Caring for doctors

Caring for patients

How to transform UK healthcare

environments to support doctors and
medical students to care for patients
Professor Michael West and Dame Denise Coia
 1

Table of contents
Case study map 3
Glossary 5
Abbreviations for organisations 6

Foreword 7

Co-chairs of the review 9

Executive summary 11
Patient safety depends on doctors’ wellbeing 12
Review approach 14
ABC of doctors’ core needs 15
Immediate steps 16
Our call to action 18

Introduction and aims 19

Aims 20
The context 21
Incidence and prevalence of strain 23
Variation between sub-groups 25
Consequences 28
ABC of doctors’ core needs 30

Improving the work environment for doctors 32

A – Autonomy/control 34
Voice, influence and fairness 35
Work conditions 40
Rotas and work schedules 44

B – Belonging 48
Team working 49
Culture and leadership 54

C – Competence 58
Workload 59
Management and supervision 67
Learning, training and development 70

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Conclusion 79

Annex 1 – Action plan 81

Annex 2 – Approach to review 99

Annex 3 – Additional case studies 112

Annex 4 – Compassionate and inclusive leadership 130

Annex 5 – Sources of support 134

Bibliography 136

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Case study map

ix

i 21
i UK-wide
xiii 13 16 18 22 24

v xi xiv

7
viii

23 19
Overseas
vii
3
2 14 21 25 x

10
iii
1 9 20

11 4 5 12 15

iv vi ix xv
ii

17

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Key
A – Autonomy/control Annex 3 – Additional case studies
1 Voice and influence in practice 37 i Wellbeing intervention pilot 113
2 Doctors’ voice and influence 38 ii Wellbeing and peer support 116
3 Creating just cultures 38 iii Listening to doctors’ concerns 116
4 Work conditions 42 iv Inter-professional education 117
5 Managing fatigue effectively 43 v Emergency medicine workforce 118
6 Effective rota management 45 vi Buddying agreements for trusts 119
7 Locum's Nest app 46 vii Listen-act-develop model 120
8 E-Rostering 46 viii Collective Leadership project 122
ix Staff wellbeing programme 123
B – Belonging x Tool to improve working patterns 124
9 Multidisciplinary board rounds 51 xi Feedback on GP appraisal 125
10 General practice team working 52 xii Supporting doctors in difficulty 126
11 Team working in a crisis 52 xiii Medical peer support 127
12 Multidisciplinary team working 52 xiv Learn Not Blame campaign 128
13 Changing cultures in the NHS 56 xv Ethnic Minority Network 129
14 Developing clinical leadership 57

C – Competence
15 Jointly reducing workload 61
16 Recruit from other countries 63
17 Task shifting in primary care 64
18 Task shifting in surgery 64
19 Workload in general practice 65
20 Releasing doctors’ time 66
21 Improving appraisal 69
22 Support for GP development 73
23 Clinical placement facilitators 73
24 Improving surgical training 75
25 Integrated foundation training 76

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Glossary
AHP Allied Health Professions
ARCP Annual Review of Competency Progression
BME Black and Minority Ethnic
BMJ British Medical Journal
CCG Clinical Commissioning Group
CLP Clinical Leadership Programme
CPF Clinical Placement Facilitator
CPS Clinical Placement Supervisor
EPR Electronic Patient Record
F1 Foundation Year 1
FOI Freedom of Information
FT Foundation Trust
GCM General Clinical Mentor
GP General Practitioner
HSC Heath and Social Care
IMG International Medical Graduate
ISG Improving Surgical Training
IT Information Technology
LGBT Lesbian, Gay, Bisexual and Transgender
NAC Newly Appointed Consultant
NTS National Training Survey
SAS Staff grade, associate specialist and/or specialty doctor
ScotGEM Scottish Graduate Entry Medicine programme
WRES Workforce Race Equality Standard

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Abbreviations for organisations

AAGBI Association of Anaesthetists of Great Britain and Ireland
BMA British Medical Association
CQC Care Quality Commission
DOH Department of Health
FMLM Faculty of Medical Leadership and Management
GCC General Chiropractic Council
GDC General Dental Council
GMC General Medical Council
GOC General Optical Council
GOsC General Osteopathic Council
GPhC General Pharmaceutical Council
HCPC Health and Care Professions Council
HEE Health Education England
HEIW Health Education and Improvement Wales
HIS Healthcare Improvement Scotland
HIW Healthcare Inspectorate Wales
HSCNI Health and Social Care Trusts in Northern Ireland
HSE Health and Safety Executive
ISD Information Services Division
MSC Medical Schools Council
NES NHS Education for Scotland
NHS National Health Service
NIMDTA Northern Ireland Medical and Dental Training Agency
NISCC Northern Ireland Social Care Council
NMC Nursing and Midwifery Council
PMCAT Primary Medical Care Advisory Team
PSNI Pharmaceutical Society of Northern Ireland
QUB Queens University Belfast
RCGP Royal College of General Practitioners
RCoA Royal College of Anaesthetists
RCP Royal College of Physicians
RCS Royal College of Surgeons of England
RQIA Regulation and Quality Improvement Authority
SAMD Scottish Association of Medical Directors
SCW Social Care Wales
SSSC Scottish Social Services Council

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Foreword

Professor Michael West and Dame Denise Coia

Foreword 8

Foreword
In 2018 the General Medical Council asked Professor Michael West and Dame
Denise Coia to carry out a UK-wide review into the factors which impact on the
mental health and wellbeing of medical students and doctors.

The detailed practical proposals in this report provide a road map to health service
leaders faced with the challenge of developing healthy and sustainable workforces.

It may not yet feel like it for those on the frontline, but we are seeing positive change.
Intentions are becoming actions. There is now clear consensus across the health
service on a range of issues that affect patient welfare and doctors’ wellbeing. All the
evidence indicates that organisations who prioritise staff wellbeing and leadership
provide higher quality patient care, see higher levels of patient satisfaction, and are
better able to retain the workforce they need.

Whilst the report emphasises the need for organisations to have leaders that act
compassionately and promote wellbeing, it also makes clear that all doctors have
an important leadership contribution to make.

The time is now. The development of people strategies across all four countries
of the UK provides an opportunity to drive real and lasting change, to deal with the
problem rather than the symptoms.

This is not just about money; it is about behaviour and actions. If we act together
we will avoid losing good doctors and seize a golden opportunity to tackle the
challenges the health service must meet now and in the future. But there must be
greater consistency across the UK. The findings and recommendations from this
review aim to achieve that, so that together we can deliver the cultures and working
environments that doctors and patients deserve.

We accept all the recommendations for us, and we encourage all organisations
referenced in this report to do the same. Promoting and supporting the work
identified in this report will be a priority for the GMC in the years ahead.

Making the NHS a better place to work and able to meet the needs of our patients
must be a shared endeavour – none of us can assume that it is someone else’s job.

Dame Clare Marx DBE DL FRCS

Chair, General Medical Council

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Co-chairs of
the review

Professor Michael West and Dame Denise Coia

Professor Michael West 10

Co-chairs of the review

Professor Michael West

Professor Michael West is a Senior Visiting
Fellow at The King’s Fund, London and
Professor of Organisational Psychology at
Lancaster University Management School. He is
a fellow of a number of societies, associations
and academies.

For over 30 years, the focus of his research has

been culture and leadership in organisations,
and team and organisational innovation and
effectiveness, particularly in relation to the
organisation of health services.

Michael has provided policy advice to many UK and international health service
organisations, including the Department of Health and Social Care in England,
Health Education England, NHS Improvement, the Department of Health in Northern
Ireland and Health Education and Improvement Wales.

He has also worked directly with a number of NHS trusts and health boards
across the UK to develop compassionate leadership and cultures of high quality
care for patients.

Dame Denise Coia

Dame Denise Coia is a clinical psychiatrist
and leader in the field of mental health.
She was a medical advisor to the Scottish
government on mental health issues from 2006,
and she conducted the review on Child and
adolescent mental health services in Scotland.
She previously held the position of Chair of
Healthcare Improvement Scotland and was Vice
President of the Royal College of Psychiatrists.

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Executive
summary

Patient safety depends on doctors’ wellbeing 12

Review approach 14
ABC of doctors’ core needs 15
Immediate steps 16
Our callMichael
Professor to action
West and Dame Denise Coia 18
Executive summary 12

Executive summary
Patient safety depends on doctors’
wellbeing
Medicine is a tough job, but we make it far harder than it should be by neglecting
the simple basics in caring for doctors’ wellbeing.

The wellbeing of doctors is vital because there is abundant evidence that workplace
stress in healthcare organisations affects quality of care for patients as well as
doctors’ own health1-5. In two studies, researchers found that doctors with high levels
of burnout had between 45% and 63% higher odds of making a major medical error
in the following three months, compared with those who had low levels6.

There is abundant evidence that workplace stress in

healthcare organisations affects quality of care for
patients as well as doctors’ own health.
Patient satisfaction is also markedly higher in healthcare organisations and teams
where staff health and wellbeing are better1-5. And there are many good examples
of such teams and organisations across the UK.

The wellbeing of doctors is also vital because it is linked to a significant problem

with retaining doctors, which is exacerbating existing difficulties with providing
the numbers of doctors needed to support our health services7. Just under half of
doctors working in hospitals and other secondary care organisations in England
are considering leaving the organisations in which they work (47%, 2018 NHS Staff
Survey in England8). Nearly one in five (17%) are considering leaving the National
Health Service (NHS) altogether8, and the same patterns are seen across the UK
(Health and Social Care Northern Ireland 2015 Staff Survey and NHS Wales
Staff Survey 2018)9-10.

