Workforce burnout and resilience in the NHS and social care Contents

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2The scale of and impact of workforce burnout in the NHS and social care

Background

8.In our report, Delivering core NHS and care services during the pandemic and beyond, we set out our 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.15

We therefore recommended that NHS England and Improvement:

Develop a full and comprehensive definition of “workforce burnout”, and set out how the wellbeing of all NHS staff is being monitored and assessed … by the middle of October 2020.16

9.We further recommended that NHS England and Improvement:

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.17

10.In its response to our Report, NHS England and Improvement told us that it would invest, during winter 2020, “a further £30m (£15m for specialist mental health services and £15m for enhanced health and wellbeing more broadly) to strengthen the support offer to staff” and that it was “very likely” that ongoing investment on a similar scale will be needed at least for the next three years. NHS England and Improvement also said that:

Research is currently underway to better understand the factors associated with burnout, with the aim of identifying evidence-based interventions to address it … we are engaging at national and local levels to monitor and assess wellbeing.18

Our report follows up on that work and looks in more detail at the scale and causes of burnout and how it can be tackled.

What is burnout and what causes it?

11.In its written submission to the inquiry,19 the Royal College of Psychiatrists referenced the World Health Organization’s definition of workplace ‘burnout’ as:

a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy.20

The Royal College of Psychiatrists highlighted that the definition refers “specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”21

12.In oral evidence, Professor Michael West of the King’s Fund gave the following definition of burnout:

Very simply, stress and burnout at work are when the demands on us exceed the resources that we have; the level of work demands is very high and the resources we have to respond are not sometimes adequate, whether to do with our own personal resources, such as lack of skills, lack of training, lack of equipment, or the resources in our teams or organisations such as staff shortages, lack of PPE equipment, inadequate technologies or, more broadly, lack of the training and skills needed.22

He added that the term was often used to describe a constellation of three factors; “emotional exhaustion”; “a sense of what is sometimes called depersonalisation: cynicism or detachment” and a “lack of personal accomplishment—that they are not really making a difference”. In relation to the NHS, Professor West concluded that burnout could also be described as “moral distress”, where the individual concerned believes that “I am not providing the quality of care that I should be providing for the people I am offering services for.”23

13.These definitions provided our inquiry with a useful framework with which to examine burnout and its consequences.

Quantifying the size of the problem

14.The NHS Staff Survey has suggested that an unacceptably high proportion of NHS staff experience negative impacts as a result of stress in the workplace and that the proportion of staff suffering from stress is on an upward trend. The 2019 survey found that 40.3% of respondents reported feeling unwell as a result of work-related stress in the last 12 months, up from 36.8% in 2016.24 The most recent iteration of the survey, where fieldwork took place during the pandemic, indicated that 44% of respondents have now reported feeling unwell as a result of work-related stress in the last 12 months. The latest survey also found that 46.4% of staff said that they had gone to work in the last three months despite not feeling well enough to perform their duties - although this was ‘notably fewer’ than in previous years.25

15.The GMC’s Caring for doctors, caring for patients report, published in 2019, considered the level of burnout among doctors. The GMC’s report found that in 2018, nearly one in four doctors in training in the UK, and one in five trainers said they felt burnt out to a high or very high degree because of their work.26 In his submission, Professor Tom Bourne told us that the level of burnout among hospital doctors in the UK was “very high–and particularly so amongst trainees,” with over 40% of trainees affected.27

16.Unfortunately, as the King’s Fund highlighted to us, data comparable to the NHS Staff Survey is not available for social care workers.28 In oral evidence, Professor Martin Green OBE, Chief Executive, Care England confirmed to us the absence of comparative data for the care sector:

Unfortunately, the problem in social care is that we do not have comprehensive datasets. We do not have things like the staff survey in a uniform way, although there is some work being done by Skills for Care to try to make sure that we have some understanding of what is going on in social care. One of our challenges is that it is a very fragmented system.29

