Caring for doctors, Caring for patients

In September 2019, Professor Michael West, Professor of Organisational Psychology at Lancaster University Management School and Senior Visiting Fellow at The King’s Fund presented at “Making Life Work Better”, a one-day conference run in partnership with our college, NHS Greater Glasgow and Clyde Health Board and Medics against Violence.

Caring for doctors, Caring for patients

Michael West photo

In September 2019, Professor Michael West, Professor of Organisational Psychology at Lancaster University Management School and Senior Visiting Fellow at The King’s Fund presented at “Making Life Work Better”, a one-day conference run in partnership with our college, NHS Greater Glasgow and Clyde Health Board and Medics against Violence.

In his address, Professor West previewed the content of his forthcoming report for the General Medical Council “Caring for doctors, Caring for patients”, which was published in November. You can find a copy of the full report online.

In the latest edition of our membership magazine “voice”, we published an edited transcript from Professor West’s lecture. In this, Professor West explains the importance of ensuring doctors’ mental health and wellbeing, and how this also helps our patients. College Members can read the full version of “voice” by logging into their online dashboard account.

“The work we do is about working together to try to ensure that those in the communities we serve live their lives in the most fulfilling way possible. This is to make the potential of people’s wonderful, unique, mysterious lives.

“What’s also important is that, in pursuit of that vision or mission, how do we ensure that those who provide health and social care also live the fullest, most fulfilling, wonderful lives possible? Because those things fundamentally go together, but we can only provide that care if it enables people, young children and ageing relatives to live their lives to the fullest extent possible. This means those who provide that care need to be fulfilling their own potential in their lives as well.

“So the focus of “Making Life Work Better” is fundamentally important. If we look at the data on stress and wellbeing amongst doctors in the United Kingdom, it tells a very deeply concerning story. We’ve drawn from the GMC inquiry that I co-chaired with Dame Denise Coia, on the data sets from the National Staff Survey in England and staff surveys in other UK countries, as well as the GMC National Training Surveys. What that tells us is in secondary care in England, 37% of doctors report being unwell as a result of stress at work during the previous year. 47% are planning to leave their organisations and 17% are planning to leave the NHS altogether.

“We see similar concerning data from GPs across the United Kingdom – 35% of GPs say they’re planning to quit general practice within the next five years and they have the lowest levels of satisfaction since we began recording GP work life satisfaction back in 1998. In Scotland, 26% are planning to leave within the next five years, many citing excessive workload as the primary factor.

Going to work unwell and workloads

“Doctors, more than other healthcare staff groups, tend to go to work when they’re unwell. We know this is damaging their long term health and wellbeing. It’s also damaging their ability to provide high quality care and can also be problematic for patients who are already immunocompromised.

“When it comes to going to work when you’re unwell this happens with 47% of doctors in Wales and 42% in England. We see lots of data from all four UK countries telling us that doctors are dealing with unmanageable workloads and working more than the hours that they’re supposed to work. What we see from the data is that working longer hours than one is contracted for is very damaging to health and wellbeing.

Professor Michael West speaking at “Making Life Work Better”

“In Scotland, only 37% of doctors say that they are able to meet all of the conflicting demands that are placed on them at work. Only 31% say there is enough staff for them to be able to do their jobs properly. We know that all of these things have an effect on our ability to be compassionate. We know that approximately 56% of clinical staff, in studies internationally, say they do not have time to be compassionate.

“The evidence we have is that compassion is probably the most potent element of healthcare. We also see that there are very high levels of perceptions of bullying and harassment amongst doctors at the highest levels for some five years, with 36% of doctors in England reporting that they’ve been bullied or harassed or abused by members of the public and 17% by their managers.

“There are some subgroups who do seem to be particularly at risk, and we see in the National Staff Survey data in England that gender discrimination amongst junior doctors has risen while perceptions of gender discrimination have risen dramatically in the last five years. We see also very high levels of discrimination reported by doctors from a BME background, particularly international medical graduates and SAS doctors. Doctors are more likely to report racial discrimination at work than any other groups of staff. So overall, this paints a very disturbing picture of the experience of the people at work who we are asking to care for the health and wellbeing of others.

“We know stress at work is generally chronic rather than transient. If you’re experiencing stress at one point in time – six months, nine months later, you will be experiencing similar levels of stress and chronic stress. Stress has a dramatic impact on our health, cardiovascular disease, likelihood of addictions, diabetes, cancers, likelihood of chronic depression. All of that has an impact on outcome.

“For me, it is an extraordinary irony that we have in the health and care services probably the most skilled, motivated workforce in the whole of industry. Yet we manage them through direction and command and control. It makes no sense. And when we look at some of the data on outcomes, we see that meeting these core needs is really important.

