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Delivering core NHS and care services during the pandemic and beyond Contents

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5Issues facing NHS and care staff: fatigue and “burnout”

126.NHS and care employees have worked valiantly and tirelessly to rise to the unprecedented challenges brought about by the pandemic. We are, however, aware that this additional pressure has led to workforce fatigue and “burnout” with a significant cost being imposed on staff members’ mental and physical wellbeing. We have also heard that pre-existing issues relating to staff recruitment, training and retention have been exacerbated by the pandemic. In light of recent international events, we have heard many concerns about discrimination and racism against Black, Asian and Minority Ethnic (BAME) NHS and care staff. No member of NHS staff or social care worker should face bullying, harassment or discrimination and in particular, we have received urgent calls for greater steps to be taken to ensure BAME staff are protected and to ensure racism—in whatever form—is eradicated from the NHS and care system.

127.Although the People Plan: We are the NHS: People Plan 2020/21 - Action for us all (July 2020)232 makes good progress in addressing these issues for the period of 2020–21, the pandemic has illustrated that further, more substantive and longer-term action is required if the NHS and care workforce is to be adequately supported. We will continue to champion these matters and solutions to them through our inquiries into Workforce burnout and resilience in the NHS and social care233 and Social care: funding and workforce.234

NHS and care workforce wellbeing during the pandemic

128.The pandemic has required the NHS and care workforce to rise to new, unprecedented and sustained challenges. However, the cost of tackling the consequences of the pandemic must not be underestimated, particularly in terms of staff mental and physical wellbeing. The evidence provided to our inquiry has shown that much of the NHS and care workforce is fatigued, exhausted and otherwise “burnt out” with no obvious let up or plan to relieve the pressure in sight. This has damaged staff morale.235 Professor Andrew Goddard (President, Royal College of Physicians) told us:

The workforce is really tired at the moment. [...]That is all parts of the workforce, not just doctors; it is nurses and other healthcare professionals, who are all part of the hospital team. There is a mountain that people know they have to climb; they are willing to climb it and willing to pull together to do it, but it seems quite a large mountain at the moment. The worry that the peak is going to get higher in winter is a big one.236

129.A survey carried out by NHS Providers of its membership, at the end of June 2020, showed that 92% of Trusts agreed with the statement “I am concerned about staff wellbeing, stress and burnout following the pandemic”.237 NHS Providers has told us that:

Trust leaders are concerned that it is unrealistic and unfair to expect healthcare workers to go from coping with one crisis to working flat out to manage the backlog of care that has arisen during the pandemic. Steps must be taken to ensure, protect, and maintain staff resilience.238

130.Those points are reinforced by the evidence we heard from Professor Derek Alderson (President, the Royal College of Surgeons of England) and Dr Katherine Henderson (President, the Royal College of Emergency Medicine) who drew our attention to the implications for workforce numbers in the context of the pandemic. Professor Alderson told us:

Our bed base and our total workforce were short. I am not just talking about surgeons but everybody who contributes to care in a hospital. We need expanded facilities. […] We still need to retain as much of our expanded workforce as we possibly can, bearing in mind that people have worked very hard for some months and are getting tired.239

Dr Henderson referred to the longer-term implications:

When we get to February, we may lose a lot of staff. The other thing is people towards the end of their career and near retirement. Will it be, “I’ve had enough. I can’t be doing with this. This is not how I thought I was going to be spending my day and I am now going to retire earlier”? We have a real worry at that end that very experienced people may feel that it has been great to deal with the crisis but the aftermath is just a bit too much to take forward.240

Mental health support

131.Concerns have also been raised with us relating specifically to the mental health support for the NHS and care workforce. It is understood that long-term exposure to high-pressured situations, particularly where staff have lost colleagues and experienced other work-related traumas, puts staff at an even greater risk of post-traumatic stress disorder and other forms of severe mental ill-health.241

132.The NHS Confederation has highlighted the importance of providing adequate mental health support for NHS staff. The NHS Confederation have said:

