Increased workloads, repeated reorganisation, and a culture of blame and fear are all taking their toll on the health and wellbeing of National Health Service staff. Emma Wilkinson reports.
The UK National Health Service (NHS) is under unprecedented pressure, attempting to do more with less, it is creaking at the seams. And now the latest staff survey figures suggest that staff are feeling the impact. Satisfaction with place of work, pay, and staffing levels have all fallen since 2013. Only 41% said they felt valued and the proportion agreeing they would recommend their organisation as a place to work has dropped.
Clare Gerada, past-chair of the Royal College of General Practitioners, is blunt about the situation: “If the NHS were a patient, it would have depression.”
A series of recent confidential listening events she organised have laid bare tales of unmanageable workload, intolerable stress, and loss of control.
Rare is the person who will admit publicly how much they are struggling for fear that they will lose their job or be deemed incompetent. One general practitioner (GP) who wished to remain anonymous told The Lancet: “Every day, I work a minimum of 12 to 13 hours without a break. I rarely see my colleagues in the practice. Most patients have extremely complex medical conditions, which we’re supposed to deal with in 10 minutes. We’re in a very deprived area and a large proportion of my workload is dealing with mental illness and difficult social problems. We don’t have enough resources and we’re constantly being told by government we’re doing a bad job. I dread going into work and I want to walk away from it all but I don’t know what else I would do.”
Gerada set up the London-based confidential NHS Practitioner Health Programme in 2008 for doctors and dentists with mental health problems and addiction. Since it began it has seen a 400% increase in demand. There has been a notable “explosion” in the past 18 months, she says, and the service is currently closed to new referrals.
Although staff are undoubtedly working harder to keep the NHS running in difficult times, particularly on the front line in primary care and emergency departments, this is not just about working flat out, says Gerada. “I think what we’re tapping into is a result of the fracturing of relationships that happened with the last major reorganisation”, she says, referring to the Coalition Government’s 2012 Health and Social Care Act, which vastly overhauled structures within the NHS.
Senior managers are no longer able to look out for the wellbeing of their staff because they are living in fear of “exposure”, she adds. “Every day there is another story of failure in the newspapers and that’s the culture. Constant battering and negative language.”
This anxiety is an issue highlighted by Robert Francis QC in his recently published review of whistleblowing processes in the NHS. He points to “shocking accounts” of the way some staff have been treated by the NHS and their managers when they have raised concerns about standards of care and the distress this has caused them. In this “climate of fear” staff are being ignored or bullied when they dare to speak out.
Gerada also argues the NHS should be an example of excellence in safeguarding staff wellbeing, yet instead it is relying on rising numbers of temporary staff—a sign of a sick organisation, she says.
At a time when many argue that need is increasing, support services for NHS staff are closing or being downgraded. A self-referral occupational health scheme in Devon and Cornwall for doctors facing burnout is one such example highlighted by doctors’ leaders.
Others point to discussions over the future of Mednet, a gold-standard service that helps doctors in the southeast with stress, depression, and anxiety.
Mark Porter, chair of the British Medical Association (BMA), is “very, very concerned” about the pressures his members are facing at a time when “tremendous resource squeeze” is reducing the opportunity to seek help.
The latest figures from a BMA quarterly tracker survey of 1000 doctors make for stark reading. Half of doctors now report low or very low morale. Three-quarters of GPs reported their workload is unmanageable or unsustainable. In reality, this means many leaving the profession through emigration or early retirement. “It is ingrained in us that the person who shouldn’t suffer is the patient. Trying to make it so whatever you do they’re not the ones who suffer”, Porter says. “We see the pressure from the inside but don’t show that to the patient until the breaking point comes.”
Additionally, in-house occupational health services are not always the answer, he believes, when health workers might feel unable to admit to those within their organisation that they are struggling to cope for fears over what that might mean for their future.
Figures showing more and more doctors quitting medicine or high rates of absence due to sickness are really showing “that moment when the doctor can’t carry on smiling any more”, he adds.
Porter believes at the root is the negative effect of constant political meddling and disruptive and wasteful reorganisations.
The BMA has just launched their No More Games campaign complete with national advertising, calling on all political parties to stop the “Punch and Judy politics” over the NHS.
Jennifer Napier, a GP and National Institute of Health Research fellow who studies wellbeing in doctors, says research in general practice has shown that whenever there are large structural changes there is a dip in morale, which then improves, but in recent years there has been layer upon layer of change with no chance to adjust. “There is a really useful distinction where an organisation is either in survival or development mode and everything we are hearing about the NHS at the moment is about survival, about how am I going to get through the day…If change just carries on happening, we can never get into development mode.”
Across the board
It is of course not just about doctors, increasing levels of work-related stress are being seen across the NHS. Kim Sunley, senior employment relations adviser at the Royal College of Nursing, says their members report finding it incredibly distressing when they are unable to deliver the high standards of care they want to because of understaffing and other pressures. “It is a massive issue and this is one of the key things that causes nurses to tip over the edge”, she says. “There is no downtime, people are doing long days, then being called in on their days off.”
“We have also noticed a high level of ‘presenteeism’, where people would usually be off work because they are unwell, yet come in because they are worried about how their colleagues would cope”, Sunley says.
NHS organisations are cherry picking guidance on wellbeing without dealing with tougher issues on how to manage staff stress, she adds.
Paul Younger, vice-chair of the College of Paramedics, reports similar concerns. “We have seen a massive increase in demand for the ambulance service, with 7 million a year now getting an ambulance response.”
An important aspect of the job, which now rarely happens, is the chance to debrief with senior colleagues. There is just no downtime, Younger says.
Outcomes for patients
Martin Powell, professor of health and social policy at the University of Birmingham, has just published a study looking at the effect of staff engagement and satisfaction on organisational performance. It showed that, generally speaking, better staff experiences are associated with better outcomes for patients. Absenteeism was one aspect that stood out—an important finding, he says, given the current high bill for agency staff.
Similar links have been shown in other sectors, including the airline industry. “Quite honestly, whatever organisation it is, it is not good to have people in front of you who are feeling unhappy with their situation”, he says.
And it is not that the NHS is unaware of the importance of having a happy workforce, he says. “It has been on the agenda since 1997 but in the NHS everything is a priority, which means that nothing is a priority.”
“There has been a tendency for the NHS to understand something, talk about it, issue some guidance, then expect that miraculously everything is implemented.”
Clearly there are some really good examples of NHS organisations supporting their staff well and producing high levels of job satisfaction, Powell says, “but how do you bottle that and reproduce it right across the UK?”
What is needed goes beyond recommendations made in the past, says Gerada, including a national conference to tease out what is happening to staff in the NHS. “There needs to be a focus on staff health and wellbeing and a national lead responsible for that.”
“It is about enabling us to deliver compassionate care to our patients.”
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