Patient dissatisfaction

“The number one predictor of patient dissatisfaction is excessive workload. So, when healthcare staff report excessive workloads or high workloads, patients are much more dissatisfied with the care they’re receiving. It undermines that sense of competence and control when staff report discrimination that there aren’t equal opportunities, patients report much lower levels of satisfaction.

“Their sense of belonging to staff is undermined when there is discrimination and inequality within our organisations. Though the staff discriminated against may be a small minority, the emotional ripples spread out. Team working, which gives a sense of belonging, is fundamentally important to patient satisfaction.

“As you see, being able to do work of a quality that I am satisfied with is vital. The belonging to autonomy and the sense of competence are vital to wellbeing. We also see that when staff are highly engaged because those core needs are being met, that in the acute sector patient mortality is significantly lower. We see clear evidence that when those needs are being met, the financial performance of organisations is better. We know, for example, that the more engaged staff are, the lower is spent on bank and agency staff.

“In fact, in the five point measure of staff engagement in the national staff survey in England, a shift upwards by an average of 0.12 for a trust in their staff engagement score is associated with annual savings of £1.7 million on bank and agency spend. So, we often get kind of caught up with financial performance as an outcome not realising the factors that drive financial
performance and the wellbeing of staff is critical.

“If we look at the work we’ve been doing for the GMC review, we’ve been using the datasets that I described to get some deeper understanding of the factors that have a negative contribution to doctors’ wellbeing and engagement and intrinsic motivation and also some of the factors that make a positive difference.

“When we look at the National Training Survey, we see that workload, working long hours, poor rotas all make a dramatic difference to the experience of burnout and to overall satisfaction. We also see that there are factors that make a huge positive difference and actually ameliorate the effects of some of these negative factors. So we see things like working in a team with clear objectives that meets regularly to review performance.

Supportive environment

“The importance of working in a supportive environment with supportive supervisors and having good educational supervision makes a huge difference to the wellbeing of doctors, so much so that it can almost wipe out the negative effects of workload pressures. When we look at secondary care, we’ve looked at a range of factors that can have an impact on outcomes like supportive leadership team work, senior leaders who listen to doctors who seek out their voices to understand what their concerns are and who empower doctors by giving them influence over the decisions that are made in their work areas and their organisations.

“When you have a supportive bundle or a context like that, then we see much higher levels of satisfaction and engagement. If we look at the impact on the kind of negative outcomes we see, that having those sorts of conditions in place makes a huge difference to doctors’ intentions to quit. The effect size again is very, very strong indeed.

“This data, as well as the published research, give some indication of the kind of interventions we might want to make. For our GMC inquiry, we’ve made a really clear decision to focus on what we’ve called primary interventions so we can distinguish between primary, secondary and tertiary interventions.

Primary interventions

“Primary interventions are those that are focused on the workplace that have an impact on the wellbeing of people at work. Secondary interventions are more focused at the individual level. Meditation practices, exercise, yoga, fun events, and so on. And tertiary interventions are those that deal with the outcomes of stress at work, counselling services are an example of this.

“We have decided to focus much more on the primary interventions. There are lots of good interventions going on in the secondary area, but we think it’s really important that we focus on primary interventions to deal with the underlying causes of many of these problems, not just to deal with some of the outcomes. So we want to promote the primary interventions that might have an effect on the core needs of people at work. If we take an area like autonomy and control, then one of the key interventions that should make a big difference is ensuring that doctors have voice and influence within their organisations – that they feel a sense of control at every level that they can influence what goes on.

“It seems to me vital that organisations and leaders of our health services pay really close attention to our findings, because the data shows that we simply cannot go on in the way we are. We can’t keep loading more and more responsibility onto doctors when they’re already failing to cope adequately. So we must transform the way that we work within our organisations. That means giving doctors much more voice and influence and moving away from what I guess can be seen often as blame cultures to cultures that are more focused on justice and learning.

“I think the other really important thing to say is that for everything I talk about today in relation to interventions, we have great examples around the UK of organisations that are doing things like this really effectively and really well. And if one organisation can do it, then all can do it. This is not only the moral issue of preserving the health and well-being of those who deliver care – it’s also because we’re able to demonstrate the extraordinarily dramatic impact of doctors, health and wellbeing on patient outcomes.

Basic work conditions

“The second is the importance of addressing basic work conditions. It costs, if you take private financing into account, over half a million pounds to train a doctor. And yet we’re placing people in working conditions, for example, where they don’t have lockers to put their valuables in. or, if
there is a locker then it doesn’t lock. In conditions here they don’t have anywhere to sleep or to rest when they’re on a 12-hour night shift, or if there is somewhere it’s a dirty old couch or they’re charged to hire duvets.