The impact of COVID-19 on the dedicated staff providing health and care and wider public services will be significant, with personal sacrifice and loss coupled with the unrelenting and unprecedented demands made of them. We do not yet know what the long-term impact will be on staff mental health and wellbeing.242

133.The NHS Confederation’s Mental Health Network has said that, while local, targeted support offerings to NHS staff is appropriate, “there is a need for national, evidence-based guidance on how to best support staff wellbeing following the emergency period”.243 The People Plan: We are the NHS: People Plan 2020/21 - Action for us all (July 2020), similarly notes:

The pandemic has already had a significant physical, mental and psychological impact on our people—and this will continue for some time to come. Many people are tired and in need of rest and respite.244 […] It is our moral imperative to make sure our people have the practical and emotional support they need to do their jobs.245

134.During our session on 30 June 2020, Amanda Pritchard (Chief Operating Officer, NHSE/I) said that “We [NHSE/I] are absolutely committed” to supporting staff246 but noted that “we have a real task ahead of us to make sure that we support our workforce. That is critical”.247 Similarly, the Department of Health and Social Care, in its written evidence, noted the risk that current work poses to staff members’ mental health and that it aims to “gather evidence and assess the potential longer-term mental health impacts of COVID-19”.248

135.Giving evidence earlier in our inquiry, Claire Murdoch (National Mental Health Director, NHSE/I) told us that “we [NHSE/I] are planning for wellbeing, resilience and mental health support for staff right now. In fact, we are delivering a lot more right now”.249 Claire Murdoch explained that “all Trusts and organisations across the country” are investing more in occupational health support, mental health support and national 24/7 helplines.250 She further explained that:

All the evidence shows that the best thing you can do for staff mental health right now resides within teams and how teams operate, with good supervision, good debriefs at the end of every shift, remembering to think about what went well and remembering to help staff go home at the end of a shift having talked about anything they are concerned about. It is about making sure they are getting sleep, rest and down-time. We are trying to reinforce good team behaviours.251

136.The People Plan provides a comprehensive and vital list of actions that are being taken and will be taken to support the mental health of NHS staff in the 2020–2021 period. It states that “Further action for 2021/22 and beyond is expected to be set out later in the year, once funding arrangements for future years have been confirmed by the Government.”252 Initiatives currently being rolled out to support the workforce’s mental wellbeing include:

• access to a confidential support service (through phone or text);
• free access to wellbeing apps and webinars, safe spaces and discussion groups;
• guidance to team leaders including the introduction of wellbeing conversations between managers and reportees;
• the piloting of resilience hubs in partnership with occupational health programmes; and
• an increase in staff working remotely and flexibly.253

137.We are extremely grateful to all NHS and care staff for their hard work and dedication in trying to meet patient needs in such exceptional circumstances. This includes those who have returned to the NHS (such as clinicians returning from academia, retirement and other industries); students who have left their training early to do so, and staff that have been redeployed to manage capacity constraints in other areas of the NHS. We share concerns that some NHS and care staff are suffering from fatigue, exhaustion and a general feeling of being “burnt out” and that the wellbeing of staff (particularly their mental health) is at significant risk.

138.We are grateful for NHSE/I’s continued support of NHS staff and welcome the further measures set out in the People Plan (July 2020) for the 2020–21 period. In particular, we welcome the important and ambitious measures set out in the People Plan which show a clear desire to address workforce fatigue and provide mental health support to NHS staff. However, given the pressures on recruitment and retention of staff, we are concerned that the People Plan does not set out future workforce recruitment objectives, therefore failing to address one of the biggest concerns that many staff have, namely whether there will be enough of them to give high quality care to patients. We also believe more must be done to support the mental wellbeing of staff. Helplines, apps, webinars and managerial training will all be of value but with many members of staff facing much more severe and sustained pressures on their mental health, more substantive action will need to be taken to support the wellbeing of staff, particularly before the busy winter period. We note that the People Plan states further announcements will be made once the Government has confirmed funding arrangements for the NHS.

