Workforce burnout and resilience in the NHS and social care Contents

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4The impact of covid-19 on burnout

Introduction

92.The pandemic presented the health and care sector with unprecedented challenges that exacerbated existing problems in the workforce. In its written evidence, the NHS Confederation outlined a range of factors resulting from the pandemic that had impacted on the mental wellbeing of the workforce. They included:

• Increased workload and working hours.
• Intensity of working in different / COVID-19-safe environment.
• The impact of the heroes narrative.
• Emotional strain from seeing large numbers of patients dying.
• Anxiety about their own and loved ones’ health and infection risk.
• Guilt experienced by those shielding or working from home.
• Worries about being able to provide high-quality care.125

NHS Providers also emphasised that covid-19 had exacerbated existing challenges around workforce, burnout and resilience.126

93.The British Psychological Society also highlighted factors affecting wellbeing during the pandemic, including junior staff unaware of the support available to them; non-front line staff feeling guilty, when re-assigned to a post vacated by staff moved to Covid wards or when shielding loved ones; and concerns about PPE (not feeling protected, fear of being infected through no fault of their own, or of possessing it and feeling guilty about ‘taking it’ from those more in need who do not have it).127

94.Healthcare Safety Investigation Branch staff who had returned to the frontline during the crisis phase of the pandemic also observed a range of factors that added to the risk of burnout:128

• unfamiliar working conditions—unknown environments, disease, and boundary of competence
• reduced staff ratios and skill mix, which can compound other safety risks.
• lack of standardisation across wards for equipment, layout, and bed numbering systems.
• design of personal protective equipment (PPE) storage with unintended negative consequences (e.g. delays in donning, difficulty accessing PPE).
• escalation pathways not known or provided, or staffed, or the designated person for escalation inexperienced in that area or that task
• rapidly changing guidance - for those who worked part time, procedures and guidance changed, often dramatically, during days off.129

95.The availability of PPE at the start of the pandemic and its effect on staff was also raised by organisations from both health and social care. A Royal College of Emergency Medicine survey in June 2020 found that 32% of respondents had episodes where they lacked access to PPE items when having clinical contact with suspected or confirmed covid-19 patients, and 34% reported having to reuse disposable PPE items. 97% of respondents to that survey felt that PPE had an impact on their ability to communicate effectively with patients.130

96.The Royal College of Psychiatrists runs the Psychiatrists’ Support Service (PSS) providing free peer support by telephone to psychiatrists of all grades who may be experiencing personal or work-related difficulties. In its written submission the Royal College said that burnout was one of the most common issues presented, with 19% of all calls in 2020 being related to it in some way.131

Effect of the pandemic on NHS staff

97.Several organisations that submitted evidence had surveyed their members on the effect of the pandemic on their staff. In June 2020, an NHS Providers survey found that 9 out of 10 trust leaders were concerned about staff wellbeing, stress and burnout following the pandemic,132 while the British Medical Association’s written submission highlighted that nearly half of the doctors that had responded to its survey reported suffering from depression, anxiety, stress, burnout, emotional distress or another mental health condition. Those figures were accompanied by data that indicated that the BMA’s mental health and wellbeing support services experienced a 40% increase in their use over March, April and May 2020.133 The Royal College of Psychiatrists has run regular surveys during the pandemic. In May 2020, over half of its members surveyed said that their wellbeing had worsened during the crisis (506 of 931), with the wellbeing of people from BAME groups disproportionately affected.134 Similarly, in oral evidence to the Public Accounts Committee in July 2020, Prerana Issar, NHS Chief People Officer, described “worrying signs of burn-out and anxiety” among nursing staff” and highlighted a Nursing Times survey indicating that 90% of nurse respondents felt higher rates of anxiety than before the pandemic.135

98.The increases in levels of stress have also been accompanied by rises in absences. FirstCare (an absence management provider) reported that from April–June 2020, absences relating to mental health increased by 22% compared to the same period in 2019.136 In a similar vein, the Nuffield Trust reported that the staff absence rate in the NHS in April 2020 was the highest since records began and that it had exceeded even the “winter peaks of sickness absence over the last 11 years”.137

99.In October 2020, the Parliamentary Office of Science and Technology (POST) published a paper, Mental health impacts of COVID-19 on NHS healthcare staff. That paper stated that the pandemic may have removed many of the usual coping mechanisms previously used by staff, including socialising with friends and family. According to POST, the BMA reported that well-being support services had seen an increase in calls from doctors who were feeling anxious about going to work to face increasingly challenging situations.138 POST found that frontline workers that were directly engaged in the diagnosis and treatment of covid-19 were particularly vulnerable; including nurses, paramedics and those working in frontline specialities, such as emergency medicine and intensive care.139