“Or they’re asked to use IT systems that simply don’t work. Where they have to have a different password for every system or they’re using mobile computers where the batteries have run out. It just makes no sense. So it’s about changing the circumstances that doctors face in their organisations that they have a sense of control because there’s voice influence, a sense of justice. It’s also about the basics of rota design.

“You will be familiar with the absurdities of rota design. We’ve heard multiple stories that just beggar belief about somebody booking their wedding and hoping to be able to be off on their wedding day six months ahead and then three days ahead still not having that confirmed. So they pay for a locum themselves. It just demonstrates inhumanity, lack of respect, lack of valuing people.

“Getting rota design right is something that many organisations do well. If one can do it then we have some great examples that we can share. The second is about creating a sense of belonging and community, and actually what the data tells us is doctors working in teams have much higher levels of wellbeing and much lower levels of stress.

Working in teams

“We human beings have been working in teams for about 300,000 years. It’s something we do very well. Not having a team structure, not being part of a home team creates a sense of disconnection and alienation. So it’s really important that we face what is quite a difficult issue. Think about how we ensure that all doctors work in a home team, that they’re part of a relatively stable team. Of course, you’re going to be members of multiple teams. But it’s important that there’s a home team that provides support and a place for learning and sense of belonging.

“As I’ve shown you, the data we have shows that being part of a team is fundamentally important to the health and wellbeing of doctors. It’s also about making sure that we are creating nurturing cultures focused on high quality care and the health and wellbeing of staff.

Leadership

“We have, again, a lot of data showing that where cultures are positive and led by leaders whose core values in their leadership are focused around compassion, that those organisations are much more effective in delivering patient care and staff wellbeing is much higher. It’s how we can continue to nurture cultures of high quality care led by compassionate leaders who don’t adopt command and control, but a much more collective stance to leadership.

“That’s a key challenge for us and that we must continue to address. We’ve developed a cultural leadership programme for NHS organisations, which was launched in 2016. There are now 80 organisations in Wales, Scotland, England, and Northern Ireland, as well as places further afield using that programme. The resources are there to create those kinds of cultures, and team working is a fundamental part of that. The third is the importance of that sense of competence.

“The most important factor here is chronic excessive workloads and I think there’s a real danger to accept the fact that working as a doctor is tough, it’s challenging, it’s hard. But, enduring chronic excessive workloads is unacceptable because we have so much data telling us that workload is the number one predictor of patient dissatisfaction. It’s the number one predictor of staff stress. It’s associated with high levels of errors made by doctors. It’s also associated with low levels of engagement and low levels of innovation.

“If we sit and simply continue to see workload as part of the wallpaper, then we’re not dealing with what I think is the single biggest challenge facing our healthcare systems. So it’s the responsibility, I think, of all leaders in healthcare to address the issue of chronic excessive workload continuously.

“Secondly, it’s really important to make sure that we’re providing supportive supervision to everyone who works in healthcare, to all doctors, whether junior doctors or consultants. We need to make sure that there is a line manager or a supervisor who can provide that compassionate support and help them deal with the obstacles that occur in the course of day-to-day work. The most important task of a leader, of a supervisor, of a manager is to help those they lead to do the job that they want to do, which is to provide high quality, compassionate care to the people of the communities we serve.

“In relation to belonging – the importance of equality and positive diversity and inclusion, is a key part of creating cultures of belonging and how we address the differential attainment in the discrimination experienced by people in minority groups. But, the most important recommendation I would make to leaders in any area of healthcare is that they nurture their
compassionate leadership.

“We have an enormous amount of evidence showing that these four behaviours in leaders are key to effective leadership. Leaders who listen with fascination to those people they lead. The most important skill of a leader is listening to those we lead. These are leaders who listen and leaders who have the courage to listen. Leaders who take the time to understand the challenges that those they lead face and who empathise with those they lead.

“Given the data, it’s really important that leaders take intelligent action to help. That’s what leadership is – intervening to help those who need it. I think compassionate leadership is vital in all of our organisations and I’m delighted that Project Lift in Scotland, the national strategy in Northern Ireland, the New National Strategy in Wales and the New People Plan in England are all emphasising compassionate leadership as the core of their leadership strategies. But I think it’s also important that doctors also model compassionate leadership and that we model compassionate leadership in our own behaviours and in our organisations.

“We should listen with fascination to each other, understanding, emphasising and taking action to help. But in order to do that effectively, to have the capacity and the resilience to be compassionate as leaders, we have to first be self-compassionate. That’s about paying attention to ourselves, understanding the challenges we face in our work lives and in our lives generally. Caring for ourselves, empathising with ourselves and then taking action to help ourselves in order that we can be the best people we can be, and stay close to the core values that give our lives meaning.

“In that way, we build deeper and closer connections with those we provide care for, those we lead, those we work with, and everybody in our lives.”


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