With the NHS nearing crisis point, Medical Workforce Unit (MWU) director Dr Nigel Trudgill outlines the results of the department's new wellbeing survey and discusses what we can do to improve wellbeing among consultant physicians.
At a time of unprecedented demand and financial constraints on the NHS, the wellbeing of staff is a strong indicator of the pressure the service is under. As the recent RCP report NHS reality check: Update 2018[1] shows, significant staff shortages are leading to a demoralised workforce.
The RCP Medical Workforce Unit asked half of all substantive consultant physicians to tell us about the current state of their wellbeing. 2,372 (32%) responded to the survey, which was conducted on behalf of RCP London, RCP Edinburgh and RCPS Glasgow.
Feeling valued
A crucial factor in our wellbeing is whether or not we feel valued by our patients, colleagues, managers and the organisations in which we work. Most consultants clearly continue to have strong working relationships with patients despite the pressures we are all under. A reassuring 89% of consultants feel valued by their patients all or most of the time.
Relationships among staff generally continue to be strong with 81% of consultants feel valued by medical colleagues all or most of the time and 75% by non-medical colleagues all or most of the time.
However, only 60% of consultants feel valued by their line manager all or most of the time. That figure falls to 39% for trust or hospital management.
Workload
Increasing workload pressures are widely evident in the NHS and are reflected in our survey:
- 40% of consultants are never or only sometimes in control of their workload.
- 49% describe their workload as excessive always or most of the time.
- 47% are working excessive hours always or most of the time.
Measures to improve job satisfaction
When asked to rank potential measures to improve job satisfaction, consultants clearly favour protected time for work other than direct clinical care. That includes leadership, education, training and research.
Protected time is followed in the rankings by the ability to work some programmed activities from home, such as SPA time, and the ability to work more flexibly through an annualised contract.
Consultants do not want to work fewer hours, but they do want some control over their work and flexibility in how it is delivered. Consultants are likely to be more productive and satisfied at work if these issues are addressed during job planning.
Impact on sleep and relationships
A 2017 report[2] highlighted the prevalence and dangers of fatigue among NHS staff. We found that 2% of consultants have difficulty sleeping due to work related issues on a daily basis and 19% every week.
Troublingly, 49% report that work has affected their relationship with their partner and 47% their relationship with their children.
Meeting with colleagues
As the RCP Improving teams in healthcare[3] resources explain, the NHS relies on teams to design, deliver and develop world-class patient care. Medicine has always relied on mutually supportive teams among doctors and healthcare staff more generally. Discussing work related issues with colleagues, eating together and meeting outside work help develop and reinforce such bonds.
Seventy-three percent of consultants meet colleagues on a weekly or monthly basis to discuss work related issues, and only 4% described this never happening. However, 35% of consultants never eat meals at work with consultant colleagues and 17% never meet with colleagues outside work.
Morale
As the RCP has found time and again[4], the morale of the medical workforce is at a low ebb. 50% of consultants say that their morale is worse than a year ago, and only 9% that it has improved. 78% say that their working conditions are affecting their morale.
Time off
Thirty-one percent of consultants took time off work due to ill health in the past year, 90% due to their physical health and 10% due to their mental health. While physical health problems were not usually related to work, mental health problems almost always were. Seventy-five percent of consultants described feeling guilty about taking time off work due to sickness.
Burnout
We examined the frequency of six symptoms that suggest someone may be at risk of burnout, based on the Maslach Burnout Inventory[5]:
- emotionally drained at work
- tired when get up before day at work
- less interested in work
- less enthusiastic about job
- more cynical about whether work contributes anything
- doubtful of the significance of work.[6]
Twenty-three percent of consultants experience two or more of the six features of burnout almost always or most of the time. 14% experience three or more always or most of the time.
Sex and age
Among the 25% of consultants most at risk of burnout, there is no difference between men and women. All consultants between the ages of 34 and 59 are equally at risk. Consultants over 60 are at lower risk of burnout, but this is likely to be explained by the fact that they have chosen to continue working despite reaching an age when they could retire or opted to retire and return.
Geography
Consultants in some regions - including Kent, Surrey and Sussex, Scotland, Northern Ireland, East of England and Thames Valley - appear to be at greater risk of burnout. Others appear to be at lower risk – including those in Wales, Wessex, East and West Midlands.
Specialty
There were differences between individual specialities. Haematology, acute internal medicine and gastroenterology have the highest numbers of consultants at risk of burnout. Renal medicine, rheumatology, palliative medicine and genitourinary medicine have low numbers of consultants at high risk of burnout.
Looking at mean scores for burnout of all consultants, the specialities with the highest scores were medical oncology, gastroenterology, haematology, genitourinary medicine, acute internal medicine, neurology and respiratory medicine. It is interesting to note that many of these specialists do not partake in the care of general medical patients or the acute take.
