where doctors work in well-led multidisciplinary teams. There is an emphasis on letting doctors have more say in how their teams are run and the work they do, as well as on the importance of good support and supervision, and a manageable workload.
8 This year we are developing analysis and insight to ensure our report takes account of the context of the coronavirus pandemic for the medical profession and the system. As part of this we will be reporting on doctors’ workplace experiences in 2020 through a barometer survey. This year’s questionnaire includes additional elements to investigate doctors’ experiences of working during a pandemic.
National training survey 2019
9 Our national training survey in 2019 noted that over a fifth of trainers and trainees reported that they felt burnt out to a high or a very high degree. Over half of both cohorts told us they always or often feel worn out at the end of the working day. Our analysis of the responses to questions on burnout in our national training survey in 2018 had suggested that burnout may be associated with high workloads, the impact of rota gaps, and lack of a supportive work environment.
Completing the picture survey
10 The Completing the picture survey ran between 21 January and 10 March 2020, before the peak of the coronavirus pandemic. It was conducted in partnership with Health Education England (HEE), the Department of Health (Northern Ireland), NHS Education for Scotland (NES) and Health Education and Improvement Wales (HEIW). We surveyed 13,158 doctors who had previously practised clinically in the UK but who weren’t doing so at the point of completing the survey. We asked them a series of questions about why they decided to stop practising or left the UK to practise elsewhere.
11 The survey’s results have been weighted and are consequently generalisable to a population of 91,313 doctors, this means that each of the below percentages can be considered as a proportion of 91,313 doctors. The survey results won’t be published until later this year but some of our initial findings are relevant to the inquiry’s call for evidence.
12 The results showed:
- 35% said they would like to return to practising medicine in the UK in the future, but only 24% thought they would be likely to do so (please note these figures were collected pre-COVID-19 so intentions may have changed). Of those who said they would be likely to return only 10% were in the UK, while the vast majority (90%) were abroad
- For 27% of doctors ‘Burnout/work related stress’ was a factor in why they left UK practice and for 35.7% ‘Dissatisfaction with previous role/ place of work/ NHS culture’ was a factor
- Further, for 21% ‘Past experiences of burnout/ work related stress’ was a barrier to them returning to practise in the UK and for 26% ‘Dissatisfaction with previous role/ place of work/ NHS culture’ was a factor
The state of medical education and practice barometer survey
13 In 2020 we commissioned IFF Research to carry out a survey of a representative sample of 3,693 doctors in the UK. The survey was in the field in June and July 2020[†]. The data are still undergoing quality assurance checks. We are sharing the data in broad rounded terms at this early stage to inform the inquiry, but on the understanding that final checks on things such as the weighting of the data may change the figures we will be publishing in more detail at the end of the year.
14 The survey included questions from the Copenhagen Burnout Inventory[‡]. For each of the questions there are a series of response options which indicate a risk of burnout. In broad terms the provisional results suggest:
About six out of ten have a very low risk of burnout
About two out of ten have a low risk of burnout
About one in ten have a moderate risk of burnout
A further one in ten have a high risk of burnout
15 Doctors most often gave negative burnout responses around the physical and emotional toll of their work with:
over two fifths reporting that they always or often feel worn out at the end of the day
nearly two fifths reporting that they find their work emotionally exhausting to a high degree.
16 There are indications that some of the profession have had a lower risk of burnout during 2020 so far, compared to our 2019 survey. The overall number who often or always ‘feel worn out at the end of the day’ is down from 63% to just over two-fifths. This should be interpreted with significant caution however for a range of reasons - this is still concerningly high, and different areas of practice and different geographical areas are affected very differently, so a national average figure may not represent the experiences of the profession well. We are currently beginning further analysis to understand where burnout is higher and where it is lower.
17 According to the survey, doctors who reported being satisfied with their day to day work were more likely in 2020 to say that they enjoyed their work or found their job fulfilling and rewarding.
18 The reduced feeling of burnout was seen across several burnout measures, particularly fewer doctors reported feeling often/always worn out at the end of the day compared with 2019. The factors which may be contributing to this are still being investigated, but anecdotal and qualitative evidence (outside of the Barometer survey) suggests that improved team working, a sense of solidarity and shared purpose, and inclusive leadership styles may all be playing a part among other factors.
19 Almost two-thirds of the doctors who do feel worn out at the end of the day have taken active steps to leave the profession, so burnout remains a significant concern for workforce planning and retention, despite the decline in the proportion reporting this since 2019.
20 While any improvements in burnout are to be welcomed and can increase our collective understanding of the drivers of positive wellbeing, burnout levels can nevertheless be highly variable and inconsistent. There is a real opportunity now for further action to be taken to address workforce burnout, but it will require concerted efforts from employers, government bodies, and regulators.
21 We are hopeful that this inquiry will encourage greater regulatory alignment around the issue of leadership and enabling more supportive working environments, and that further regulatory collaboration will be encouraged at both a national and a local level.
Supporting the medical profession
22 The pandemic has reinforced the importance of addressing the environments in which doctors work and the impact of this and systems pressures on medical practice and retention of doctors in the workforce.
23 We are working with partners to improve healthcare environments and cultures. This will attract and retain staff by supporting their wellbeing and enable them to provide high quality and safe patient care.