139.We recommend that NHSE/I set out in detail what further specific steps it would like to take over the coming years to support the mental and physical wellbeing of all staff and a plan to deal with the specific issue of sustained workplace pressure due to the current pandemic and backlog associated with the coronavirus. This information should be made available to us in advance of any forthcoming Government spending announcements or by the end of October 2020 (whichever is earlier) in order for us to clarify what NHSE/I’s priorities for NHS staff are, and to judge how far the Government’s eventual spending commitments enable their implementation.

140.We further recommend that NHSE/I should develop a full and comprehensive definition of “workforce burnout”, and set out how the wellbeing of all NHS staff is being monitored and assessed. This information should be made available to us by the middle of October 2020, to enable us to scrutinise it in the course of our inquiry into Workforce Burnout and Resilience in the NHS and social care.

141.We note, meanwhile, that there is no equivalent of the NHS People Plan for the social care workforce. We will have more to say about support for those working in social care in our forthcoming report on Social care: workforce and funding.

Support for BAME NHS staff members

Impact of COVID-19

142.The delivery of core health and care services during the pandemic has posed an unprecedented risk to Black, Asian and Minority Ethnic (BAME) NHS staff. Coronavirus has and continues to disproportionately harm those from BAME communities with recent data showing a significant excess deaths amongst BAME communities when compared with other groups. For example, Public Health England statistics (August 2020) stated that:

[Coronavirus-related] deaths in Black males were 3.9 times higher than expected in this period (20 March to 7 May 2020), compared with 2.9 times higher in Asian males and 1.7 times higher in White males. Among females, deaths were between 2.7–2.8 times higher in Black, Mixed and Other ethnic groups in this period, compared with 2.4 in Asian and 1.6 in White females.254

143.NHSE/I have similarly noted the disproportionate impact coronavirus has had on BAME individuals in society, as well on frontline BAME NHS workers. A recent statement from NHSE/I noted:

We know there is evidence of disproportionate mortality and morbidity amongst black, Asian and minority ethnic (BAME) people, including our NHS staff, who have contracted COVID-19. It is critical that we understand which groups are most at risk, so we can take concerted action to protect them.255

144.On 30 June 2020, Professor Steve Powis (National Medical Director, NHSE/I) told us that NHSE/I had been working, throughout the pandemic and as evidence emerged, to support individuals—including BAME NHS staff—“who are most at risk of complications and harm from COVID-19.”256 Professor Powis explained:

We worked with independent experts and NHS employers to formulate a risk assessment and a risk framework. Risk assessment tools were distributed to organisations, and we have been asking organisations, where they have not completed those risk assessments, to complete them in the next few weeks.

[…] Where adjustments need to be made, which could be redeployment to another work setting, working from home or a variety of measures, we have asked organisations to go through that process and ensure that all staff who have increased risk have that conversation and the opportunity to adjust their working environment to minimise risk.257

Issues facing BAME staff in the NHS

145.During the pandemic, recent international events have also put a much-needed spotlight on the issues facing BAME NHS staff. We are conscious of the wider debate about racism in society and the forms of discrimination BAME staff encounter in all workplaces. We recognise this extends even to organisations like the NHS which are rightly recognised for their inclusiveness. Such discrimination ranges from unconscious bias to fully-fledged racism.258 As The King’s Fund noted in its recent report Workforce race inequalities and inclusion in NHS Providers (July 2020), “addressing race inequalities in the NHS workforce is critical on multiple levels”.259 The report highlighted the following recent findings:

• 15.3% of ethnic minority staff report experiencing discrimination at work from a manager, team leader or other colleague—more than double the proportion of white staff reporting discrimination (6.4%);260
• 29.0% of ethnic minority staff have experienced harassment, bullying or abuse from staff in the past 12 months, compared with 24.2% of white staff;261 and
• people from an ethnic minority background make up only 8.4% of boards in NHS trusts across England,262 and “as the pay bands increase, the proportion of ethnic minority staff within those bands decreases”.263

146.The NHS Workforce Race Equality Standard’s report 2019 Data Analysis Report for NHS Trusts (February 2020) also presented key findings, including:

• 19.7% of staff working for the NHS were from a BAME background in 2019;
• Only 8.4% of board members were from a BAME background (up from 7% in 2017 and 7.4% in 2018);
• The number of BAME staff at very senior manager level has risen by 30% since 2016, but the total proportion is only 6.5%; and
• 29.8% of BAME staff compared to 27.8% of white staff reported experiencing harassment in 2018, a worse disparity than in 2017.264

147.Commenting on the issue of racism and diversity in the NHS, Richard Murray (Chief Executive, The King’s Fund) told us:

There is a whole series of very practical issues about trying to make sure that the leadership of the NHS reflects the communities it serves and to make sure that we are not wasting the incredible talents that all the staff can deliver.