17.In oral evidence, we asked Professor Jeremy Dawson, Professor of Health Management at Sheffield University about the feasibility of introducing an equivalent staff survey for social care. While he acknowledged that it would be “much more difficult”, he told us that he had seen the benefit that the staff survey for the NHS has had over the last 17 years, and was confident that “if it could be carried out in social care, similar improvements could be driven by the same route.”30

18.Notwithstanding the absence of data in the care sector, workforce burnout was raised as a serious problem by a wide range of organisations representing staff. They included organisations representing orthopaedic surgeons, dentists, pharmacists, nurses, cardiothoracic surgeons, anaesthetists, midwives, health visitors and general practitioners, palliative care workers and paediatric intensive care workers, in addition to those representing staff in adult social care.31

19.When he gave oral evidence, Professor West told us that a shared metric was needed in order to understand the extent of burnout across health and care:

We need to establish a single measure across our whole health and care system—Professor Green talked about the need for measurement in the social care system as well—which gives us a very clear and standardised indication of the extent of the problems.32

Effect of burnout

20.Work-related stress has a wide range of consequences. The King’s Fund’s written submission stated that NHS staff were 50% more likely to experience high levels of work-related stress compared with the general working population. This was likely to damage their health and affect care quality, and was associated with patient satisfaction, financial performance, absenteeism and organisational performance. Poor staff health and wellbeing was also linked with turnover and intention to quit, along with higher levels of patient mortality in the acute sector.33

Chronic excessive workload

21.Chronic excessive workload has been identified as a key factor of burnout and staff shortages were identified as “the most important factor in determining chronic excessive workload”,34 with shortages of around “one in 10 or one in 12 staff” in the NHS in January 2020, before the pandemic fully hit.35

22.In his oral evidence, Professor West explained the relationship between excessive workload and burnout:

I want to be clear about the issue of excessive workload. The danger is that we do not see it. It is like the pattern on the wallpaper that we no longer see, but it is the No. 1 predictor of staff stress and staff intention to quit. It is also the No. 1 predictor of patient dissatisfaction. It is highly associated with the level of errors.36

He explained that the risks of excessive workload could not be tackled without a comprehensive strategy:

Unless we have a well worked-out plan for how we can fill all the vacancies and reduce the attrition rate of staff in the NHS […] we are going to be in trouble”.

23.Professor West went on to tell us that the high attrition rate was not confined to nurses, midwives and doctors, but applied to groups of staff across the NHS; and that a “well- worked-out, thought-through strategy, based on a vision of the kind of health and care we want to be providing in 10 years’ time”, was “fundamental” in the ability for the NHS to plan for the numbers that will be required in the years to come.37

Effect of vacancies in the health and care sector

24.A number of written submissions to our inquiry also highlighted the link between shortages in the health and care workforce and burnout, along with the scale and impact of vacancies across the NHS and social care workforce. For example, the Royal College of Nursing (RCN) noted that prior to the onset of the pandemic there were 50,000 nursing vacancies in the NHS across the UK.38 Furthermore, its 2019 employment survey identified that nearly a quarter of nurses and midwives were looking for a job outside the NHS.39 In a similar vein, the Royal College of Psychiatrists told us that one of the biggest causes of workforce burnout in mental health services was the “lack of professionals to support all the patients who need help”.40

25.That picture is replicated in adult social care. In October 2020, Skills for Care estimated that 7.3% of roles in adult social care had been vacant during the financial year 2019–20, equivalent to approximately 112,000 vacancies at any one time.41 Skills for Care’s annual State of the adult social care sector and workforce report found that the number of registered nurses had continued to decrease, down 2,800 jobs (7%) between 2018–19 and 2019–20 and 15,500 jobs (30%) since 2012–13.42 In addition, the staff turnover rate of directly employed staff working in the adult social care sector was 30.4% in 2019–20, equating to approximately 430,000 people leaving their jobs over the course of the year. As around 66% of recruitment was from within adult social care, this meant that approximately 149,000 had left the sector.

