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Overhaul needed to tackle workforce burnout: report courtesy of the Clinical Services Journal (1) « Contents

A Committee of MPs has warned that workforce burnout presents an “extraordinarily dangerous risk” to the functioning of health and social care. The findings of the report, which are summarised in this article, reveal the situation has reached “emergency levels”.

In a highly critical report, the Health and Social Care Committee found that workforce burnout across the NHS and social care has reached an emergency level, posing a risk to the future functioning of both services. Although COVID-19 had a huge impact on workforce pressures, staff shortages across the NHS and social care were reported to be a significant problem prior to the pandemic and these shortages were identified as the biggest driver of workforce burnout. The committee of MPs concluded that a total overhaul of workforce planning was required.The inquiry into workforce burnout and resilience looked at:

The Committee received over 100 written submissions and held four oral evidence sessions, including anonymous in-depth interviews with frontline staff. What do we mean by ‘staff burnout’?Professor Michael West of the King’s Fund provided the following definition of burnout in an oral evidence session to the Committee: “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.”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.” 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. 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.

The report stated that there are many causes of burnout, but chronic excessive workload is a key driver and must be tackled as a priority. It added that 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”.

Understanding levels of stress

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, 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.

The level of burnout was found to be very high among doctors and nurses, but the King’s Fund highlighted that there was very little data for social care workers, since there is no equivalent to the NHS staff survey. The report stated that:

“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.”

It therefore recommended that the Department for Health and Social Care should extend the NHS Staff Survey to cover the care sector.

Rising demand and capacity

Chris Hopson, chief executive of NHS Providers, pointed out that there has been a mismatch between rapidly rising demand and capacity, which has placed staff under considerable strain: “The way we tried to close the demand/capacity mismatch was by asking our staff to work harder and harder. The reality is that the demand/capacity mismatch was already showing up before we went into [the pandemic].”

He warned that chief executives of Trusts were telling him that after this ‘immediate period’ of the pandemic, people would leave the NHS including “those near retirement, junior doctors or people who have come over here from overseas who wanted to train”.

He concluded that core workers would leave the NHS because, “effectively, the whole concept of trying to close that gap by asking staff to work harder and harder is creating an impossible and unsustainable workload for frontline staff”.

Chris Hopson emphasised that “we absolutely do not have enough people working in the NHS” and added that one of the really important things that needed to come out of the pandemic was a commitment, right the way across Government, to undertake long-term workforce planning.

Supporting staff

In his oral evidence Paul Farmer, the CEO of Mind, highlighted the importance of cultural change and improving support for staff. He highlighted the need for NHS Trust boards to focus on the mental wellbeing of their staff and to ensure that there were adequate numbers of champions inside their organisations. ‘Our Frontline’ also recommended that all employers across NHS and social care:

While the committee of MPs acknowledged the additional support provided for staff during the pandemic, they emphasised that this must be maintained during the recovery period and beyond to stop staff from leaving. The Department and employers need to ensure that such services are accessible to all and used by all who need them. This will require embedding a culture where staff are explicitly given permission and time away from work to seek help when it is needed.

In his oral evidence, Paul Farmer suggested the introduction of a “scorecard approach” for individual NHS and social care employers that measured mental wellbeing. The scorecard would monitor both negative factors – including sickness absence due to mental ill health, and positive factors, including the extent to which colleagues feel in control of their workload, or well-supported by their line manager. Freedom to speak upThe report also highlighted the need to ensure staff have the confidence to ‘speak up’, which must be matched with a culture in which organisations demonstrate that they are not just listening to, but also acting on, staff feedback.

While NHS organisations have a formal structure to raise concerns through Freedom to Speak Up Guardians, there is no equivalent for adult social care. Therefore, the Committee called for the extension of Freedom to Speak Up Guardians for this care domain.

Helené Donnelly OBE, ambassador for cultural change at Midlands Partnership NHS Trust, and former Mid Staffs whistleblower, said that there was a “real appetite” for compassionate leadership across the service. However, it was undermined by managers and, in particular, middle managers being “sandwiched between their teams and trying to support them, but also trying constantly to meet targets with ever-increasing pressure.

”She told the Committee that although the “vast majority of staff”, throughout health and social care, worked exceptionally hard, bullying remained a “real problem” that had to be acknowledged and addressed. She said that it was “in the minority” but emphasised that the results of that behaviour could be “catastrophic”.