100.These statistics give the overall picture of the additional stress placed on staff in the health and care sector. But they do not give a sense of the human cost of that stress. A number of submissions contained personal testimony that made clear the effect on individuals. In its written evidence, Macmillan Cancer Support quoted the words of a Lead Cancer Nurse on the emotional impact of the pandemic:

We’ve all got that Covid fatigue. We’re exhausted by the way we’re living and working. And it’s really difficult. The thing is, we’re coming up to winter, we’ve got to step up to the mark again. And it’s whether we have the resilience to deal with that. And, of course, we’ll have to because there’s just no more capacity and no more staff to handle it.140

101.Another quote from a Macmillan GP explained that even the most resilient of colleagues were “cracking” under the pressure.141 The BMA’s submission included testimony from a doctor who faced feelings of guilt from the belief that they had put their family at risk by working during the pandemic:

I signed up to be a doctor. But my family didn’t choose this career path, I feel like I’ve forced the risk on them and I can’t get away from the guilt.142

102.In oral evidence, Professor Dame Clare Gerada, told us of the emotional load facing all staff in the NHS during the pandemic:

I always talk about the porter. The porter who has to wheel a dead baby to the mortuary is just as much in need of space and time to talk about that and what he has just done as is, for example, the consultant in ITU who has lost a patient. It is anybody who is doing front- facing emotional toil. It is more so if you are involved in clinical work, of course, but it should not leave behind all the others.143

Another Macmillan nurse highlighted the personal stress caused by patients not receiving treatment:

In the background I was also worrying about the cancer patients and them getting their diagnosis because everything just stopped. And I’m still worrying about that now, will we ever catch up? Will there be too many late diagnoses? We’re going to be in for an explosion and how are we going to manage that?144

Professor Dame Clare Gerada told us that the two most important solutions were to “address the intensity of the workload” and to “allow spaces in protected time where people can come together to talk about the emotional impact of their work”.145

103.Although our call for evidence closed at the end of October, we received submissions that included references to the potential impact of a second wave of covid-19. The Royal College of Psychiatrists pointed to a BMJ assessment of the mental health impact of staff working with patients suffering from covid-19 and other similar outbreaks. It highlighted the risk of not giving staff the chance to “reset” following a crisis. That assessment suggested staff working with patients with covid-19 were 70% more likely to develop both acute and post-traumatic stress disorder (PTSD) or to suffer from psychological distress.146

Covid-19: social care staff

104.The evidence we received on the effect of the pandemic on NHS staff was echoed by the submissions covering staff working in social care. Care England told us that social care workers had had to grapple with long hours (sometimes not being able to take leave) and the need to be adaptable in response to changing needs.147 The United Kingdom Homecare Association (UKCA) noted staff had “worked above and beyond their contractual requirements in an emergency situation” and that this could not be considered a long-term position.148

105.The effect on staff was made clear by Skills for Care which found that the percentage of days lost to sickness had almost tripled from 3% to 8% from March to July 2020 compared to usual levels. This figure would equate to around 6.35 million additional days lost to sickness than would usually be expected in that period.149 In addition, the LGA told the Committee that self-isolation and quarantine had exacerbated absence levels, with staff feeling anxiety and guilt about putting their own families at risk.150

106.Care England explained that adult social care staff had also had to take the place of residents “relatives and loved ones” including “helping residents isolate in their bedrooms, at the bedside of dying residents”. Care England told us that staff had felt bereft and grief stricken when residents died and were concerned for their own safety as a result of a lack of testing. It concluded that the “physical and mental strain on staff during this period was “unprecedented”.151 The Diocese of Rochester also told us that the additional pressures placed on care staff had been accompanied with a feeling of being “‘abandoned”, with the focus especially early in the pandemic on protecting the NHS.152 This view was repeated by the Carers Trust who told us that social care and its workforce felt less valued than their counterparts in the NHS.153

107.In oral evidence, Jo Da Silva, a homecare worker, told us that the recognition of the work of social care needed to be put on an equal footing with medical professionals:

To be on a par with other people means more than anything. […] We have done things that are on a par with other medical professions, if I am honest. […] We have a duty to care, and we do the job for a reason. I think the main thing is to be recognised.154