What is a bit of a worry is that in the crisis of COVID-19 some of those long-standing issues are getting overlooked. We can see by the way the virus has moved through the country that they are just played out all over again. If anything, it should make us more determined and more resourceful in trying to overcome some of those long-standing race inequalities.265

148.During the same session, Dr Jennifer Dixon (Chief Executive, The Health Foundation) said:

COVID-19 has exacerbated existing inequalities that we know exist in the population. Maybe now it is time for an inequalities strategy, off the back of COVID-19, to try to address some of those issues more purposefully than we have been able to do over the last 10 years.266

149.On 30 June 2020, we questioned Sir Simon Stevens on the challenges facing BAME staff. Sir Simon told us “I think there are systemic features to discrimination and racism, and the NHS is both part of the problem and part of the solution” and that “The reality is that the NHS has always relied on a diverse workforce and we have to become a better employer”.267

150.Sir Simon also outlined the steps that had been taken to support BAME staff in the NHS. This included the Workforce Race Equality Standard, which has begun to track the experiences of BAME at every Trust,268 a greater focus on the Freedom to Speak Up guardians network269 and the funding of the independent NHS Race and Health observatory with the NHS Confederation which will, in part, aim to support BAME staff.270 Sir Simon said that he hoped that these initiatives would “help shine a light on whether there are particular practices in particular organisations that need to change.”271

151.The People Plan: We are the NHS: People Plan 2020/21 - Action for us all (July 2020) provides further detail on the initiatives that Sir Simon outlined to us. The People Plan also commits to tackling discrimination and racism in the NHS and states that there “has never been more urgent need for our leaders to take action and create an organisational culture where everyone feels they belong – in particular to improve the experience of our people from Black, Asian and Minority Ethnic (BAME) backgrounds.”272

152.The NHS is founded on the principle of equality and is one of the most diverse and inclusive organisations in the UK. It hugely benefits from the diversity of its staff as in turn so does the nation. In recent months, there has been a much-needed focus on supporting NHS staff from a Black, Asian and Minority Ethnic background (BAME). COVID-19 has, regrettably, disproportionately harmed and resulted in excess BAME deaths. We welcome the introduction of risk assessments and other initiatives, as set out by Professor Steve Powis, which are being implemented to protect BAME NHS staff from the risk of catching coronavirus.

153.We have also heard that some BAME NHS staff face discrimination and racism in the NHS and that, across the NHS, the levels of diversity must be improved. We accept Sir Simon Stevens’ comments that “there are systemic features to discrimination and racism, and the NHS is both part of the problem and part of the solution”.273 Nonetheless, it is unacceptable that any BAME NHS employee should face discrimination, harassment or racism when working for the NHS. It is clear that more must be done to ensure that all NHS staff—regardless of their race, ethnicity or cultural heritage—feel safe, confident and proud to work for the NHS.

154.The NHS must increase its efforts to eradicate all forms of discrimination and racism from in its organisation. We therefore recommend that NHSE/I provide a full and comprehensive definition of the “racism and discrimination” that it seeks to eradicate from the NHS. We invite NHSE/I and the Department for Health & Social Care to set out in detail its strategy to tackle racism and discrimination and to promote diversity in the NHS, including information on targets and deadlines by the end of 2020. We expect full and constructive engagement with NHSE/I and the Department as we further investigate matters relating to diversity and race in the NHS as part of our future work, including our Workforce burnout and resilience in the NHS and social care inquiry, in which we will review the root causes of these matters (including the difference between correlation and causation relating to coronavirus and excess deaths amongst BAME communities) and potential solutions.

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