A second problem highlighted by Helené Donnelly was the practice whereby those who had behaved negatively did not leave the system altogether, but instead were moved on elsewhere.

This approach merely passed on the problem and led to “more and more staff to feel apathetic and disillusioned”.

She also highlighted the fact that, despite the excellent work of the National Guardians, some Trusts were “still not getting it.” In those cases, “significant deep dive drills” were required to identify where the problems lay and what the barriers were. She added that “greater accountability and sanctions” were required for those who “refuse to reflect and those who persistently and consistently display bullying and intimidating behaviours, even when support has been offered.”

To tackle these problems, she recommended:

Work/life balance

Resetting the work/life balance for staff was also highlighted as an important factor. Rather than being an optional extra or a logistical challenge, flexible working should be seen as a means by which the NHS and social care can keep more staff in health and care careers for longer.

Prerana Issar, NHS chief people officer, told the Committee of MPs that staff in the NHS wanted flexibility “whether that is working from home, when possible, or having a shift system that is not three 12-hour shifts ‘back-to-back’” and that the NHS was looking into “e-rostering and flexibility apps” to support Trusts to that end.

Unequal impact on BAME community

A number of written submissions to the inquiry set out the specific challenges faced by staff from Black, Asian and minority ethnic backgrounds in relation to workplace culture, burnout and resilience. In oral evidence, Dr. Chaand Nagpaul CBE, chair of the BMA Council, said there was a “very definite and worrying impact on BAME doctors, who feel particularly unable to speak out and are more likely to be blamed. There is a lot of evidence that they experience worse inequalities in the NHS.”The Royal College of Midwives also highlighted similar experiences in relation to its members.

The Royal College pointed to data from 2019 indicating that 42% of midwives had reported experiencing discrimination based on their ethnic background.

Lord Adebowale commented that “leaders in the NHS, who are mainly white, generally are not held accountable for leading all the people all the time”. He described this situation as a “systemic issue” in which in the 20% of the workforce that come from Black, Asian and minority ethnic backgrounds are not being adequately represented by their leaders.

Lord Adebowale also highlighted the need for leaders to be held accountable; and that it needed to be “a core measure of system performance and individual performance”. While he supported the work of the CQC, he found it “astonishing” that a Trust could be rated “Outstanding” while 30% of its BAME staff stated that they were performing below standard because of bullying and harassment.

Need for systemic solutions

Ultimately, the report cautioned against a focus on the resilience of individual staff members, advising instead to consider systems and systemic solutions. Cultural change, effective leadership, practical support and long-term capacity planning will be required to address the problem of workforce burnout both now and in the future.

The Rt Hon Jeremy Hunt MP, chair of the Health and Social Care Committee, concluded: “Workforce burnout across the NHS and care systems now presents an extraordinarily dangerous risk to the future functioning of both services. An absence of proper, detailed workforce planning has contributed to this, and was exposed by the pandemic with its many demands on staff. However, staff shortages existed long before COVID-19.

“Staff face unacceptable pressure with chronic excessive workload identified as a key driver of workforce burnout. It will simply not be possible to address the backlog caused by the pandemic unless these issues are addressed.”

Responding to report, Suzie Bailey, director of leadership and organisational development at The King’s Fund, added: “This report provides a stark depiction of the chronic excessive workloads endured by staff across the NHS and social care. It is a bitter irony that so many health and care staff are made ill because of their work. It is particularly shocking that ethnic minority staff report worse experiences of working in the health and care system. In the latest NHS Staff Survey, 17% of black and minority ethnic staff reported experiencing discrimination at the hands of their own colleagues. Sustained and concerted efforts are needed to rid health and care services of this systemic discrimination.

“The added pressure of the COVID-19 pandemic has left many staff physically and emotionally drained, but health and care services have been dogged by staff burnout and workforce shortages for many years. Despite this, successive governments have seen health and care workforce pressures as a problem for tomorrow. In line with the Health and Social Care Committee, we are calling for a new duty to require the regular publication of independently verified workforce projections. While this alone won’t solve the workforce crisis, it will mean Government can be held to account for ensuring the health and care system has the workforce it needs.

“There is an urgent need for a fully funded workforce strategy to increase recruitment, tackle staff burnout, and support health and care leaders to create compassionate and inclusive workplace cultures that staff want to work in. Without such a plan, we will continue to witness the vicious cycle that sees workforce shortages lead to overstretched staff leaving their profession prematurely.

”To download the full report, visit: https://committees.parliament.uk/publications/6158/documents/68766/default/

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