The wellbeing of doctors is vital because it is linked

to a significant problem with retaining doctors.
The eighth National GP Worklife Survey in England, published in 2017, reported the
lowest levels of job satisfaction among GPs and revealed the highest levels of stress
since the survey began in 1998; it also showed that 35% of GPs were intending to
quit direct patient care within the next five years11. In Scotland 26% of GPs said they
are unlikely to be working in general practice in five years’ time, citing unsustainable
workloads and unmanageable stress levels as the main reasons12.

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Executive summary 13

Over a third of doctors working in secondary care also indicated that they’d been
unwell as a result of work-related stress in the previous year, 37% of doctors in the
2018 NHS Staff Survey in England8; 36% of doctors in the 2015 Health and Social
Care Northern Ireland (HSCNI) Staff Survey9; and 34% of doctors in the NHS Wales
Staff Survey 201810.

Our aim should be to ensure that the NHS is a

model for the world, in creating workplaces that
support doctors and other healthcare staff by
promoting their mental health and wellbeing.
Nearly one in four doctors in training in the UK, and one in five trainers said they felt
burnt out to a high or very high degree because of their work (2018, General Medical
Council (GMC) national training surveys (NTS))13. And nearly half of doctors in training
reported working beyond their rostered hours, while one in five said that their
working pattern had left them short of sleep.

Our aim should be to ensure that the NHS is a model for the world, in creating
workplaces that support doctors and other healthcare staff by promoting their
mental health and wellbeing. This is consistent with the service’s core purpose,
to develop the health of our population – of which doctors, numbering more than
300,000, constitute a sizeable group14. Doctors’ health and wellbeing are critical to
the quality of care they’re able to provide for patients and communities; affecting
their compassion, professionalism and effectiveness1-5. While this review has covered
the wellbeing of the medical profession, it is important to note the issues apply
to other staff working alongside doctors in healthcare, as highlighted by Health
Education England’s (HEE) NHS Staff and Learners’ Mental Wellbeing Commission.

Ensuring that working conditions, in both primary and secondary care, are
supporting doctors in their work is fundamental to the success of our health
services. Including private funding, the total cost of training a doctor is over half a
million pounds15; yet many workplace environments are not designed to ensure best
use of their skills. Instead, workplace factors are often reducing productivity and
undermining good patient care, by damaging the health and wellbeing of doctors1-5.

We face a situation that demands integrated and targeted action to address the
underlying factors that affect doctors’ wellbeing. There are some primary and
secondary care organisations that are effectively supporting doctors to do their vital
work and we have included case studies in this report to show how they are doing
this. This should be achievable in all healthcare settings.

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Executive summary 14

System partners, including regulators and improvement bodies, have a role in

working with the profession, employers of doctors, and each other to improve
doctors’ working lives. Existing initiatives include:

● The People Plan by NHS England

● The Health and Social Care Workforce Strategy 2026: Delivering for
Our People, in Northern Ireland

● The Ministerial Short Life Working Group on Culture, and Project Lift,
in Scotland

● The Health and Social Care Workforce Strategy and the Health and Social
Care Leadership Framework, in Wales

We must build on good practice and these initiatives

to create the conditions to ensure the NHS attracts,
supports and retains its doctors.

The GMC has said it is keen to cooperate with those coordinating these programmes
to ensure the wellbeing of doctors.

We must build on good practice and these initiatives to create the conditions to ensure
the NHS attracts, supports and retains its doctors. That is the aim of this review.

Review approach
The focus of this report is on identifying causes, consequences and solutions.
The review aimed to take account of the experience of all doctors and medical
students working and learning within the UK’s healthcare systems, in both primary
and secondary care. The starting point is understanding the needs of doctors in
the workplace.

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Executive summary 15

ABC of doctors’ core needs

To ensure wellbeing and motivation at work, and to minimise workplace stress,
people have three core needs, and all three must be met.

A 
Autonomy/control – the need to have control over our work lives, and to
act consistently with our work and life values.

B 
Belonging – the need to be connected to, cared for, and caring of others
around us in the workplace and to feel valued, respected and supported.

C Competence – the need to experience effectiveness and deliver valued

outcomes, such as high-quality care.

The review identified inspiring examples of organisations that meet these three core
needs for doctors. An integrated, coherent intervention strategy will transform the
work lives of doctors, their productivity and effectiveness, and thereby patient care
and patient safety.

We’ve focussed on developing greater consistency of good work environments

across the four UK countries by changing the workplace factors that affect the
wellbeing of doctors at work; rather than on initiatives to improve their ability to
cope with stress or provide treatment when they become unwell.

Set out in the report are eight vital recommendations, each with several key
elements, to address the pressing issues that impact on doctor wellbeing.

This requires that institutions and organisations implement all of the eight
recommendations and constituent elements, rather than adopting those that
seem the easiest or most attractive. In this summary, we describe the most
immediate steps needed under the three headings of autonomy/control,
belonging and competence.

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Executive summary 16

Six urgent steps needed

A: Autonomy and control
Voice, influence and fairness
To introduce mechanisms for doctors in primary and secondary care to influence
the culture of their healthcare organisations, and decisions about how medicine
is delivered.

How: Clinical leaders and managers should consult doctors (and other healthcare
staff) and gather feedback about how healthcare teams are established and
maintained, how their work is organised and delivered and the response to concerns
to ensure a focus on learning not blame.

Work conditions
To introduce UK-wide minimum standards for basic facilities in healthcare
organisations.

How: All healthcare employers should provide all doctors with places and time to
rest and sleep, access to nutritious food and drink, the tools needed to do their job
and should implement the BMA’s Fatigue and Facilities charter.

Work schedule and rotas

To introduce UK-wide standards for the development and maintenance of work
schedules and rotas based on realistic forecasting that supports safe shift swapping,
enables breaks, takes account of fatigue and involves doctors with knowledge of the
specialty to consider the demands that will be placed on them.

How: NHS England, NHS Wales, NHS Boards in Scotland and the Department of
Health (Northern Ireland) should fully implement the BMA’s and NHS Employers’
Good Rostering Guide (see new deal monitoring guidance in Scotland) in all
healthcare environments.

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Executive summary 17

B: Belonging
Team working
To develop and support effective multidisciplinary team working across the healthcare
service.

How: All healthcare organisations should review team working and ensure that all
doctors are working in effectively functioning and, ideally, multidisciplinary teams.
The teams should have a shared purpose and clear objectives (one of which is team
member wellbeing). Team members should be clear about their roles and meet
regularly to review their performance, including inter-team/cross-boundary working.
Quality improvement should be a core function of all teams.

Culture and leadership

To implement a programme to ensure healthcare environments have nurturing
cultures enabling high-quality, continually improving and compassionate patient
care and staff wellbeing.

How: All UK healthcare organisations that haven’t already done so, should start and
implement a programme of compassionate leadership across all healthcare sectors;
and they should obtain feedback from doctors and healthcare staff to evaluate its
effectiveness. It should include mechanisms to ensure clinical leads and other leaders
of doctors at all levels in the healthcare system are recruited, selected, developed,
assessed and supported to model compassionate and collective leadership.

C: Competence
Workload
To tackle the fundamental problems of excessive work demands in medicine that
exceed the capacity of doctors to deliver high-quality safe care.

How: All organisations that oversee the work of doctors should undertake, in
collaboration with doctors, a programme to review workload in their organisations.
This will help them to use resources in the most efficient way, to ensure workloads
do not exceed doctors’ ability and capacity to deliver safe, high-quality care.
Initiatives are underway across the UK to increase staffing numbers and this should
be supported by additional solutions including, but not restricted, to:
● A programme to deploy and develop alternative roles to enable doctors to work
at the top of their competence, supported by effective multidisciplinary team
working in all areas of healthcare, and to support doctors to return to work after
a break in practice.
● A review of new technologies being used in UK healthcare systems to increase
efficiency, working with the voluntary sector, and focusing on preventive care.
● A programme of process improvements that increase productivity especially by
supporting communication in regular team meetings between healthcare staff.

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Executive summary 18

These urgent steps emphasise the responsibility of organisations that oversee and
provide healthcare across the four UK countries. But we also highlight the importance
of involving doctors themselves in making these improvements. Their collective voice is
a powerful force for change.

All the recommendations in the report are provided in full in the action plan at Annex 1. They include
other elements that are necessary to tackle the issues of:

● voice, influence and fairness

● work conditions

● rotas and work schedules

● team working

● culture and leadership

● workload

There are also recommendations relating to training and development, and to management and supervision.

Our call to action

There is now much evidence for the beneficial effects of compassion on patient
outcomes and on the wellbeing of those who provide care. Neglect, incivility, blaming
and harassment have quite opposite effects. Helping leaders, doctors and others in
healthcare to develop compassionate ways of working will equip them, their teams
and organisations to deal effectively with the challenges they face.

Our call to action is for all NHS leaders

to lead with compassion by implementing all
the recommendations in this report.
Our call to action is for all NHS leaders to lead with compassion by implementing
all the recommendations in this report. Those NHS organisations with cultures
of compassion promote fairness, and foster individual, team and organisational
wellbeing. And they meet doctors’ needs for autonomy, belonging and competence
at work, which in turn improves productivity and efficiency, and better promotes the
wellbeing of the patients and communities they serve.

That is the challenge and the imperative for leaders and doctors in all NHS and
primary care organisations across the UK.

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Introduction
and aims

Aims 20
The context 21
Incidence and prevalence of strain 23
Variation between sub-groups 25
Consequences 28
ABC of Michael
Professor doctors’Westcore needs
and Dame Denise Coia 30
Introduction and aims 20

Introduction and aims

Aims
The aims of this report are to:

● Identify the stressors which are negatively impacting on the health and
wellbeing of the 304,000 General Medical Council (GMC) registered doctors
and 41,000 medical students in the UK14.