24 Our supporting a profession under pressure programme is a key part of one of four themes in our 2021-25 corporate strategy, ‘enabling professionals to provide safe care’.
25 In 2019 we published three independent reports which have contributed to the collective understanding of the pressures faced by doctors and the healthcare system and some of the solutions. The three reviews looked at:
Gross negligence manslaughter and culpable homicide in medical practice
Why some groups of doctors are referred for fitness to practise concerns, more or less than others
The wellbeing of doctors and medical students across the UK.
26 The reports evidenced the impact of these pressures on staff burnout:
Impact on health and wellbeing of doctors/ staff
“there is abundant evidence that workplace stress in healthcare organisations affects quality of care for patients as well as doctors’ own health.” [§]
Impact on patient safety
“Doctors with high levels of burnout have between 45% and 63% higher odds of making a major medical error, compared with those who have low levels.”[**]
27 The issue of workforce retention in the NHS is an important consideration too. Before the COVID-19 pandemic, in England alone there was a workforce shortage of around 100,000 staff across the NHS and nearly one in five doctors were considering leaving the NHS altogether.[††]
28 These findings highlight the link between workplace stress and patient care, as well as the likely implications for workforce capacity and the resilience of healthcare systems. They also reflect our wider regulatory role to protect, promote and maintain the health, safety and wellbeing of the public.
29 Prior to the pandemic, we were making progress to deliver the recommendations for us and, in February 2020, we held roundtables in each of the four countries of the UK. These events brought together leaders from across the UK’s health systems to discuss the reports and recommendations, and to identify areas for action. While discussions and priorities varied in each country, reflecting local issues and environments, participants across all the events agreed to support a collective, system wide response to deliver change.
30 Our partnership working was paused due to the pandemic. Over the last few months however we have published information to support doctors during the pandemic, responded to requests for support and started to prepare for future work with partners. We are now planning for recovery and have gathered intelligence to ensure our priorities reflect the needs of a post-COVID healthcare system.
31 We were pleased to see the NHS People Plan aligns well to the themes and recommendations in the independent reports that we commissioned. We’re keen to help support the delivery of the People Plan. We will also be looking at what we can do both internally and by working with others externally to deliver the aims of our supporting a profession under pressure programme through UK-wide and country-specific plans. For example, we will be sharing good practice and relevant data and engaging with partners to progress work on specific priority themes, such as Health Education England’s work to improve induction.
32 We were pleased to see an increased focus on wellbeing for doctors and other healthcare staff during the coronavirus pandemic. It is important that the health and wellbeing of healthcare staff continues to be prioritised at both national and local levels for the long-term to help protect against professional burnout.
33 We are also troubled by the inequalities highlighted by the pandemic such as the disproportionate effect of COVID-19 on black and minority ethnic (BME) healthcare professionals. Part of the solution to addressing such inequalities, which have a negative impact on burnout, is to ensure that all staff have a voice and influence at work, including the ability to raise concerns without fear of retribution. Implementing the recommendations of the Fair to refer? report should help address these longstanding inequalities of opportunity and support fair treatment for BME health workers. Additionally, supporting leaders to better care for BME staff is vital (for example by encouraging participation in compassionate leadership programmes, as recommended in Caring for doctors, Caring for patients).
34 More broadly, we would also like to see legislative reform that would grant professional regulators greater flexibility. In particular, we believe that legislative change which would enable our fitness to practise processes to be faster, fairer and fewer would help to ease pressure on the profession and allow us to divert more of our resources into supporting doctors in other ways.
Workforce capacity and flexibility
35 It is crucial that efforts to retain the medical workforce we currently have remain a key priority, particularly as the coronavirus pandemic is likely to have significant impacts on the supply of overseas doctors to the UK.
36 As we set out in previous written evidence to the Committee, the Secretary of State for Health and Social Care wrote to us on 25 March 2020, informing us that the UK-wide emergency powers in Section 18A of the Medical Act (1983) had been triggered.
37 These powers meant that the GMC was able to grant temporary registration to certain groups of suitable people to help supplement doctor numbers and provide cover in a range of roles. Over the proceeding weeks we granted temporary registration to nearly 35,000 doctors.
38 It is critical that these powers are not turned off too early as the pandemic eases and as the NHS moves towards a period of recovery and renewal. Keeping the powers active will allow us to take a phased approach to the removal of temporary registration from specific groups in a staged and managed way rather than all doctors at once when the powers are turned off. This would better support the interests of the current medical workforce and the resilience of the health system during the course of the pandemic and beyond.
39 This could be particularly important given the backlog for services that were paused during the peak of the pandemic, the risk of future peaks of the virus, as well as the wider impact of the pandemic on the physical or emotional health and wellbeing of some members of the medical profession.
40 We are also keen to support the retention of returners who wish to stay in practice and are already undertaking work on how we may be able to support their transition to full registration.
41 A consideration of the skills and scope of practice of the medical workforce is also highly relevant to discussions around health service resilience, contingency planning and patient care. We believe that some skills could be shared more broadly across the workforce, including on public health, healthcare inequalities and the use of technology, and that collecting and sharing information about the skills of the current workforce could better support workforce planning in the future. A stronger focus on cross-specialty learning and generic skills in medical education could support greater flexibility in the medical workforce too, and both our outcomes and our support for greater flexibility across specialties are supportive of this.
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