Written evidence submitted by The Royal College of Obstetricians and Gynaecologists (WBR0073)

Background

1. The Royal College of Obstetricians and Gynaecologists (RCOG) is a professional membership organisation made up of over 16,000 members worldwide. We work to improve health care for women, by setting standards for clinical practice, providing doctors with training and lifelong learning, and advocating for women’s health care.

2. Our response addresses the causes and impact of burnout on clinicians, women and their families within the context of obstetrics and gynaecology (O&G) services in England.

Key points

3. The welfare of the O&G workforce is at the centre of delivering the best care for our patients. The RCOG acknowledges that, like many other specialities, we are experiencing workforce shortages in response to increasing demands and pressures on the service.

4. Key solutions include addressing widespread rota gaps through recruitment and retention of O&G doctors, more flexible working opportunities across all O&G career stages, and addressing undermining and bullying behaviour within the speciality.

5. Within the profession there are many examples of successful team and working practices and sustainable workforce modelling and planning that support healthy working environments for O&G professionals. We must showcase best practice, celebrate and learn from their success.

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? 

6. The NHS was experiencing shortages across the O&G workforce before the COVID-19 pandemic which largely manifests itself in rota gaps.
7. Middle grade obstetricians are those who are in their third year of specialist training and above, and provide around-the-clock direct care, supported by consultants. In 2019, 87% of obstetric units reported gaps in their obstetric middle grade rota.[1] The proportion with entirely unfilled gaps decreased from 43% to 35% between 2017 and 2019, while the proportion requiring locum cover to staff the rota remained the same at 83%.[2] These staff shortages can affect job satisfaction, postgraduate training, quality of care and staff wellbeing.

8. The increasing pressure brought about by middle grade rota gaps is also leading to more units introducing resident consultant working out of hours. This is successful in many units and for some consultants. However others, especially newly appointed consultants, are expressing frustration citing unpredictable work patterns, lost professional development opportunities and a lack of management support from consultant colleagues.[3]

9. The GMC’s 2019 national training survey found that over a quarter of respondents (of any speciality) said it wasn’t rare to lose training opportunities due to rota gaps.[4] Further data collected by the RCOG as part of the NHS Resolution Maternity Incentive Scheme found that across all trusts that responded (66/132), an average of 53% of trainees were losing opportunities due to rota gaps. This has an impact on O&G attrition, job satisfaction and burnout.

10. The RCOG is into its third year of working with NHS resolution on the CNST Maternity Incentive Scheme for Trusts which addresses losses in training due to rota gaps. Using feedback from the schemes safety action no.4 ‘can you demonstrate an effective system of medical workforce planning to the required standard?’, the RCOG is developing a standard action plan template for trusts for 2021, a report to showcasing best practice to our Members, and supporting the development of safety actions for 2021 through advisory group work. In addition to this the RCOG and NHS E will be publishing a locum passport and guidance on the engagement of locums in late 2020.

11. We have also been aware of the pressures on other parts of the workforce for some time. O&G services rely on the significant contribution of SAS (Specialty and Associate Specialist) and locally employed doctors (i.e. those who neither are consultants nor in training posts, but who have postgraduate experience in a relevant specialty and who can contribute to NHS service delivery).

12. There is a significant turnover among this group with around 12% leaving the NHS workforce in England each year.[5] Just over a quarter of SAS doctors and nearly a third of locally employed doctors told the GMC that they feel burnt out because of their work, indicating that this group of doctors are feeling the impact of system pressures.[6] Well over a quarter of all SAS and locally employed doctors said they’ve experienced bullying in the past year.[7] Anecdotal evidence suggests that many leave the workforce due to a lack of career development, professional support and recognition of skills.

13. The RCOG advocates for interventions to retain, reskill and upskill SAS doctors. Please see more about our work for SAS and locally employed doctors, including our national advisory group, on our website.

14. Senior obstetricians and gynaecologists are essential to a well-balanced medical workforce. In recent years the BMJ has repeatedly reported that official bodies, including the BMA, are worried about an impending medical workforce crisis compounded by early retirement.[8]

15. The commonest reasons given by doctors for taking early retirement are pressure of work and reduced job satisfaction. Obstetricians and gynaecologists are among those most likely to cite “out of hours work” as a reason for retiring.[9]

16. The RCOG’s Later career and retirement report made recommendations around supporting doctors who want to remain in the NHS workforce and how to make the later career stage as attractive as possible to all. These include improving the flexibility of job plans, reducing or stopping on call after the age of 55-60 where desired, celebrating skills through teaching and mentorship, reforming pension taxation, improving workplace culture, reducing administration surrounding revalidation, and recognising time needed to use electronic administrative systems in job plans.

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? 

17. Maternity services have been classified as a core service both in the context of the current pandemic and in any potential future waves of COVID-19. As such, it is essential to have in place a sufficiently staffed and supported workforce across maternity, perinatal mental health and health visiting to ensure the physical and mental wellbeing of mothers and their babies. Given the continuous demand for maternity services, the RCOG is clear that staff in these roles should be protected from redeployment as far as possible.