● Show how to transform doctors’ workplaces so they thrive and flourish and
are better able to provide the compassionate and high-quality care they and
their patients wish them to deliver.

The review was co-chaired by Professor Michael West and Dame Denise Coia.
It involved extensive analysis of research literature and data; and engagement across
all four countries of the UK with individuals and organisations including:

● doctors and their representative bodies

● postgraduate medical education bodies

● medical royal colleges and faculties

● medical schools, students and undergraduate medical education bodies

● government departments in each country of the UK

● national bodies overseeing health services

● systems regulators/ improvement bodies

● local and international provider organisations and employer bodies

● leading researchers nationally and internationally.

The focus of the report is on identifying the causes, consequences and concrete
solutions to poor wellbeing amongst the medical profession.

Research shows that staff wellbeing significantly

improves productivity, care quality, patient safety,
patient satisfaction, financial performance and the
sustainability of our health services.

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Introduction and aims 21

In identifying solutions, we have focussed on the many encouraging primary

interventions that have been shown to work and which address underlying causal
workplace factors. Organisations should ensure that they meet the needs of their
workforce by providing wellbeing support and ensuring those charged with caring
for patients in the UK themselves get treatment for ill health. However, it is critical
that they also tackle the underlying causes of stress such as excessive workload,
bullying, poor supervision, discrimination and poor team working rather than
focusing solely on the consequences. They should not expect doctors to put up
with poor workplace environments.

Doctors’ work lives should be fulfilling and life enhancing, challenging though
the job is. Research has clearly shown that staff wellbeing significantly improves
productivity, care quality, patient safety, patient satisfaction, financial performance
and the sustainability of our health services1-5.

We know that there are many bodies who are addressing these issues, and other
organisations which are well placed to make these changes happen. The GMC
should take a collaborative approach with those organisations. This report must be
a springboard for swift, positive, sustained and effective change in the working lives
of doctors.

The context
Drawing on the findings from the annual Labour Force Survey, the Health and Safety
Executive has reported that people working in health and social care consistently
report higher rates of stress, depression and anxiety related to their work than those
in most other sectors16.

We recognise that all NHS staff are under huge pressure, not just doctors. There
are over 100,000 staff vacancies in the NHS in England, representing one in 11
of all posts7; HSCNI reported approximately 7,500 vacancies in Northern Ireland,
representing one in eight posts17; and statistics from NHS Scotland showed 7.8%
of medical and dental consultant posts were vacant18. There is no official national
data on vacancy rates in Wales, but responses from health boards and trusts to a
BMA Cymru Wales freedom of information request (FOI) showed a 6.8% vacancy
rate19. There are also very high levels of staff turnover with large numbers of nursing,
midwifery, and medical staff leaving7.

The workforce shortage in nursing and medicine

threatens the ability of the service to deliver safe,
high-quality care for patients, and threatens the
wellbeing and commitment of NHS staff.

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Introduction and aims 22

Sickness absence (a key human indicator of organisational performance) in the

NHS in England (3.4%) is twice the rate in the private sector (1.7%)20. It is higher in
Northern Ireland at an estimated 5.3%21, Scotland at 5.3%22, and Wales at 5.6%23.
Moreover, most NHS organisations struggle to recruit and retain staff. The workforce
shortage in nursing and medicine threatens the ability of the service to deliver safe,
high-quality care for patients, and threatens the wellbeing and commitment of
NHS staff.

Numerous doctors we met told us about unacceptable working and training

conditions which damaged their wellbeing and effectiveness. We heard consistent
stories of doctors feeling undervalued in the workplace; isolated from seniors, teams
and colleagues; unsupported in their roles; fearful of making a mistake and being
blamed or prosecuted; overwhelmed by their workloads and feeling that they have
little control over their work lives.

Analysis of data from the GMC national training surveys (NTS) shows that,
where doctors reported heavy workloads and a lack of supportive environment,
there was often a negative impact on wellbeing and effectiveness, although the
majority of doctors in training are, on the whole, broadly positive about their
educational experience.

When doctors cannot meet patients’ needs to the

appropriate standard, they often feel moral distress.
Our engagement across the healthcare system revealed that doctors feel they
are facing a significant increase in the volume of patients and the complexity of
their health needs and demands, without a corresponding growth in support.
When doctors cannot meet patients’ needs to the appropriate standard, they often
feel moral distress24-25.

Some doctors told us about the mechanisms that had supported them in the past,
such as some aspects of strong communities for hospital doctors. Collegiate ties
have a positive impact on wellbeing but must be inclusive for all diverse groups of
doctors and healthcare staff to be beneficial. Some doctors told us changes in many
organisations, such as the loss of team structure, have left them feeling exposed,
with increases in bullying, blaming and undermining. Yet, we found examples of
some organisations in primary, community and secondary care that have achieved
exactly the opposite. Nurturing workplace cultures that are positive, supportive and
compassionate.

We begin by describing the incidence and prevalence of strain and mental health
problems in the UK’s medical workforce.

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Introduction and aims 23

Incidence and prevalence of strain

Previous research has shown that 50% more NHS staff in England report debilitating
levels of work stress compared to the general working populationi. National staff
survey findings in England, Northern Ireland and Wales indicate that between 37%
and 40% each year report being unwell because of work stress during the previous
year (2018 NHS Staff Survey in England, HSCNI 2015 Staff Survey, NHS Wales
Staff Survey 2018)8, 10, 11. Such stress is likely to be chronic (measures of work stress
repeated over time among healthcare professionals are highly consistent). In the
BMA’s quarterly survey in 2017 (quarter two), 50% of the 422 doctors who responded
reported feeling unwell due to work-related stress during the previous year26.

In describing levels of stress among doctors, we have relied particularly on results

from the NTS, and data available from national surveys of health service staff.
However, it’s important to note that the content of staff surveys is not consistent
across the four countries of the UK (for example, there is no measure of stress
currently in Scotland), and as such, in places, we are more reliant on data from the
English survey.

The NTS is conducted across the UK and provides valuable insights. It is notable
that there is little variation in patterns of findings by country, suggesting that the
situation faced by doctors is broadly comparable (where there is variation, we report
it below). There is also much more evidence available for secondary than primary
care, but we have accessed data on GPs and primary care wherever this is available.

There is a clear need to improve the quality of measurement of stress, workplace

wellbeing and related issues across all four country surveys, both because of the
inadequacy of some measures, and because some important factors are simply not
measured. There is also an urgent need to develop and implement a staff survey
across primary care in all four countries using robust, validated and peer-reviewed
measures of key workplace factors affecting doctors’ wellbeing and mental health.

Nearly one in four UK doctors in training, and one

in five trainers were burnt out to a high or very high
degree because of their work.
The 2018 NTS employed an internationally used and validated measure of burnout
(Copenhagen Burnout Inventory). This showed that nearly one in four UK doctors in
training, and one in five trainers were burnt out to a high or very high degree because
of their work. Nearly one in five said they don’t have energy for family and friends
(spending quality time with loved ones is a key determinant of wellbeing)13.

The latest Labour Force Survey results from 2015/16 show that 11.7 million working days were lost to work-
i 

related stress, anxiety and depression in the UK, with the main factors being “workload pressures, including
tight deadlines, too much responsibility and a lack of managerial support” (HSE, 2016). Poor workplace mental
health costs UK public sector employers between £8 and £10 billion per year.

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Introduction and aims 24

There is also evidence that while doctors are less likely than other healthcare workers
to take time off due to sickness (a rate of 1.3% for hospital doctors compared with
4.2% for all NHS hospital staff27), attending work while unwell (presenteeism) may be
much more prevalent. The medical and dental staff group also had the lowest rate of
sickness absence in Wales, at 1.9% compared with 5.3% across NHS staff21. 42%
of doctors in England and 47% in Wales report having recently attended work
despite not feeling well enough to perform their duties8, 10.

Doctors report coming to work when unwell because they feel they have a
responsibility to their patients or do not wish to burden colleagues who will pick
up the work. But previous research has shown that staff attending work while sick
are unlikely to be able to perform effectively, while also passing on their illness to
colleagues or patients28-29.

Work periods of over eight hours carry an increased

risk of accidents that accumulates, with twice the
risk of an accident at around 12 hours compared
with eight hours of work.

Excessive workload and the need to work additional hours create work stress30.
In Northern Ireland, 27% of doctors in the HSCNI 2015 Staff Survey report working
additional paid hours and 93% work additional unpaid hours, with 39% of all
respondents working more than five additional unpaid hours per week9. In England,
the figures from the 2018 NHS Staff Survey are 43% working additional paid
hours and 81% working additional unpaid hours8. These figures are significant in
accounting for some of the most serious effects on doctors’ mental health.

The latest NTS showed that nearly half of UK doctors in training worked beyond their
rostered hours (England 48.5%, Northern Ireland 50.5%, Scotland 46.9%, Wales
51%), while one in five said that their working pattern had left them short of sleep13.
Long working hours and shift work impact on doctors’ personal safety, increasing
the likelihood of occupational accidents and needle-stick injuries31.

Work periods of over eight hours carry an increased risk of accidents that
accumulates, with twice the risk of an accident at around 12 hours compared with
eight hours of work. This imperils both patients and doctors32. Excessive workload
affects patient safety, productivity, efficiency and mental health and wellbeing.

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Introduction and aims 25

Variation between sub-groups

We have focused on the following sub-groups to reflect important variations in the
data on mental health and wellbeing. This is not to prioritise action for any group of
either students or doctors, but to highlight important trends relevant to their wellbeing.