Feeling valued
Consultants at high risk of burnout described feeling less valued by patients (78%), colleagues (60%) and non-medical colleagues (54%). In particular, low numbers feel valued by their line manager (38%) and their trust or hospital management (16%). Those at lowest risk of burnout feel much more valued by patients (97%), colleagues (97%), their line manager (81%), and trust or hospital management (64%).
Workload
The majority of consultants at high risk of burnout are never or only sometimes in control of their workload (70%), always or most of the time work excessive hours (68%), and have an excessive workload (75%). Those at low risk of burnout report the opposite: 29% work excessive hours and 25% have an excessive workload.
Impact on sleep and relationships
Among those at highest risk of burnout, 7% have difficulty sleeping due to work related issues on a daily basis and 35% every week. The comparative figures for those at lowest risk of burnout were nil and 6%.
Seventy-three percent of those at highest risk of burnout said that work had affected their relationship with their partner and 69% their relationship with their children. For those at low risk of burnout the figures were 28% and 26%.
Meeting with colleagues
Forty-four percent of consultants at high risk of burnout never eat meals at work with consultant colleagues, compared with 28% of those at lowest risk. Similarly, 25% never socialise with colleagues outside work, compared to 12% of those at lowest risk of burnout.
Morale
Not surprisingly, morale over the past year was almost universally worse among those at high risk of burnout (81%), unlike those at low risk (21%).
Awards
There was no difference in the frequency with which consultants at high (56%) and low risk (52%) of burnout held CEA point or national awards. Such awards are therefore unlikely to help alleviate burnout.
Time off
Consultants at high risk of burnout were more likely to have taken time off work due to ill health in the past year (36% versus 25% for low risk). Among those who had taken time off, those at highest risk of burnout were much more likely to have taken time off due to their mental health (56% versus 8%). Overwhelmingly, this time off was due work related issues (97%).
What can we do to improve wellbeing among consultant physicians?
As NHS reality check: Update 2018, says, the first thing we need to do to improve morale is to reduce the pressure. While consultants have to act down frequently to cover rota gaps and focus largely on direct clinical care, they will be unable to undertake activities such as leadership, research, education and training. Their wellbeing and morale will suffer as a result.
We therefore need to recruit more doctors from outside the UK and have a robust plan for developing the future workforce. Employers should explore changes to consultants' job plans to keep them working later in their careers and at the same time avoid burnout. The RCP Later careers[7] guidance explains how less than full time working can benefit everyone concerned.
We need to make sure the environment in which doctors work is supportive and enables them to meet and retain professional standards:
- Effective job planning is vital to avoiding burnout among consultant physicians.
- Trusts and hospitals who make sure consultants feel valued are likely to have a positive impact on the risk of burnout.
- Encouraging socialising, both at work and outside it, may have a positive effect on the risk of burnout. The provision of communal places to eat is an important element.
- Formal opportunities to reflect on difficult clinical situations should be encouraged. These include Schwartz rounds[8] and Balint meetings[9].
- Good sleep hygiene, mindfulness, regular exercise and expressing gratitude on a daily basis may all play a role in helping doctors become more resilient[10].
Finally, we need to know more about the causes of burnout. For example, the belief that partaking in the care of general medical patients or the acute take is a major contributor is not supported by these findings. In particular, some specialist societies should consider investigating the factors that contribute to an increased risk of burnout among their members.
Dr Nigel Trudgill FRCP is the director of the RCP's Medical Workforce Unit and consultant gastroenterologist at the Sandwell and West Birmingham Hospitals NHS Trust
References
- https://www.rcplondon.ac.uk/projects/outputs/nhs-reality-check-update-2018 [Accessed 2 April 2018]
- https://www.theguardian.com/society/2017/jul/06/half-of-junior-doctors-having-accidents-or-near-misses-after-night-shifts [Accessed 2 April 2018]
- https://www.rcplondon.ac.uk/projects/improving-teams-healthcare [Accessed 2 April 2018]
- https://www.rcplondon.ac.uk/guidelines-policy/keeping-medicine-brilliant [Accessed 2 April 2018]
- https://en.wikipedia.org/wiki/Maslach_Burnout_Inventory [Accessed 2 April 2018]
- Christian Korunka, Sara Tement, Cristina Zdrehus, Adriana Borza. Burnout: Definition, recognition and prevention approaches; 2010.
- http://www.rcplondon.ac.uk/later-careers [Accessed 5 April 2018]
- https://www.pointofcarefoundation.org.uk/our-work/schwartz-rounds [Accessed 2 April 2018]
- https://balint.co.uk/about/introduction [Accessed 2 April 2018]
- https://www.walesdeanery.org/how-to-guides/how-use-coping-strategies-and-become-more-resilient [Accessed 2 April 2018]