Health Select Committee: inquiry into Workforce burnout and resilience in the NHS and social care

The RCoA submitted evidence to the Health Select Committee for an inquiry on Workforce burnout and resilience in the NHS and social care.

How resilient was the NHS and social care workforce under pre-COVID-19 operating conditions, and how might that resilience be strengthened in the future?  

Prior to the pandemic, the NHS and social care workforce was already facing considerable pressures due to our ageing, changing, and growing population. It is clear from our research that anaesthetists were going to great lengths to deliver safe care for patients within that challenging climate, often at the expense of their own health and wellbeing. For this reason, the RCoA advocate for an increase in number of the anaesthetic workforce as the most important way in which resilience could be improved. We also monitor how workforce pressures have impacted the morale and wellbeing of our members.

In 2017 the College carried out a survey carried of 2,312 anaesthetists in training (accounting for half of the total of anaesthetists in training in the UK)[1]. The findings showed that trainees were under considerable pressure:

• 85% of anaesthetists in training were at high risk of burnout
• Up to 78% of anaesthetists in training had experienced a detrimental impact to their health as a direct result of their employment
• 61% of respondents felt their job negatively affected their mental health

These pressures have continued and in 2019 the Association of Anaesthetists published the findings from a survey on extent and impact of fatigue on consultant anaesthetists and intensivists[2]. The survey received 3,847 responses, and found that:

• 91% of consultant doctors who responded experience work-related fatigue and 50% of them reported this had a moderate or severe impact on health, wellbeing, work and home life
• 45% of respondents admitted to either having a car accident or near miss when commuting whilst fatigued, with 1 in 10 of these as a consultant
• only a third (34%) said they had access to a private rest facility when on-call
• most respondents (62%) did not feel supported by their organisation to maintain their health and wellbeing

What has the impact of the COVID-19 pandemic been on resilience, levels of workforce stress, and burnout across the NHS and social care sectors? 

Anaesthetists of all grades have played an indispensable role in treating the sickest COVID-19 patients and a considerable proportion of the anaesthetic workforce was redeployed at the peak of the pandemic to support the efforts of Intensive Care Units.

Between April and July 2020, the RCoA conducted surveys to develop snapshot ‘views from the frontline[3]’ of anaesthesia aimed at producing a detailed picture of the issues faced by anaesthetists during COVID-19, including their wellbeing.

The first survey[4], conducted at the peak of the pandemic, found that one in ten anaesthetists (14%) were at risk of burnout, while over two thirds were under a high degree of pressure. One-third (34%) had felt physically unwell, and four in ten (44%) felt mentally unwell, as a direct result of COVID-19 stress.

In a subsequent survey in May[5], as the number of COVID-19 patients requiring intensive care started to decrease, the above findings persisted with 12% of respondents feeling at risk of burnout, 32% having felt physically unwell and 42% having felt mentally unwell.

The last survey was carried out in July[6], after the peak of the pandemic. Despite the sharp decrease in COVID-19 cases, the findings showed that anaesthetists were still experiencing stress, with nearly two-thirds of respondents (64%) suffering mental distress because of COVID-19, furthermore nearly one in four (24%) were not able to take the time off they needed to seek help or rest. 

In addition, a study[7] commissioned by the RCoA, Association of Anaesthetists and the NIHR Imperial Patient Safety Translational Research Centre to The Behavioural Insights Team found that 80% of anaesthetists in training surveyed said coronavirus had negatively affected their wellbeing at work.

The Faculty of Intensive Care Medicine (FICM) surveyed its consultant membership from 1st to the 15th October 2020. The findings show that the pandemic has resulted in consultant intensivists suffering significant physical and mental stress. More than 80% had to increase their total working hours due to COVID-19 as well as the usual clinical critical care demands, which although less, were also present throughout the pandemic and increased significantly after the 1st wave. There has been little or no significant rest period. During the worst months, more than 70% had to cover colleague’s sick leave, and in addition most had leave cancelled, conversion of supporting professional activities into clinical sessions, and sessions in other specialities (anaesthesia mainly) converted into critical care sessions. Due to the huge increase in clinical demand many consultants were resident on-call, and many had a large increase in their weekend working, impacting on their family.  

As a second surge of coronavirus cases emerges it is clear that the pressures on anaesthetists outlined above will be magnified by the need to maintain services for non-COVID patients whilst also supporting the work of intensive care units.

What long term projections for the future health and social care workforce are available, and how many more staff are required so that burnout and pressure on the frontline are reduced? To what extent are staff establishments in line with current and future resilience requirements?