Medical students
Studying medicine at university is an intense experience and the course is a
demanding one. In the UK, mental health issues are still the most common issue
declared to the GMC by UK medical graduates in their application for provisional
registration33. There has been a large rise in percentages reporting depression,
anxiety and stress in the last four years and in the numbers declaring a mental
health issue (8% of all 2018 applicants)33.

Consultants
Stress levels among consultants have stayed constantly high over the last five years
(with around 36% reporting illness as a result of work-related stress in the past year
in the 2018 NHS Staff Survey in England)8.

Doctors in training
For this group, stress levels (being unwell because of work stress in the previous
year) have risen from 31% in 2014 to 39% in 201813. Doctors in training report higher
levels of work-related stress and burnout and lower engagement than consultants13.

General practitioners (GPs)

Working in primary care can expose doctors to stressors that differ from those
in secondary care. A number of GPs told us their working environment can be
lonely, with long hours spent seeing many patients without the opportunity to talk
with colleagues. Trainees can find that support is lacking in practices struggling
with staffing levels, which in turn can lead to inappropriate workloads such as
unsupervised home visits. We were told that in addition to lone working, further
stressors can include unsustainable patient volume, the added demand of
scheduling an average of only ten minutes with each patient, and inadequate time
to catch up with other tasks. GPs are also among the specialities that experience
denigration from other specialties and this can elicit resistance when they refer
patients to secondary care.

The findings of research on the retention of GPs are congruent with studies
of hospital doctors in the UK. Poor working conditions (high workload, low job
autonomy, long hours, low social support, work-life conflict) and poor mental
health (high burnout, symptoms of depression and anxiety) are associated with
an increased intention to leave medicine11-12.

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Introduction and aims 26

A Commonwealth Fund survey of GPs across 11 countries found that GPs in the UK
had the highest levels of stress, with 59% reporting that their job was ‘extremely
stressful’ or ‘very stressful’, compared with 18% in the Netherlands and an average
of 35% across all 11 countries34. GPs were the second most likely group of
respondents in a 2019 BMA survey of 4,300 doctors and medical students to have
a ’high’ or ’very high’ risk of burnout – behind doctors in training. Respondents who
worked more than 51 hours in a week were most likely to be at risk of burnout35.
The BMA followed this survey by commissioning qualitative research with some
of the respondents; the findings were published in the report ‘Mental health and
wellbeing in the medical profession’35. GP trainees had even higher levels of
burnout than their non-GP trainee counterparts in the 2019 NTS.36 England’s eighth
National GP Worklife survey carried out in 2015 reported the lowest levels of job
satisfaction among GPs since 2001 and the highest levels of stress since the start
of the survey in 199811. The ninth survey (2017) revealed that 39% of the over 2,000
GPs responding intended to quit direct patient care in the next five years37. This had
increased from 31% in 2012 and was the highest level recorded since the survey
began. Some 85% reported having insufficient time to do the job properly and 92%
of having increasing workloads.

Physicians
A recent survey by the Royal College of Physicians (RCP) found that four out of
five doctors in training reported that their job ‘sometimes’ or ‘often’ caused them
excessive stress38. More than half revealed that their work negatively affected their
physical health and a quarter indicated that it had a serious impact on their mental
health. Another report from the RCP focusing on Wales showed that two thirds of
trainee physicians in Wales reported regular, frequent rota gaps, with 74% of medical
registrars in Wales saying work-life balance is the first thing to suffer39.

Surgeons
Oskrochi et al. found that surgeons had high rates of depression and psychiatric
distress40. Surveys of surgeons reveal that between 16% and 36% had high levels
of traumatic stress symptoms, with 12% indicating possible post-traumatic stress
disorder41.

Emergency medicine
Doctors working in emergency medicine, where crisis management has become
the norm, are amongst those experiencing the highest levels of burnout. The 2019
NTS revealed that doctors working in emergency medicine had very high rates of
burnout (69.2% of trainees and 63% of trainers reported moderate or high levels of
burnout)13. This is considerably higher than the average (49.9% of doctors in training
overall and 46.8% of trainers).

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Introduction and aims 27

Demographic variation
Ethnicity
The evidence on the experience of NHS staff from a black and minority ethnic (BME)
background in relation to discrimination at work is stark. The 2018 NHS Staff Survey
in England showed that, of those experiencing discrimination at work in the previous
12 months (10% from patients/ relatives etc, and 9% from managers/team leaders
or colleagues), doctors are the most likely to experience discrimination on the
grounds of ethnicity (57.7% compared with 34.9% across all staff groups)8. The level
of discrimination on grounds of ethnicity has also risen over the last five years from
52% to the current 57.7%.

‘Fair to refer?’, independent research by Dr Doyin Atewologun and Roger Kline,

commissioned by the GMC, highlighted that managers struggle to give feedback to
those from a different ethnic group to them42. Discrimination has dramatic influences
on workplace stress and physical health43.

Age
There is no clear pattern of age differential susceptibility to stress amongst doctors.
While the perceived stigma surrounding mental health prevents many doctors from
seeking help, some studies show that it is usually younger doctors who approach
support servicesii.

Gender
Findings on gender are mixed and inconclusive. The systematic review conducted
by Imo indicated mixed findings about differences between male and female doctors
in burnout and psychiatric morbidity46. In contrast, more recent research showed
that female GPs reported better mental health than their male counterparts. In the
NHS Staff Survey in England, female doctors were somewhat more likely to report
musculoskeletal disorders, to report having been unwell as a result of stress during
the previous year, and to go to work when unwell8.

Overall, the evidence is clear that doctors are dealing with high levels of stress in
their work which is affecting turnover, absenteeism, presenteeism and performance –
and of course the quality of patient care.

We now examine these consequences in more detail.

The average age of doctors accessing the NHS Practitioner Health Programme, a confidential service for
ii 

doctors that offers support for mental health issues, has dropped from 51.6 to 38.9 in 10 years. During this
time more than 5,000 doctors accessed this service, around two-thirds of whom were women44. Similarly, a
2007 study found that the largest group attending MedNet, a confidential consultation service for doctors and
dentists in London, were aged between 30-39 years old45.

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Introduction and aims 28

Consequences
Longitudinal analyses of data from the NHS Staff Survey in England, have consistently
shown associations between staff reports of stressful and unsupportive work
environments and poorer patient satisfaction, quality of patient care and financial
performance1-5, 47 and (in the acute sector) increased patient mortality48. Better staff
wellbeing is linked to positive patient outcomes within NHS organisations.

Below we describe behavioural, physiological and psychological consequences

of work stress and strain, detailing the impacts in healthcare.

Behavioural
Cognitive and emotional outcomes of work stress include negative effects on
concentration, mood disturbance, depression, anxiety, health complaints and
work performance. The consequences for work are considerable such as poor
performance, sickness absence, intention to quit and early retirement. There are
also effects on productivity, role performance, organisational citizenship behaviour,
engagement and, inevitably, patient experience and satisfaction with care49. Strain
leads to more errors on cognitive tasks including deterioration in memory, reaction
time, accuracy and task performance. This has implications for doctors’ health and
patient safety. Strain is associated with more medical errors amongst healthcare
workers50 and there is now considerable evidence that stress and strain impair
doctors’ decision-making, productivity and patient safety (including medical errors)51.

In two studies, researchers found that doctors with high levels of burnout had
between 45% and 63% higher odds of making a major medical error in the following
three months, compared with those who had low levels6. Another study from the
University of Washington suggested that doctors experiencing high levels of stress
were four times more likely to provide substandard patient care52. And a study of
7,905 surgeons by the Mayo Clinic found that highly stressed surgeons were three
times more likely to make a major surgical error than those with low stress levels53.
Among nurses in intensive care units, high stress levels were associated with higher
patient mortality rates54. A UK survey of 681 doctors working in emergency medicine
suggested that compassion fatigue (one symptom of burnout or stress) was
associated with reducing care quality standards in a way that could harm patients56.

Psychological
Psychological burnout, first described by Maslach and Leiter (1997)56, refers to three
sub-dimensions of strain – emotional exhaustion, depersonalisation (becoming
hardened and treating patients as objects), and a sense of ineffectiveness57. Burnout
is associated with sleep deprivation58, medical errors53, 59, poor quality of care52, 60,
and low patient satisfaction61.

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Introduction and aims 29

Physiological
People in sustained stressful situations are at a higher risk of heart attacks62,
gastrointestinal problems63-64, poorer functioning of the immune system and of
coronary heart disease62, 65. Chronic stress is also associated with increased risks
of cancer, chronic fatigue syndrome, depression, sleep and eating disorders, and
musculoskeletal injury66-67.

A 2015 meta-analysis of 228 studies assessing ten workplace stressors and health
outcomes found that high job demands raised the odds of diagnosed illness by 35%
and that long work hours increased mortality by almost 20%68.

Other consequences
Excessive workload and work stress contribute to higher levels of bullying,
harassment and discrimination69.

In national staff surveys (2018 NHS Staff Survey in England, HSCNI 2015 Staff Survey,
NHS Wales Staff Survey 2018, 2017 Scotland Dignity at Work Survey)8-10, 70:

● 23-36% of doctors reported being bullied, harassed or abused by members

of the public, patients or their carers (England, Northern Ireland, Wales). In
Scotland, 33% reported emotional verbal abuse from members of the public.

● 9-16% of doctors reported being bullied by managers and 14-22%

reported being bullied by other colleagues (England, Northern Ireland and
Scotland). In Wales, 19% of doctors reported being bullied by managers and
colleagues combined.

For doctors in training, gender discrimination (among those experiencing

discrimination at work) has risen from 33.1% to 43.5%13. The level of discrimination
experienced by doctors on the grounds of ethnicity has risen over the last five years
from 52% to the current 57.7%8.