108.During the first wave, the UK public showed their recognition of the work of staff in the health and care sector through the weekly “clap.” However, while many staff appreciated it, the Adult Social Care Taskforce Workforce Advisory Group also noted that the “all in this together” sentiment may have “created a climate” that pressurised some staff into working “in ways that they didn’t feel they had a choice about, and may have had to do so at great personal sacrifice”.155 It further noted that care workers did not have a code of practice equivalent to nurses and social workers that would have been “instrumental” in supporting them in to say “no.”156

109.The additional pressures and the perception of not being recognised and appreciated extended to other areas of the sector. An anonymous submission from a Community Pharmacist told us that despite staying open throughout the pandemic community pharmacy felt “very underrecognized” and” undervalued.” They described community pharmacists as the “hidden sponge” that soaked up a large number of people that would otherwise have presented at A&E or a GP practice; and that it would be a “real travesty” should that work be forgotten.157

Supporting mental health during covid-19 and beyond

110.Looking forward, a number of organisations that submitted written evidence told us of lessons that needed to be learned from the pandemic and changes that needed to be made to better support mental health and wellbeing in adult social care. The Adult Social Care Taskforce Workforce Advisory Group recommended:

• All members of the social care workforce (including those who have left the sector due to coronavirus) be protected by Government investing in occupational health services, signposting, mental health first-aid, and bereavement services, including access to face-to-face consultations, where appropriate.
• The active promotion of a positive view of occupational health for the wellbeing of the workforce that recognised cultural sensitivities including people that may be more reluctant to engage with those services.
• Employers had the ability to access training and resources to manage sickness/absence fairly and efficiently; and where that was unavoidable, to terminate contracts on health grounds fairly and lawfully.158

111.In his oral evidence Paul Farmer, the CEO of Mind, also highlighted the importance of cultural change and improving the offer of support to staff. He highlighted the need for NHS trust boards to focus on “the mental wellbeing and support of their staff” and to ensure that there were adequate numbers of champions inside their organisations. He also highlighted the importance of tackling the stigma of mental wellbeing and to ensure that there was “a really clear set of offers” in place and that every member of staff was aware of those offers.159

112.The Royal College of Psychiatrists called for the implementation of the NHS People Plan to 2020–21 along with the recommendations of the NHS Staff and Learners’ Mental Wellbeing Commission,160 while Our Frontline called for the adoption of the recommendations set out in the Mental Health and Wellbeing of Nurses and Midwives in the United Kingdom report.161 Our Frontline also recommended that all employers across NHS and social care:

• Provide adequate evidence-based training and tools to strengthen the resilience of staff in health and social care.
• Promote anti-stigma messaging to encourage people to reach out if they need support.
• Invest in mental health services specifically for NHS and social care staff who may be experiencing trauma following covid-19.
• Embed mental health training as a core part of new staff members induction.162

113.The Academy of Medical Royal Colleges set out in its submission that “active national support through a sustained and coordinated approach to mental health and wellbeing” was essential for staff engagement and retention as the system moved into the recovery period. According to the Academy, emerging evidence suggested that the need for psychological support among NHS staff (and other employee groups) would now increase, with those who have been shielding or have required significant work adjustments because of underlying health or other issues perhaps needing specific support to return to work.163

114.The Department of Health and Social Care’s (DHSC) written evidence explained that it had recognised this need for enhanced wellbeing support for NHS and social care staff at “an early stage”,164 and had commissioned NHS England and Improvement to develop a comprehensive emotional, psychological and practical support package for NHS staff with “many elements” extended to staff in social care. The Department told us that throughout the pandemic, NHS staff could access:

• A dedicated and confidential staff support line, operated by the Samaritans and a 24/7 text support line operated by Frontline.
• Specialist bereavement support through a helpline provided by Hospice UK, manned by a team of fully qualified and trained bereavement specialists.
• Free access to mental health and wellbeing apps.
• Virtual staff common rooms, in partnership with NHS Practitioner Health, which gave staff the opportunity to reflect, share experiences and find ways to cope with how Covid-19 is affecting their life at home and at work.
• The “#LookingAfterYouToo: Coaching Support for Primary Care Staff service” developed in collaboration with the Royal College of General Practitioners that provided access to individual coaching sessions to support the mental health and wellbeing of all clinical and non-clinical primary care workers.165

115.Health Education England also provided a range of free e-learning resources including, support for individuals returning to practice or moving areas of work; an e-portal on statutory/mandatory training required by staff and those returning to practice; and a Learning Hub providing access to Covid-19 related education and training resources for the health and care workforce.166