Intensity of workload

26.While staff numbers are crucial, we also heard that intensity of workload was a factor in causing burnout. Professor West told us that staff could “deal” with “episodic, transient demands” but it became a problem when that demand became “chronic.” Stress tended to be chronic in the healthcare sector, with the measure of stress “at one point in time and then again six months later” usually at a similar level. Whether intensification was in terms of “amount or quality”, chronic work stress predicted a number of serious conditions including cardiovascular disorders, cardiovascular disease, addictions, diabetes, cancer and depression.43

27.Anonymous evidence from a Practice Manager demonstrated how the covid-19 pandemic had increased the intensity of workloads, despite the decrease in face-to-face work:

Obviously, we do a lot less face-to-face work now, but we actually have a lot more patient contact. We worked out we probably have 50% more patient contact than we had before. It may be done by telephone, but there is still far more of it. Also I think it’s far more… because the patients are so worried and themselves so stressed and depressed, it’s far more draining on the staff. The patient contacts are exhausting in some cases because you’re trying to support people who are really in a very bad way. We’ve definitely never worked so hard in our lives as we’ve worked in the last year. It’s been relentless.44

Pay and reward

28.Although pay and reward were not the focus of this inquiry we received evidence that suggested that pay could also contribute to stress and burnout in health and care. Low pay is a particular issue in the social care workforce, while it is estimated that 56% of NHS staff work unpaid additional hours on top of their contract.45 For the Local Government Association (LGA), pay was not the only area of reward discrepancy between the social care and NHS workforces, with less favourable sick pay and pension arrangements likely where social care workers are employed in the independent sector rather than by a local authority. It also pointed out that NHS workers were also more likely to have access to retail and other discounts, although this was beginning to change.46

Discrimination

29.Discrimination was also raised as a factor in burnout. The King’s Fund highlighted that Black, Asian and minority ethnic staff in the NHS reported worse “and often shocking” experiences compared with White staff and were under-represented in senior posts.47 More widely across the NHS, rates of all types of bullying and harassment continued to be very high, according to the King’s Fund.48 The 2020 NHS Staff Survey set out the following data in relation to bullying or harassing behaviour directed towards NHS staff:

• 26.7% of staff reported being bullied, harassed or abused by patients/service users, their relatives, or other members of the public in the past twelve months.
• 12.4% reported that behaviour by managers.
• 18.7% reported that behaviour by other colleagues.49

Systems and working cultures

30.Although our terms of reference included workforce resilience in the NHS and social care; a number of written submissions cautioned against focussing on the resilience of individual members of staff. Instead, they advised that the focus should be on systems and systemic solutions. The Healthcare Safety Investigations Branch (HSIB) told us that:

Although staff need to be psychologically well-supported, the idea that they can be trained to be ‘more resilient’ limits the potential benefit that this inquiry can achieve for the NHS. We would encourage the Committee to explore how Covid has shown where the system can be better designed, so that it can better adapt to demands and shift the burden from individuals on to the system.50

The Healthcare Safety Investigation Branch added that safety science had established that patient safety would “gain more by looking at organisational resilience than staff resilience”. The British Society for Rheumatology also warned against appearing to apportion blame to individuals. Rather, the Society said that the focus be on “addressing current rota gaps and unsustainable workloads” to build resilience at a system level.51

31.The Academy Trainee Doctors Group said that the term “moral injury” was preferable to burnout and resilience as it “more accurately frames the problem as being driven predominantly by external factors”.52 In her oral evidence, Professor Dame Clare Gerada agreed. She said that resilience described “bending with the pressure, bouncing back and learning from that” and that “no amount of resilience training or psychological or physical PPE will protect you from a toxic environment”.53 This was also supported by Our Frontline, which recommended that working culture and organisational factors should be the focus when tackling mental health issues amongst staff:

While we understand the need to focus on and build the resilience of the workforce, much of our evidence points towards poor working cultures and organisational factors being the biggest drivers of poor mental health for those working on the frontline. These factors, and the root causes of poor mental health across the workforce, need to be tackled as a priority if we want to see a truly resilient health and social care sector.54

The impact of burnout

32.Burnout not only affects staff but can have an impact on patients and patient safety. The GMC’s Report, Caring for doctors, caring for patients, had previously found:

Abundant evidence that workplace stress in healthcare organisations affects quality of care for patients as well as doctors’ own health […] Patient satisfaction is also markedly higher in healthcare organisations and teams where staff health and wellbeing are better.55

33.This was also the view of the Medical Protection Society. The Society told us that burnout directly and indirectly affected medicolegal risk and that the poor wellbeing of doctors had “major implications for patient outcomes and the overall performance of healthcare organisations”.56 In a similar vein, the Royal College of Midwives noted that:

Staff who are burnt out are at increased risk of error-making and are more likely to suffer from low engagement (lack of vigour, dedication and absorption in work), cynicism, and compassion fatigue.57

Similarly, the RCN’s written evidence cited a meta-analysis of 21 studies which concluded that burnout was linked to a decline in patient safety and outcomes, and an increase in patient dissatisfaction and complaints.58

34.An anonymous submission from a consultant, eloquently illustrated the impact of burnout on staff and the pressure felt by colleagues whose decisions in relation to care could face intense scrutiny:

It feels like you’re a jug that’s pouring all the time, into all the areas, and you’re driving yourself fairly hard. […] I think you just push and push at that and then eventually other things come along and it kind of empties your resources and suddenly you can’t cope anymore. The jug is suddenly empty and it comes as quite a shock.

One of the things that empties that jug, that I’ve seen in myself and colleagues, is complaints, court hearings and difficult coroners cases.

[…]

Doing intensive care, I make difficult life and death decisions a lot. It’s a very high-pressured speciality so as you start to feel a bit more paranoid, and if you have those decisions challenged in court, you start to question yourself. That’s exhausting because you have to be confident in what you’re doing for the team and second guessing all decisions cripples you.

The consultant added that a cause of burnout was the undermining of confidence that came from “complaints and things like that, combined with chronic high levels of stress”.59

35.Burnout is a widespread reality in today’s NHS and has negative consequences for the mental health of individual staff, impacting on their colleagues and the patients and service users they care for. There are many causes of burnout, but chronic excessive workload is a key driver and must be tackled as a priority. This will not happen until the service has the right number of people, with the right mix of skills across both the NHS and care system.

36.Understanding the scale and impact of workforce burnout can only be achieved with a metric for staff wellbeing and staff mental health that covers both the NHS and social care. We therefore recommend that the Department for Health and Social Care extends the NHS Staff Survey to cover the care sector.

37.We further recommend that the NHS Staff Survey and any social care equivalent includes an overall staff wellbeing measure, so that employers and national bodies can better understand staff wellbeing and take action based on that understanding. The Staff Survey already allocates a scale out of 10 for each ‘theme’ it covers, which could provide the starting point for the calculation of such a measure.

38.We welcome the additional support provided to health and care staff during the pandemic. However, we conclude that such additional support will need to be maintained during the recovery period and beyond to stop further staff from leaving. Furthermore simply offering support services, however important, is not on its own enough. The Department and employers need to ensure that those services are accessible to all and used by all who need them. This will require removing barriers to seeking help, and embedding a culture where staff are explicitly given permission and time away from work to seek help when it is needed.

39.We recommend that Integrated Care Systems (ICSs) be required to facilitate access to wellbeing support for NHS and social care workers across their systems, and that they are accountable for the accessibility and take-up of those services.

40.We further recommend that the level of resources allocated to mental health support for health and care staff be maintained as and when the NHS and social care return to ‘business as usual’ after the pandemic; and that the adequacy of resources allocated to that support be monitored on a regular basis.