How then do we change the workplace factors that are affecting doctors’
wellbeing?

To answer this question, it is important to begin by clearly defining what are core
human needs at work that, when satisfied, are associated with wellbeing and intrinsic
motivation.

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Introduction and aims 30

ABC of doctors’ core needs

The core workplace needs to ensure the wellbeing of doctors are; autonomy and
control; belonging; and competence (the ABC of needs)71. When these needs are
met, people are more intrinsically motivated and have better health and wellbeing.
If any one of them is not met, then wellbeing and motivation suffer.

● Autonomy/control – the need to have control over our work lives, and to act
consistently with our work and life values.

● Belonging – the need to be connected to, cared for, and caring of others
around us in the workplace and to feel valued, respected and supported.

● Competence – the need to experience effectiveness and deliver valued

outcomes, such as high-quality care.

How do we translate these elements into appropriate interventions in the many

different contexts that doctors operate in?

Our review and the research evidence together suggest that of the three needs
outlined in this report, the need for autonomy or control is the least met by the
health services, where the culture is typically controlling. All doctors (and NHS staff)
should feel they have voice and influence in the genuine co-design of services and
the management of their organisations. This requires inclusive leadership. Doctors
will engage when they feel their organisations are just and fair places to work, where
procedures are transparent and fair, particularly in relation to recognition, rewards,
rotas, bullying, sexual harassment and discrimination. Workplace conditions make a
big difference to the experience of control – having somewhere to get a hot drink or
some food on a night shift; a locker to put clothes or valuables in; and having rotas
well in advance so that other responsibilities can be managed.

Doctors' needs for belonging are met when they work within supportive teams
and organisations and feel valued, respected and supported. This requires an
organisational commitment to the delivery of high quality and compassionate care;
leadership and management that ensure trust, motivation and compassion; clear,
agreed and manageable work objectives for all; and effective team and inter-team
working. This necessitates inclusive and compassionate leadership at every level.

Doctors’ need for competence is likely to be met first and foremost when their
workloads are not chronically excessive. They must also have enabling and
supportive clinical leadership and supervisory support, focused on removing
obstacles to their work. Directive, controlling leadership that emphasises blame
rather than learning and accountability undermines competence. Doctors must be
supported to continually grow, develop and learn so that their skills and competence
are constantly improving.

The actions that we propose focus on meeting doctors’ core needs by not only
removing stressors in the work environment but also amplifying factors that
promote positive wellbeing. Positive emotions, such as hope, pleasure, compassion,
happiness, humour, excitement, joy, love, pride and involvement are important
sources of human strength72-74. When we feel positive we think in more flexible,
open-minded ways and consider a much wider range of possibilities.

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Introduction and aims 31

This enables doctors to successfully undertake complex tasks such as diagnosis

and treatment, and we are more likely to be helpful, altruistic, generous and
compassionate. This report therefore addresses both the workplace factors that
cause negative emotion and mental ill-health, and those that improve positive
emotion and psychological wellbeing.

We offer inspiring examples from across healthcare in the UK of where this

has been achieved.

Caring for doctors Caring for patients

Improving the
work environment
for doctors

Professor Michael West and Dame Denise Coia

Improving the work environment for doctors 33

Improving the work environment

for doctors
A meta-analysis of 65 international studies75 examined the effect of protective and
detrimental factors on burnout among doctors. Constraining aspects of work such
as workload, organisation structure (e.g. inflexible work arrangements), professional
values (e.g. compromising standards) and specific demands (working in emergency
medicine) were strong predictors of burnout. The findings suggest that multilevel
interventions are required to reduce the risk of burnout for doctors – such as
changing organisational factors, the functioning of teams and their individual roles.

If we are to transform the work lives of doctors

and the quality of patient care, we must implement
an integrated intervention strategy.
We have aimed our eight core recommendations at both primary and secondary
care. There is an urgent need to develop and implement a staff survey across
primary care in all four countries of the UK. This should use robust, validated and
published measures of key workplace factors affecting wellbeing and mental health.
This will aid further improvements in community care.

If we are to transform the work lives of doctors and the quality of patient care,
we must implement an integrated intervention strategy. This requires institutions
and organisations to implement all the recommendations below rather than
adopting simply those that seem easiest or most attractive. An action plan for the
implementation of these recommendations is shown in Annex 1.

In this report, we outline the issues, the evidence, good practice and case studies
before making recommendations in relation to each of the core needs for autonomy/
control, belonging and competence.

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A – Autonomy/
control

Voice, influence and fairness 35

Work conditions 40
Rotas and
Professor work
Michael Westschedules
and Dame Denise Coia 44
A – Autonomy/control 35

A – Autonomy/control
Autonomy/control is probably the most important of the three needs that must be
met in the workplace76.

The key workplace factors identified in this review that impact on autonomy and
control are voice and influence in a just workplace; the right work conditions; and
manageable and predictable work schedules and rotas.

Voice, influence and fairness

Evidence from the review
Having a voice and influencing decisions within a team or organisation is
fundamental to autonomy/control. Equally, we feel more in control when we see
our work environments as fair and just. Doctors are among the most skilled and
motivated people in any industry, yet they frequently reported not having influence
at work and feeling unfairly treated in workplaces that emphasised blame rather
than learning.

This reduces the pool of knowledge, creative ideas and experience available to
decision makers overseeing our healthcare organisations. It also reduces doctors’
engagement, motivation and wellbeing77. The challenge for clinical and all other
leaders is to empower doctors to influence the direction of their organisations and to
implement their ideas for better ways of doing things, in psychologically
safe and supportive environments.

The data from the NHS Staff Survey in England revealed that doctors who were
able to make suggestions to improve the work of their team/department and had
frequent opportunities to show initiative, had higher levels of work engagement,
more satisfaction with their organisation, and more satisfaction with their immediate
work environment. They were less likely to be intending to leave their organisations
and only half as likely to have been unwell in the previous year as a result of
work-related stress8.

Clinical leaders and senior management play an important role in this. In the
NHS Staff Survey in England, doctors were asked about the extent to which
senior managers try to involve them in important decisions; the extent to which
communication between senior managers and staff is effective; whether senior
managers act on staff feedback; and even if they knew who the senior managers
were in their organisations. The more positively they responded to such questions,
the higher were doctors’ levels of work engagement, satisfaction with their
organisation, and their work environment8.

Inclusion is fundamental to perceptions of organisational justice. It requires

leadership that includes rather than excludes doctors in decisions about key team
and organisational processes. This applies both in primary and secondary care78-79.

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A – Autonomy/control 36

Discrimination is a pernicious form of exclusion that is demonstrated in the ways that

doctors are recruited, selected, promoted, disciplined and developed. We heard that
certain groups may be perceived as ‘outsiders’ within healthcare environments – for
example BME and overseas doctors, female doctors, and doctors who have or who
develop a disability, particularly mental ill health. Feelings of disempowerment, which
impact on wellbeing, were significantly amplified in these groups. These reports are
in line with the findings of the ‘Fair to refer?’ report commissioned by the GMC into
disproportionate referrals by employers42.

In 2018, 46% of hospital doctors in England were from a BME background, and yet
only 16.4% (source: WRES data in England) of medical directors in NHS trusts were
of BME origin. In plain numbers, there were only 37 BME medical directors across
the 225 NHS trusts in England. In more than three-quarters (77.4%) of all NHS trusts,
BME staff reported higher rates of bullying, harassment and abuse from colleagues
than white staff80.

The benefits of diversity include improved performance and innovation. These are
realised in cultures or climates of positive inclusion rather than exclusion. Inclusive
practices ensure all (including women, BME staff, lesbian, gay, bisexual and transgender
(LGBT+) staff, staff with disabilities) influence key decisions and processes within their
teams and organisations. This results in a richer information pool, more comprehensive
decision making, more positive staff attitudes and higher levels of patient satisfaction78-79.
Steps should be taken to ensure that the needs of doctors more likely to be perceived
as ‘outsiders’ are considered and are given voice and influence.

Good practice and case examples

We heard of a number of good practice examples to support inclusive and just
cultures, including:

● development plans to support teams

● a standardised framework to support learning from incidents

● a guide for creating safe, listening, inclusive and compassionate working

environments

● a process for empowering doctors to transform cultures.

Engaging doctors and their teams in designing and driving change by equipping
them with data, administrative support, and improvement methodologies is
particularly powerful81.

A substantive piece of collaborative work has been undertaken by a number of

organisations in Scotland, forming a Scottish wellbeing advisory group. This group
has provided leadership and helped build momentum and negotiating power to make
potentially an effective impact on doctors’ mental health across NHS Scotland (see
more details in Annex 3). In Northern Ireland, the Department of Health has established
an Improving Junior Doctors and Dentists Working Lives group. In April 2019, NIMDTA
and Queens University Belfast hosted a ‘Redefining F1 Summit’ to explore the issues
impacting Foundation Year 1 doctors in Northern Ireland. This summit addressed several
areas, such as the induction and shadowing process and clinical workload and duties.

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A – Autonomy/control 37

Case study
1
Voice and influence in practice
In 2013, Birmingham Children’s Hospital (BCH) NHS Foundation Trust ran a staff
engagement week attended by 1,200 staff. Among other things, workshops
asked what would make colleagues feel better at work. Most people highlighted
the importance of feeling valued and recognised for what they do, including
awareness by the senior leadership team.

The Trust followed this with the development of their own wellbeing programme.
This was led by a small team, with support from a committee looking at the staff
survey results and with advice from a Consultant in public health.