116.For social care staff, the Department introduced a new CARE branded website and app—CARE Workforce—which provided information and signposting support. In May 2020 it published wellbeing guidance for adult social care staff and employers, and in June 2020 it published a collection of bereavement resources.167

117.The Department further highlighted the work it had undertaken with Our Frontline (a collaboration between Samaritans, Shout, Hospice UK and Mind, providing information, emotional support and access to a crisis text service for those working on the frontline, including in social care); the Samaritans and Hospice UK to provide additional mental health, bereavement and other support to health and care staff.168

118.The Association of Clinical Psychologists UK was largely positive about the NHS England Staff Wellbeing Programme.169 However, the Association noted that the “take-up” of the various forms of psychological support had been “remarkably low thus far” (as of September 2020) and that research was needed to understand the reasons for ‘both take-up and non-engagement with these offers”. In February 2021, NHS Chief People Officer Prerana Issar said that an expert advisory group had provided advice on health and wellbeing over the year. She told us that staff recovery was “very individual” and that “we will all need to recover in different ways, depending on what our experience has been over the year and what our family situation has been”. Alongside that there needed to be “team processing and reflection time” and that “team debriefs, check-ins and some support for facilitated conversations with teams [would] be key for recovery”. In addition, Prerana Issar told us that 40 mental health hubs had been made available. for people who have more serious burnout symptoms.170

119.Despite the unprecedented stress placed on staff during the pandemic, a number of written submissions saw positive workforce developments that could leave a constructive legacy. UNISON, for example, noted the growth in flexible and remote working,171 while the King’s Fund, highlighted the public’s demonstration of how much they valued key workers; a raised awareness of the need to actively ensure that different staff groups are not made vulnerable by normalised discrimination and disadvantage; and examples of NHS staff rapidly forming teams which delivered effective care and were supportive.172 That rapid formation of teams has, anecdotally, been linked to greater levels of delegation of authority, greater flexibility in individuals’ role assumptions, greater attention to wellbeing and more supportive regulation. The King’s Fund believes that evaluation of the factors enabling this resilient teamworking in the NHS is needed, and that learning should be taken forward.173

120.The Academy of Medical Royal Colleges also noted the growing acceptance of delivering care in different ways and greater recognition of the value of multi-professional team working. It also saw benefit in evaluating those innovations “to ensure positive changes are retained, and negative changes are discarded.”174

121.Covid-19 has exacerbated existing problems with staff welfare, but also brought some benefits, including higher levels of recognition and different ways of working. While enhanced recognition of the work of health and care staff is welcome, adequate and holistic support for their mental health and wellbeing is of primary importance. That support was not just needed during the waves of covid-19: it will be needed through the recovery as the health and care sector returns to ‘business as usual.’

122.We recommend that national bodies must continue to monitor the impact of covid-19 on the NHS and adult social care workforce and ensure that workforce planning builds in time for recovery after the pandemic is over.

123.We recommend that the Department of Health and Social Care, the national bodies, and individual organisations across the NHS and social care commit to capturing and disseminating the innovations—in particular giving greater levels of autonomy to staff and new forms of integrated working—during the pandemic so that they can be embedded in organisations as they return to ‘business as usual’.

The impact of covid-19

124.During this inquiry, we received evidence on the specific effects of the pandemic on staff from Black, Asian and minority ethnic backgrounds and the challenges that they faced. POST’s note on the mental health of NHS staff during the covid-19 pandemic found that staff from minority ethnic backgrounds had been disproportionately affected by the pandemic, including in relation to deaths from covid-19.175 Submissions to our inquiry supported those findings. The Royal College of Psychiatrists’ May 2020 member survey found that staff from Black, Asian and minority ethnic groups were disproportionately affected by covid-19 compared to professionals from white backgrounds,176 and the RCM reported that–despite advice to NHS trusts to conduct covid-19 risk assessments for staff from Black, Asian and minority ethnic backgrounds working in patient facing roles—an investigation in June 2020 had found that only 23% of Trusts had done so.177 The RCM added that there was evidence to suggest that requests from staff from BAME backgrounds for personal protective equipment (PPE) were more likely to be refused, and that healthcare workers from BAME backgrounds had felt more pressure to work with covid-19 patients than their white counterparts.178 A report from the Royal College of Nursing also found that healthcare staff from Black, Asian and minority ethnic backgrounds were less likely to be able to secure PPE, and less likely to receive PPE training compared with their white colleagues.179