18. Concerned at reports of redeployment of maternity staff, we conducted a survey of our members in May 2020.  The survey found that junior grade trainees, foundation doctors and locally employed doctors were redeployed outside maternity services in 53% of the trusts/units that responded. In almost a quarter of these trusts/units, all junior grade doctors were redeployed without reference to specialty requirements.[10]

19. There have been several consequences of this redeployment. Over 80% of respondents said junior grade doctors had missed out on training opportunities. Consultants and middle grade doctors have been placed under increased and unsustainable stress running a core service without a valuable part of the workforce. More than a quarter reported significantly longer hours for those available to work. There has also been a notable increase in locum use, with 37% of units reporting an increase in the use of internal locums, reflecting the increased pressure on maternity services.

20. Despite the concerns raised, many survey respondents felt that there were also learning opportunities to be found in the response to COVID-19. The most collective positive outcome highlighted was the noted increase in staff morale at all levels and sense of comradery amongst teams.

21. The acceleration of telephone triage, outpatient management and streamlined pathways within trusts to meet demand also had a number of positive effects. Some units reported improved efficiency in their service delivery as senior staff only were doing telephone clinics which resulted in fewer follow-ups.

22. The national focus on NHS staff and other key workers has led to a renewed focus on their health and wellbeing. Some measures will not be sustainable in the long term, but access to improved rest and break facilities, comfortable seating and better parking should be retained. There has also been greater understanding of psychological wellbeing and support for healthcare professionals. Trusts should proactively provide this support for all staff suffering from, or at risk of, stress and burnout, anxiety or a mental health problem.

23. However, these positives may be undermined by the accumulation of a significant backlog of patients awaiting treatment, an issue that is being felt within O&G and throughout the NHS. Staff welfare needs to be kept front and centre in the coming months to ensure doctors do not burn out under the pressure of trying to restore services, especially as the NHS enters winter pressures.

24. For further information on innovation and good practice please see the RCOG’s regularly updated report Restoration and Recovery: Priorities for Obstetrics and Gynaecology.

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?

25. The prevalence of burnout in O&G is one of the highest of any specialty - the number of doctors using our support services continues to grow year on year.  This high level of burnout may be related to the high-acuity and rapid turnover of patients associated with O&G. It is also associated with increased job turnover and reduced workforce retention.[11]

26. A 2020 study found that that two‐thirds of O&G doctors reported exposure to traumatic work‐related events.[12] Of these, 18% of both consultants and trainees reported clinically significant PTSD symptoms. Organisational impacts of PTSD included sick leave, and ‘seriously considering leaving the profession’.

27. A 2019 study into the prevalence of burnout amongst UK obstetricians and gynaecologists conducted by Imperial College London found that found that 36% of doctors who responded met the burnout criteria, with levels highest amongst trainees (43%).[13]

28. The study found that burnout was associated with increasingly defensive medical practice, a negative impact on physical and mental wellbeing “and is strongly associated with depression, anxiety and suicidal thoughts”. [14] This has clear implications for the retention of doctors as well as on the efficiency and sustainability of O&G services.

29. Several UK reports indicate that among doctors, burnout is a factor in early retirement.[15] Our Later careers report  found that reasons for retirement included a lack of flexibility in job plans and on-call, increased pension taxation, not feeling valued, increasing workplace bureaucracy and poor team cultures, as well as concerns that they will not be able to maintain the best possible personal health and wellbeing.[16]
30. Lack of support available for doctors experiencing menopause symptoms can also contribute to feelings of stress and burnout and ultimately lead to early retirement.
31. A recent BMA report on doctors working through the menopause suggests that doctors are sometimes leaving medicine early because they cannot manage their symptoms at work even though they still enjoyed their career.[17]
32. The most common adjustment that respondents had or wanted to make was a reduction in their working hours and the report recommended that this should be made available across all specialities, and for those in, or applying for, senior roles. The RCOG called for the NHS to introduce robust menopause workplace policies in the Better for women report. These policies should detail the reasonable measures that should be available for women experiencing symptoms, including flexible working patterns, physical workplace adjustments and training and support available for line managers.

33. Undermining and bullying behaviour has long been recognised as a problem in O&G. Trainees report more undermining behaviour than any other medical specialty and 64% of consultants say they have experienced or witnessed other consultants being bullied.[18]

34. The RCOG has developed a network of Workplace Behaviour Champions to support trainees and SAS and locally employed doctors deal with unwelcome workplace behaviour such as bullying and undermining, and our Peer to Peer Support Service is available to help consultants who experience similar issues.

35. In conjunction with the Royal College of Midwives (RCM), we have developed a free toolkit to improve workplace behaviours. The toolkit includes good practice case studies of interventions that have reduced the incidence of bullying and undermining behaviours in O&G workplaces at various levels. Plans are underway to revamp this toolkit in 2021.

36. The RCOG and the Royal College of Surgeons of Edinburgh (RCSEd) run an annual anti-bullying event (the next one is scheduled for Wales in 2021) where we explore themes such a civility saves lives, compassionate leadership and how to support medical staff to speak up when they experience bullying and undermining. Plans are also underway to run a joint RCOG/RCSEd anti-bullying and undermining training course for trusts and medical units from 2021.