Anyone who was a manager or team leader of people, e.g. managers, charge
nurses, consultants, went on the programme, which was based on the seven
steps for a ‘team maker’ by Professor Michael West. The programme received
a lot of positive feedback and highlighted the importance of managers and
leaders getting to know the people in their teams, of setting clear objectives and
of giving feedback.

In addition, the organisation introduced:

● an employee assistance programme

● free exercise classes

● an annual calendar of wellbeing events, including events promoting health

(hydration challenge, blood pressure measurement)

● making use of national campaigns, e.g. mental health awareness week and
smoking cessation week, to communicate wellbeing messages

● an annual calendar of events to celebrate diversity and inclusion e.g.

Eid celebrations

● listening events using the ‘mad, sad and glad’ technique, revealing
practical things that could be fixed (e.g. lab test requesting system) to
support staff wellbeing.

Staff engagement work also led to a better understanding of the experience of

doctors in training at the Trust. Doctors in training were encouraged to attend
Trust-wide events and leadership meetings and to contribute their ideas, leading
to innovation within the organisation. Weekly Thursday morning meetings became
the medium for this innovation. Thirty-four rotas were redesigned and new roles
were created to support junior doctors’ work – advanced clinical practitioners and
physician associates. Clinicians led the innovation and developed the new roles.
The Trust acknowledged that at points it can be challenging to gain buy-in from
all colleagues, but the evidence for this approach is very compelling.

BCH was the first children’s hospital to be rated ‘outstanding’ by the Care Quality
Commission (CQC).

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A – Autonomy/control 38

The learnings supported the development of approaches after the merger to form
Birmingham Women’s and Children’s NHS Foundation Trust in 2017. Across the
organisation, the seven principles of team effectiveness, staff listening sessions
and focus on wellbeing were applied in ‘hot spot’ areas, e.g. neonates and radiology,
and this continues to support improvements in staff experience.

Case study
2
Doctors’ voice and influence
Engagement of doctors is the cornerstone of Wrightington, Wigan and Leigh
NHS Foundation Trust’s staff engagement strategy. In 2016, a monthly forum was
established, attended by the Chief Executive, Medical Director and Director of
Workforce. Doctors in training are encouraged to identify specific topics that they
would like the forum to address. This has led to:

● the provision of hot meals for junior doctors working night shifts

● a review of car parking provision for staff working overnight

● improving access to emergency accommodation when staff are too tired at

the end of their shift to commute home

● improvements to technology and safe systems of working.

Doctors have also been involved in redesigning rostering and bleep systems.

As part of the Trust’s ‘Go Engage’ programme, there are quarterly Trust-wide and
divisional ‘Your Voice’ surveys that provide granular detail of staff concerns that are
then addressed.

Case study
3
Creating just cultures
After developing and piloting its approach in 2016 in collaboration with staff,
colleagues and operational managers, Mersey Care NHS Foundation Trust formally
introduced its ‘Just and Learning Culture’ into the organisation in 2017. In doing so, it’s
aspiring to create an environment where staff feel supported and empowered to learn
when things do not go as expected, rather than feeling blamed. The approach (called
‘restorative just culture’) involves all those who have a stake in a specific adverse event
working together to address harms and obligations. In a restorative approach three
questions drive the restorative process: who is hurt; what do they need; and whose
obligation is it to meet those needs. The Trust has also supported staff psychological
safety by developing a ‘civility and respect’ work stream, to emphasise the role of
the bystander, raising awareness of the impact of bullying and encouraging people
to speak up. The Trust has developed a standardised framework to support learning
from incidents and a guide for colleagues and service users on Just and Learning
expectations to describe the shared responsibility to create a safe and compassionate
environment. For the first year of the scheme, they set three objectives:

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A – Autonomy/control 39

● 72-hour reviews: sharing copy of an incident 72-hour report with all members
of the relevant teams within a week of it occurring.

● Share good practice stories: good practice stories published every month for
learning from things that went well and from those that did not.

● Improve support for employees: publish quarterly data on the Trust website to
transparently demonstrate whether staff felt supported when things had not
gone as expected.

The Trust worked to embed the objectives into practice within the year and continues
to set annual objectives in partnership with colleagues and ambassadors so as to
continuously strive for improvement.

The implementation of restorative practice was followed by a reduction in staff

absenteeism, staff turnover, suspensions and disciplinary actions; improved incident
reporting and in employees seeking support for workplace issues. There has been
a 75% reduction in disciplinary investigations since 2016 and 92% reduction in
suspensions. The Trust estimated savings of £2.5 million due to higher productivity,
reduced back fill costs due to staff suspensions, reduced time to conduct an
investigation and reduced legal and termination costs.
Source: Economic Benefits of Restorative Practice report, prepared by Art of Work for Mersey Care NHS
Foundation Trust, 24 September 2018.

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A – Autonomy/control 40

Key recommendation one

Voice, influence and justice
To introduce mechanisms for doctors to influence the culture of their healthcare
organisations and decisions about how medicine is delivered.

● Clinical leaders and managers should consult doctors (and other healthcare staff) and gather
feedback about how healthcare teams are established and maintained, how their work is organised
and delivered and the response to concerns to ensure a focus on learning not blame.

● The leadership and boards of every organisation employing doctors should establish a key
performance indicator for voice and influence and review feedback to assess performance.

● Systems regulators, improvement bodies and suggested partners should check that
employers have and are using mechanisms for obtaining and reviewing feedback from
doctors about their work.

● The GMC should work with partners listediii to:

- Support monitoring and assessment of engaging leadership, and just and fair cultures.
- Assure progress across healthcare teams and organisations in both primary and
secondary care.

● Healthcare providers should promote a workplace in which discrimination of any form is not
tolerated, by ensuring prompt identification and addressing of issues.

● The GMC should work with partners listediv to confront divisive cultures in healthcare
organisations by reporting on progress with implementing the recommendations of the
‘Fair to refer?’ report.

Work conditions
Evidence from the review
Including private funding, the total cost of training a doctor is over half a million
pounds15, yet many workplace environments are not designed to make best use of
their skills. Minor chronic frustrations multiply and steadily sap commitment.

In our conversations with doctors, they described absence of basic facilities and
some of these appeared not only inadequate but out of step with employment law
(e.g. access to toilets, food, water and taking breaks). Doctors also raised the issue of
having somewhere to sleep before driving home after night shifts. We heard of doctors
being involved in serious road accidents when sleep-deprived, including some that
tragically resulted in death. Doctors told us about the impact of night working and
the risks from fatigue, both to patient safety from errors and to personal safety. Yet,
many hospitals do not have rest facilities or on call rooms. One doctor told us that
they simply took naps on trolleys in the theatre recovery bay or on the floor.

iii 
See action plan in Annex 1.
iv 
See action plan in Annex 1.

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A – Autonomy/control 41

The decision by the Department of Health in England to provide funding for doctors’
rest rooms is therefore welcome. However, it’s important that appropriate facilities are
actually provided and that a similar commitment is followed through in all of the four

UK countries82. Doctors sometimes have a room but some told us the rooms available
in some locations are unfit for purpose as the doors don’t lock and they only contain
dirty mattresses with used linen. But where good facilities were provided, doctors told
us about them in glowing terms.

Doctors repeatedly mourned the loss of the doctors’ mess. Such facilities offered a
space for doctors to share their difficult experiences in the course of their work, to
learn from each other, to provide social support and to laugh and relax. They ensured
that doctors could eat well during the course of their work, rather than having to make
do with fast food or no food at all – particularly on night shifts. With multidisciplinary
working, we are not proposing a return to doctors’ messes but a staff canteen, separate
from facilities for patients, where doctors can eat with each other and other staff. This
creates a sense of being valued, respected and supported by their organisations.

Another frequent complaint was that doctors did not have lockers to put their valuables
in, such as coats, wallets, phones and keys. If they did, the lockers often did not lock.
Doctors working in surgery told us that they often had to go in search for the right size
of scrubs because of inadequate supplies.

There was widespread frustration about inadequate IT systems that meant doctors
could not provide the care needed because so much of their time was spent battling
with technology – slow systems with out of date or dysfunctional software. For
example, doctors talked to us about having to try multiple passwords until they could
login to a computer, having computers crash unexpectedly and software that did not
communicate between primary and secondary care.

Such basic problems create persistent frustrations for hard-pressed doctors. Medicine
is a demanding and stressful profession, so doctors need working conditions that
provide them with the facilities to carry out their roles effectively and provide good
quality care to patients.

Good practice and case examples

Good workplaces make provision for:

● break times and central locations to take breaks with access to nutritious
food and drink, including during night shifts

● places to sleep where appropriate

● lockers to secure belongings

● effective IT systems or support with using them

● support for day-to-day work e.g. the right size, clean scrubs, and somewhere
to change

● time and support for essential tasks, such as preparing for appraisal/ annual
review of competence progression (ARCP) and revalidation.

This should apply equally in primary and secondary care.

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A – Autonomy/control 42

Case study
4
Work conditions
Imperial College Healthcare NHS Trust identified concerns about the facilities
available to junior doctors, their wellbeing and their lack of engagement while working
in the organisation. The Trust focused on rest and eating facilities; poor involvement
with the Junior Doctor Forum; the quality of the doctors’ mess; and the sleeping
accommodation for junior doctors when on-call, or when too tired to safely travel home.

A group was formed to address the issues, including a junior doctor and senior
representation from Medical Education, the Medical Director’s Office, Estates, Facilities,
Accommodation, and Human Resources. A systematic approach was taken with each
of the four main areas identified, using guidance such as the Fight Fatigue campaign
materials and the BMA Fatigue and Facilities charter. The actions and consequences
are shown in the figure below. Many trusts / boards have similar programmes.