125.The first 10 doctors in the UK named as having died from covid-19 were all from Black, Asian or minority ethnic backgrounds.180 The Royal College of Emergency Medicine’s (RCEM) June 2020 membership survey found that 30% of staff from BAME backgrounds were “very concerned” about their health, compared with 8% of White staff,181 and the BMJ reported in April 2020 that 63% of healthcare workers who had died from covid-19 were from BAME backgrounds.182

126.Those concerns were replicated in the social care sector. Staff from BAME backgrounds represent around 21 per cent of all social care staff,183 and in London, 66% of the adult social care workforce are from minority ethnic backgrounds.184 In its written evidence the Local Government Association told us that, with social care being a “hands-on” industry and effective social distancing an “immense challenge”, social care workers from BAME backgrounds faced particular challenges as they had been shown to be more vulnerable to covid-19.185

127.Shining a light on the effect of the pandemic on staff from BAME backgrounds, Dr Chaand Nagpaul told us that over 90% of the doctors who have died have had come from Black, Asian and minority ethnic backgrounds; a statistic that he described as “stark” and that went “beyond any statistical variation”. Dr Nagpaul also cited BMA members who had reported “higher levels of bullying and harassment during the pandemic”.186

128.Public Health England’s report, Beyond the data: Understanding the impact of COVID-19 on BAME groups, published in June 2020, found that “the highest age standardised diagnosis rates of covid-19 per 100,000 population were in people of Black ethnic groups (486 in females and 649 in males) and the lowest were in people of White ethnic groups (220 in females and 224 in males)” and that “People of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British”.187 In relation to the health and care sector, the report stated that of the deaths of healthcare workers reported, “63% were in BAME groups: 36% were of Asian ethnicity (compared to 10% of NHS workforce) and 27% were of black ethnicity (compared to 6% of the NHS workforce).” The report stated that:

Stakeholders felt strongly that more must be done to protect and support BAME staff working in health and care services (including pharmacies and domiciliary care). They play a vital role in our society, more should be done to recognise this and celebrate this. There are deep concerns raised about the support that BAME front line workers have received. This fundamental break in trust between employers and organisations should be a priority to address as we move into recovery phase of COVID-19.188

129.In October 2020, the BAME Communities Advisory Group reported to the Social Care Sector COVID-19 Support Taskforce. The Group’s report made a number of recommendations to tackle the specific impact of the pandemic on BAME groups. Those recommendations included:

• Parity between staff working in the NHS and social care in research, the design, development, and delivery of programmes that support BAME staff through the current and future pandemics.
• NHS Confederation, Care Providers Alliance and British Association of Social Work to share best practice and coordinate their advice and support to Employers and BAME staff.
• That faith and ethnicity be recorded on death certificates and data sets.
• The development of a ‘Trusted Places and Trusted People’ strategy as the way of disseminating awareness, knowledge and information.
• That greater efforts are made to improve cultural ‘competence’ at government level.
• An increased robustness in co-ordination between the NHS and Local Authority, Social Care and Public Health to better support BAME staff in social care.
• The publication of clearer guidance and expectations that deliver improved messaging on the need to protect BAME workers across social care.189

130.In response to concerns about the impact of covid-19 on staff from BAME backgrounds in the NHS , NHS England and Improvement issued the following specific areas of focus to address the impact of Covid-19 on staff from Black, Asian and minority backgrounds in the NHS:

• Protection of staff.
• Engagement with staff and staff networks.
• Representation in decision making.
• Rehabilitation and recovery, with a bespoke health and wellbeing offer for Black, Asian and minority ethnic colleagues being created.
• A range of support, including a free to access dedicated bereavement and trauma support line for colleagues of Filipino origin.190

131.The NHS People Plan includes a number of references to tackling discrimination faced by NHS staff, and notes the impact of covid-19 on colleagues from Black, Asian and minority backgrounds:

It has never been more urgent 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 backgrounds.191

132.From September 2020, the People Plan commits NHS England and NHS Improvement to refreshing the evidence base for action, to ensure the senior leadership (very senior managers and board members) represents the diversity of the NHS, spanning all protected characteristics.192

133.It is clear from the evidence collected by Government, the NHS and other organisations that staff from Black, Asian and minority ethnic groups have been disproportionately affected by the pandemic in a way that has shone a light on deeply worrying divisions in society. Both the Public Health England and BAME Communities Advisory Group reports set out a series of actions to address this problem. We recommend that the Department set out how it plans to implement those recommendations, with a corresponding timeframe.

134.We further recommend that Integrated Care Systems have a duty to report on progress made against those recommendations made to improve the support for their staff from Black, Asian and minority ethnic backgrounds.