Data collected through the latest RCoA Medical Workforce Census 2020[8] paints a worrying downward trend for the UK anaesthetic workforce:

• The mean growth rate for consultant anaesthetists across the UK, 2007-2020 is now at 2.1% per year, less than the 2.3% growth rate per year, 2007-2015 noted in the last College census
• More than 90% of anaesthetic departments in the UK have at least one unfilled consultant post
• A comparison of previous censuses with the latest 2020 census shows that the funded workforce gap in consultant anaesthetists has been steadily increasing across the UK from 4.4% in 2015 to 8% in 2020, and that the aspirational gap (the number of anaesthetists required to deliver the service sustainably) is currently at 12%
• There were 680 funded but unfilled consultant posts at the time of completing the latest census
• The anaesthetic workforce is ageing. The number of consultants who now work beyond 60 and approaching retirement is up from 5% in 2015 to 7% in 2020.
• Specialty and Associate Specialist (SAS) and Trust doctor numbers are unchanged compared to the 2015 Census, despite increased demand and their key role in delivery of anaesthetic services and, in many instances, supporting anaesthetic rota gaps. 39% of respondents across the UK report an increase in trainee/SAS rota gaps over the last 12 months.  

Based on the workforce gaps identified by our latest census, we estimate that an additional 600 to 700 anaesthetists in training will be required over the next seven years (the length of the full anaesthetic training programme) to meet future demand.

In an already understaffed consultant intensivist workforce, any reduction in the number of staff through stress or burn out will have a significant effect on the ability to manage a second surge, and also a significant impact on colleagues. Hospital administrative boards need to minimise the loss of consultant intensivists by putting measures in place to mitigate the demands on the critical care workforce, and to reward them fairly. This has not been the case equally across the U.K and leads.

If demands increase too far in the second surge then despite efforts to maintain other NHS services, additional support will again be required in critical care to reduce the burden. Many intensivists are apprehensive about a potential loss of support from their anaesthetic colleagues, from surgical proning teams, respiratory medicine and infectious disease consultants. The junior critical care staff have really stepped up, many into consultant work, and have provided an invaluable service.

The RCoA recommends the adoption of a sustainable, long-term approach to the funding of medical training places in the UK, which takes into account long-term workforce planning requirements at system level, the ability of hospitals to accommodate trainees year on year and the experience and quality of training for doctors.

To what extent are there sufficient numbers of NHS and social care professionals in training for service and resilience planning? On what basis are decisions made about the supply and demand for professionals in training? 

There is no single dataset on the UK workforce in anaesthesia, critical care and pain medicine that includes:

• The numbers enrolled in a training programme from the start of core training through to the end of the specialty training programme (i.e. CT1 to ST7)
• The number of doctors working across all grades (and including Anaesthesia Associates)
• A projection for the demand for anaesthetic, critical care and pain services over an

agreed time-set, that is universally recognised as the ‘official’ projection

• Comprehensive figures on the recruitment, retention and retirement of the workforce

This is an issue faced by all medical specialties and many Medical Royal Colleges continue to call for a centralised real-time workforce dataset to be made available to national, system and local bodies to enable them to carry out accurate workforce planning based on population needs and local service demand.

Will the measures announced in the People Plan so far be enough to increase resilience, improve working life and productivity, and reduce the risk of workforce burnout across the NHS, both now and in the future? 

There are many excellent initiatives in the People Plan to address the morale and wellbeing of the NHS workforce and we welcome its commitment to make the NHS a great place to work. However, no amount of wellbeing initiatives will improve morale and reduce burnout without a long-term sustainable commitment to addressing workforce shortages across the whole of the health and social care system.

By addressing workforce shortages, not only will NHS staff be happier, healthier, and more productive, but patient safety will be maintained and public confidence restored.

[1] RCoA. Welfare and Morale Report 2017

[2] AAGBI. Anaesthesia: A national survey of the effects of fatigue on trainees in anaesthesia in the UK 2019

[3] RCoA. Views from the frontline of anaesthesia during the COVID-19 pandemic 2020

[4] RCoA. View from the frontline of anaesthesia during COVID-19, April 2020 survey results

[5] RCoA. View from the frontline of anaesthesia during COVID-19, May 2020 survey results

[6] RCoA. View from the frontline of anaesthesia during COVID-19, July 2020 survey results

[7] The Behavioural Insights Team. Dear Doctor’: Results from a RCT 2020

[8] RCoA. Medical Workforce Census Report 2020 (due for publication November 2020 - data available on request)