Junior doctor wellbeing, facilities and engagement

Break and rest facilities Junior doctor forum
Actions Actions
● Inspected each mess, logged all repairs and ● Moved to lunchtime and provided food
replaced items as necessary ● Advertised events in a variety of formats
● Installed reclining chairs on each site ● Requested executive attendance
● 
Purchased food preparation equipment such ● Publicised actions and outcomes
as microwaves, toaster, kettles
● 
Improved confidentiality e.g. annonymised
● Installed hot meal vending machines minutes, allowed annonymous comments
Results to be sent digitally
● Access to food out of hours Results
● Improved mess utilisation ● Improved attendance rates

Mess culture Sleeping accommodation

Actions Actions
● Establish a mess committee ● Established an order of priority for bedrooms
● 
Upgraded bank account depending on shift type
(debit card and digital banking) ● Reviewed accommodation booking process
● 
Supported committee with communication, ● 
Bedroom reserved for staff too tired to travel
finance and administration home after a shift
● Mess joining process simplified ● 
Alternatively taxis home can be authorised
Results by site managers out-of-hours
● Several successful social events organised Results
● Rising mess membership levels ● Fair and transparent booking system
● Contractual requirements now met

Figure 1: Actions and results in the four areas of focus by the Task and Finish Groups for the facilities available
to junior doctors at Imperial College Healthcare NHS Trust.

The group identified early stakeholder engagement, consulting relevant staff groups
about changes, and taking an organised and strategic approach as crucial elements
to their success. It created inspection checklists and gave joint responsibility to the
mess committee and specific members of the medical education team. It produced
guidance about how to create or upgrade rest and catering facilities, which has been
communicated across the Trust.
Source: Imperial College NHS Trust Junior Doctor Wellbeing, Facilities and Engagement Task & Finish Group
Project – AAGBI conference poster by Dr M O’Brien, Postgraduate Medical Education Fellow, Imperial College
Healthcare NHS Trust

Caring for doctors Caring for patients

A – Autonomy/control 43

Case study
5
Managing fatigue effectively
Following the tragic death of an anaesthetist in training, who fell asleep while driving
in 2016, the Association of Anaesthetists of Great Britain and Ireland (AAGBI)
has worked to address issues of fatigue. It found that many doctors had been in
accidents when driving home following a night shift. AAGBI has defined standards
for rest facilities and cultural attitudes towards rest in hospitals. Dr Michael Farquhar,
a consultant in sleep medicine at Guy’s and St Thomas’ NHS Foundation Trust
has championed its “HALT: Take A Break” campaign. This campaign emphasises
the importance of managing fatigue, especially at night. Dr Farquhar has provided
guidance on managing night shifts, sleep and fatigue, which employers can use to
better protect their staff by providing them with the time, resources and facilities they
need to avoid excessive fatigue and stay safe. Suggestions include:

● Providing appropriate rest areas overnight, which allow staff to nap during
breaks if they need to.

● Providing beds, free of charge, for post-nights staff who feel too tired to
drive home.

● Offering regular screening of shift workers for primary sleep disorders

in London.

● Using forward-rotating (day-evening-night) rota designs.

● Minimising frequent transitions between day and night shifts.

● Providing adequate recovery time after nights to re-establish normal

wake/sleep patterns.

● Providing basic education for staff at induction regarding sleep and

working nights.

● At least 30 minutes of continuous protected rest after approximately four

hours duty.

● At least one 30 minute paid protected break for a shift rostered to last more
than five hours and a second 30 minute paid protected break for a shift
rostered to last more than nine hours .

● Encouraging a team-based ‘hospital-at-night’ approach, including bleep

filtering and policies to permit consistent breaks.

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A – Autonomy/control 44

Key recommendation two

Work conditions
To introduce UK-wide minimum standards for basic facilities in healthcare organisations.

●  ll healthcare employers should provide all doctors with places and time to rest and sleep, access
A
to nutritious food and drink, the tools needed to do their job and should implement the BMA’s
Fatigue and Facilities charter.

●  he leadership and boards of every organisation employing doctors should review facilities to
T
ensure compliance with the BMA’s Fatigue and Facilities charter.

●  ystems regulators, improvement bodies and partners listedv should check that employers have
S
implemented the BMA’s Fatigue and Facilities charter in all working environments.

●  he GMC should continue to work with partners via the insights and data obtained through their
T
NTS to monitor, assess and support implementation. Where issues are identified, the GMC should
work with postgraduate deans, medical royal colleges and employers to ensure they are promptly
and fairly addressed.

Rotas and work schedules

Evidence from the review
During our engagement processes, many doctors complained about rotas and shift-
work. Having control over your own life, whether in work or outside of work, is a
fundamental need. The 2018 NTS found that those reporting low satisfaction with their
rotas experienced more burnout and lower satisfaction than those who rated their rotas
more positively13. Yet we heard accounts of trainee doctors being denied time off work,
despite a partner experiencing stillbirth, being in intensive care, or in labour, not being
able to book time for their wedding or to attend a relative’s funeral. We heard accounts
of doctors being told to produce marriage or death certificates to get such time off.

Dr Joanna Poole, an anaesthetic registrar, gathered many such examples from over
400 trainees across the UK83. Dr Poole reports sleeping in her car at service stations
during rotations when she had a long drive home. She had to use annual leave to
attend induction days when starting at a new trust.

Work schedule refers to shift work, night work, rotas, unpredictable hours, and long
or unsociable hours. Shift work is known to cause strain to varying degrees84 with a
high level of sleep disturbance amongst those on rotating shifts85-86. Fatigue and sleep
deprivation (associated with working long hours and shift pattern working) affect error
rates and quality of care as well as personal safety87.

Many doctors have to, or feel an obligation to, work outside their contracted hours in
order to ensure patients are getting the care that they need – GP partners particularly.
More than half (54%) of secondary care doctors in England say they work more than

v 
See action plan in Annex 1.

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A – Autonomy/control 45

10% over their contracted hours in the 2018 NHS Staff Survey in England8. Those who
reported working extra unpaid hours had lower levels of engagement, less satisfaction
with their organisation and were 50% more likely to have been unwell as a result of
stress at work during the previous year. Even doctors who worked extra paid hours
reported higher levels of intentions to quit than those who did not work extra hours8.

Doctors told us of widespread problems of poor rota design coupled with increased
demand. There was a perception that arbitrary rota decisions are made by people
who have no day-to-day contact with those affected by their decisions, and who did
not understand the impact that shift work has. This adds to doctors’ sense of loss of
autonomy and control, and leads to anger and resentment.

Although their contracts state rotas must be available six weeks ahead of the schedule,
many doctors told us this was not achieved routinely in their organisations.

We heard that doctors who wish to work flexibly are often treated as an inconvenience.
Conflict between work and home life is a widespread problem in healthcare, which
impacts on wellbeing88. Those experiencing such conflict are up to 30 times more likely
to suffer depression or anxiety89. Employees who experience depression or anxiety
also experience lower job satisfaction, high emotional exhaustion and are also more
likely to quit their jobs90.

And we heard many examples of trainees being posted far from their homes, partners
or families. There is a need to review how trainees are allocated to organisations, not
least because the current system means that those who perform best in exams tend to
be allocated to the most in-demand hospitals, and those who are likely to need most
support, struggle to perform or may not do well in an interview are placed furthest from
their support network and can be at higher risk of poor wellbeing.

Good practice and case examples

Healthcare organisations need a consistent and enlightened approach to work
scheduling and rota design. The BMA’s guidance on rostering91 sets out clear
principles that include a transparent and collaborative process for rota design with
equal opportunity for employers and doctors to provide input. There is good practice
across our healthcare services – for example, we were told that some anaesthetic
trainees in Newcastle get their rotas for the entire rotation in advance.

Case study
6
Effective rota management
Brighton and Sussex University Hospitals NHS Trust has a staff rota system that
has created greater flexibility and enabled staff to choose their shifts to suit their
other commitments, provided all the necessary clinical shifts are covered. As well
as providing substantial benefits to patient care, the new approach to rotas has also
improved educational opportunities throughout A&E. Benefits have included: being
fully staffed, reduced turnover of staff, improved recruitment, reduced returns to A&E
following discharge and reduced A&E waiting times throughout the day. The approach
has helped the department win the Royal College of Emergency Medicine training
Department of the Year 2018.

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A – Autonomy/control 46

Case study
7
Locum's Nest app
The Locum's Nest app, which is in use at Western Health and Social Care Trust in
Northern Ireland, publishes shift vacancies and allows doctors to volunteer to cover.
We heard from doctors working at the Trust that they don’t feel pressure to cover extra
shifts and, since using the app, there has been a rise of up to 44% in shifts being filled
through the use of Locum Nest.

Case study
8
E-Rostering
In Wales, Betsi Cadwaladr University Health Board provides E-Rostering for staff to
manage their shifts. Key benefits include:

● Correct staffing levels at the right time to meet the demands for patient care.

● Ensures skill/competence of staff rostered meet service demand.

● Cross-ward visibility enables good management of peaks and troughs in

demand.

● European Working Time Directive compliance, providing transparency of

shift and rest times.

● Greater fairness and impartiality for staff.

● Enables clarity in relation to financial implications of staffing decisions.

● Automatic payroll feed to ESR to ensure accurate payments to staff.

● Full tracking of sickness, annual leave and training.

All of this is important for wellbeing and a range of other benefits. Analyses from the
NHS Staff Survey showed that staff satisfaction with work-life balance was linked with
better financial performance of trusts/ boards, lower staff absenteeism, higher patient
satisfaction and lower risk of infection rates in hospitals. Such findings highlight the need
for evidence-informed initiatives to promote work-life balance and recovery from work.