37. The RCOG, RCSEd and the National Freedom to Speak Up Guardian also lead a national anti-bullying alliance comprising of over 30 healthcare organisations aimed at developing practical solutions to address bullying in the medical workplace.

38. We know that the GMC fitness to practise process can put considerable pressure on the workforce and increase attrition and early retirement rates. A study on the impact of complaints on doctor welfare in the UK demonstrated that they are associated with an increased risk of depression, anxiety and suicidal ideation as well as increased defensive practice.[19]

39. The RCOG runs an Expert Opinion Service to help doctors and their employers to resolve complaints locally or enable Trusts to support doctors returning to work after a period of absence due to suspension.[20]

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

40. A recent meta-analysis suggested that burnt out doctors are twice as likely to be involved in patient safety incidents and deliver a lower quality of patient care.[21] This is a significant issue in O&G, a specialty already associated with high levels of litigation. Of all clinical negligence claims notified to CNST in 2018/19, obstetrics claims represented 10% (1,068) of clinical claims by number, but accounted for 50% of the total value of new claims, £2,465.5 million of the total £4,931.8 million..[22] These incidents can be catastrophic or life changing for patients.

41. Both the high level of litigation in O&G and burnout itself impact the quality of patient care through increased defensive practice (deviation from standard practice in response to complaints or criticism). A recent study found that consultants with burnout are three times more likely to report both avoidance (avoiding cases or procedures) and hedging (overprescribing or over-referral) which may have significant and serious consequences on patient care.[23]

42. Defensive medicine may be a strain on healthcare resources. Though the cost to the NHS is unknown, it is estimated to cost health services in the USA $46 billion annually.[24]

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?

43. The complexity of women’s healthcare needs is expected to increase, which will affect all areas of practice. This is for a variety of reasons, including women becoming pregnant at an older age, increasing obesity in mothers, changing population demographics that mean women are living longer and the increase in older women living with multiple morbidities .[25] Workforce models for O&G need to reflect these changes.

44. Although the majority (63%) of doctors provide both O&G services, 20% provide services in gynaecology only, which must be factored into workforce planning.
45. Workforce planning also needs to account for the intentions and actions of different sections of the workforce.
46. 54% of those on the O&G Specialist Register are international medical graduates with 14% from the EEA. The long-term impact of the UK’s exit from the EU on this group of doctors is as yet still unknown. It is also unclear whether the same numbers of EU doctors will seek to work in the NHS in the coming years.
47. There is concern among job planners that, due to workplace pressures, consultants in the future may start to retire earlier than is currently the case. This would lead to the loss of much needed specialist skills and leadership support and have a detrimental impact on more junior colleagues.

48. Workforce planners predict an increased number of consultants will be required on top of projected supply by 2021.[26] Training more staff will not be sufficient to meet current imbalances. Work must also focus on attracting and retaining those already in training, and retaining experienced and skilled staff working in or qualified to work in O&G services. This must include working with employers and other bodies to recognise increasing trends for part-time and more flexible working arrangements.

49. We are working with HEE to develop a future consultant model which addresses skill retention, growing subspecialisation, retention and the role of SAS doctors within the O&G workforce.

50. The impact of geographic location on training, recruiting and retaining staff is another factor that must be considered in workforce planning. The Nuffield Trust has recently noted the need for high-quality local training programmes geared to the needs of rural areas.[27]

51. Doctors take time out of practice for many reasons including burnout, but also maternity/paternity leave, research or out of programme experience. Returning to the workplace can be a daunting prospect and doctors must be supported at this time. The RCOG has developed a Return to Work Toolkit tailored for the needs of doctors at different levels including trainees.

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? 

52. At an average of 30%, attrition from the O&G training programme is one of the highest of any specialty. Our research suggests that among the causes are poor work-life balance, bullying and undermining and the absence of a team structure.[28]

53. HEE recognised the need to address these challenges and agreed to implement recruitment at ST3 (previously recruitment was only possible at ST1) from 2018.[29] Although this doesn’t address all of our rota gap issues it does help to plug gaps created by trainees leaving the specialty training programme in years one and two.

54. As previously stated, although the majority (63%) of doctors provide both O&G services, 20% provide services in gynaecology only, which must be factored into workforce planning.

55. The RCOG and HEE have established a medical workforce working group to explore current and future workforce numbers and training needs. As part of this work we will be exploring the future needs of and for the specialty based on multiple regional population projections including data from the NMPA and HEE.

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? 

56. The RCOG has long called on policy makers, regulators and NHS leaders to develop a long term plan to address workforce welfare. We welcome the commitments to developing support for employers to provide flexible working options made in the latest iteration of the NHS People Plan.

57. However, we support the Academy of Medical Royal Colleges response to the latest version of the NHS People Plan which notes that there is a need to address the staff shortages that are at the heart of issues related to morale and wellbeing, which will require significant funding. We await further details from government on the pricing of the plan.

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?

N/A