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A – Autonomy/control 47

Key recommendation three

Work schedule and rotas
To introduce UK-wide standards for the development and maintenance of work schedules and rotas based
on realistic forecasting that supports safe shift swapping, enables breaks, takes account of fatigue and
involves doctors with knowledge of the specialty to consider the demands that will be placed on them.

●  HS England, NHS Wales, NHS Boards in Scotland and the Department of Health (Northern
N
Ireland) should fully implement the BMA’s and NHS Employers’ Good Rostering Guide (see new
deal monitoring guidance in Scotland) in all healthcare environments.

●  ealthcare organisations across the UK should develop and maintain mechanisms to enable doctors
H
to report rotas that are not compliant with the BMA’s and NHS Employers’ Good Rostering Guide
(see new deal monitoring guidance in Scotland). Guardians of safe working hours in England should
encourage doctors in training to raise exception reports about rostering issues and should monitor
such exception reports and take steps to address the issues raised.

●  ystems regulators, improvement bodies and partners listedvi should check employers have
S
implemented the BMA’s and NHS Employers’ Good Rostering Guide (see new deal monitoring
guidance in Scotland).

●  he GMC should work with partners listedvii above to monitor implementation of the BMA’s and
T
NHS Employers’ Good Rostering Guide (see new deal monitoring guidance in Scotland).

vi 
See action plan in Annex 1.
vii 
See action plan in Annex 1.

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B – Belonging

Team working 49
CultureMichael
Professor and leadership
West and Dame Denise Coia 54
B – Belonging 49

B – Belonging
Medicine has always been stressful, and while the stressors have undoubtedly
increased, some doctors told us that a key factor is the loss of aspects of a strong
community as experienced by some hospital doctors in the past.

Collegial ties offer a significant buffer for doctors from the stresses of their work.
But, such collegiate communities must be inclusive and embracing of all the
diverse groups of doctors in modern healthcare, as well as other healthcare staff
that doctors work with. Doctors work in multidisciplinary teams both in primary
and secondary care but the development of those teams within supportive
cultures has been slow and patchy92.

Central to doctors’ sense of belonging is the quality of team working and the
culture and leadership within their teams and organisations. It is of critical
importance that such cultures are inclusive and take account of the needs of all.
We deal with each of these interrelated issues in turn.

Team working
Evidence from the review
Teamwork is fundamental to the effective delivery of healthcare and is associated with
higher quality care, better staff wellbeing, higher levels of patient satisfaction, and
lower levels of avoidable patient mortality. Team working in healthcare is often taken
for granted, but we know that the quality of team and inter-team working in healthcare
in the UK is often poor5, 92-95.

We heard feedback from doctors about how modern workplaces with complex rotas
often result in them working continually with people they don’t know. This can mean
nobody notices their presence or absence, except in how it relates to their function on
the rota. Ward hopping, where doctors work across multiple wards simultaneously, is
common in secondary care and creates feelings of isolation, alienation and vulnerability.

Doctors need the skills to work effectively across multiple teams, but dropping in and
out of teams undermines coherence, community and belonging and can create a feeling
of always being an outsider. A related observation was that the ‘good old days were not
that good’ with long hours and some difficult consultants, but that doctors were happier
because they were surrounded by a stable group of supportive colleagues and could
talk about their challenges and difficulties. We heard that doctors sometimes feel easily
replaceable, like cogs in the system, rather than valued professionals.

In secondary care, the 2018 NHS Staff Survey in England data suggests that only 40%
of staff work in ‘real teams’ (teams with clear objectives that meet regularly to review
performance) despite 96% of staff saying they work in teams8. Working in ‘pseudo-
teams’ (that do not have these two basic characteristics – clear objectives and meeting
regularly to review performance) is associated with worse staff mental health, poorer
care quality, lower patient satisfaction, higher numbers of errors and injuries, and (in
the acute sector) with higher levels of patient mortality1, 5, 92, 94-95. Our analysis of the
data from the 2018 NHS Staff Survey in England, revealed that doctors who worked

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B – Belonging 50

in real teams had higher levels of work engagement, and more satisfaction with their
organisation and work environment. They also had far lower intentions to quit and were
less likely to be unwell from stress.

We must find new ways to enable doctors to work as part of effective and supportive
multidisciplinary teams. This will be challenging, but clinical leads and other senior
leaders and managers who respond positively to this challenge can make a profound
difference to doctors’ wellbeing, productivity and to patient care.

Quality of team working is a problem in all sectors of the healthcare system92, 94-95.
Effective team working in primary care is central to the delivery of high-quality
primary care services. Some GPs reported that they are so busy that time for team
meetings, reviews of team performance and quality improvement initiatives are
sacrificed. Others reported on the experience of working in a dynamic and well-
functioning team, and how it makes a large positive difference to morale, wellbeing and
practice effectiveness. In the Royal College of General Practitioners (RCGP) Scotland
Workforce and Wellbeing survey, half (49%) of respondents felt that more opportunities
for team building and learning within their practice would be the best approach to
improving their wellbeing12. With the advent of more integrated systems in healthcare,
inter-team working is increasingly central also. We also heard that GPs face significant
communication challenges with managing the interface with secondary care, and
those challenges reveal a lack of understanding of roles and skills between primary
and secondary care. They valued support from system bodies to enable them to focus
on effective team and inter team working and leadership, including peer coaching
and mentoring. Some GPs felt the First Five programme run by the RCGP could be
adapted, adopted and extended to include all GPs.

For trainees, multiple rotations were reported as having a significant impact on

wellbeing, undermining their ability to be a member of any team or embedding into
an employing organisation. Multiple rotations also fracture continuous supervision
and prevent the development of stable peer networks. The impact may be greater on
trainees from some groups, including BME and international medical graduates (IMG)
but also disabled doctors, for whom forming relationships may take longer42.

Good practice and case examples

Good practice would see all medical students, doctors and doctors in training
belonging to a stable ‘home team’ or ‘lead network’ (where possible – multidisciplinary)
that enables:

● involvement in quality improvement initiatives

● clarification of roles and responsibilities

● a sense of belonging and social support

● a space to discuss challenges, difficulties, frustrations

● a space for supportive supervision

● opportunity for appreciation and recognition

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B – Belonging 51

● peer coaching and mentoring

● professional development

● leadership development and teamwork training.

Face-to-face multidisciplinary team working should be the first choice. Teams need
stability of membership to become cohesive, time for meetings on the rota, accessible
space to meet and ways of involving all team members. Social interactions such as
shared coffee breaks, meals and celebrations also build a sense of cohesion and
psychological safety96.

Doctors need training and on-going support to continuously develop their

multidisciplinary team and team leadership skills from the beginning of their
undergraduate education onwards. The Generic Professional Capabilities framework
sets out the competencies for team working and leadership. Team leadership should
be included as part of a doctor’s appraisal/ARCP for developmental purposes. It is
also essential that there is a strong focus on wellbeing and the support available to
appraisees in annual appraisals.

Case study
9
Multidisciplinary ‘board rounds’
Board rounds at Sandwell and West Birmingham Hospitals NHS Trust are scheduled
daily. These are multidisciplinary team discussions on patient care that include
as many members of the team as possible. Board rounds can be used to share
information from relatives, prioritise tasks, delegate responsibilities and maximise
the effectiveness of time spent with the patient. Each patient can be discussed in
under a minute – including presenting complaint, diagnosis, management plan and
expected discharge date – so most wards can complete them in 20 to 30 minutes.
The board round discussion determines an integrated management plan with
estimated discharge date and criteria for discharge. The ward round is punctual,
held in a confidential space, well-chaired, and each member of the team leaves with
clarity about their tasks. A large screen provides extensive patient information so
that anyone can pick up mistakes or key information. All rounds are completed by
9.30am to provide information to other points in the hospital. The software package
can be accessed from any Trust computer by clinical teams (to aid patient care) and
by operational managers (to assist with bed capacity planning). Consultant job plans
have been adjusted to account for these working arrangements as consultants are
expected to attend board rounds four out of five days a week.

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Case study
10
General practice team working
The general practitioners (GPs) working at Jubilee Medical Practice in Leicestershire
make time to discuss cases and issues together as a team. This helps boost
confidence and a sense of working inclusively, and their data suggests the approach
has significantly reduced referral rates.

The Nuffield reports on a practice in Norfolk that created a team of nurse practitioners
to manage urgent care and home visits, as well as substitute roles to shift workload
away from GPs.

In the North West of England, GP practices facing a serious recruitment challenge

came together and developed a new multidisciplinary team including pharmacists,
paramedics and mental health workers. Their offer of sustainable, innovative, high-
quality care has also led to an increase in numbers of GPs applying to work there.

Case study
11
Team working in a crisis
Hywel Dda University Health Board saw a reduction in cardiac arrest calls in acute
adult general wards after integrating multidisciplinary team working principles into
a medical simulation programme for support staff, nurses and junior doctors. This
encouraged good team working and reflective discussions, where all contributions
were valued. Resuscitation team leads reported that feedback and reflection among
the clinical staff following incidents was a powerful learning process leading to more
effective care.

Case study
12
Multidisciplinary team working
Barts Health NHS Trust is ensuring its leadership teams (combining nursing, AHP,
scientific, managerial and medical staff) have protected time, skilled facilitation and
team coaching to build team effectiveness. Aimed at both clinical and managerial staff,
its ‘Super T’ team development programme has seen improvements in its staff survey
scores, particularly in relation to engagement – the key staff survey predictor of trust
performance in England. Space for reflection and learning is cited as a core benefit of
the programme, and all teams continued to prioritise team time for reflection beyond
the duration of the formal programme. A key benefit, identified by the organisation,
was that the programme enabled much-improved matrix working and collaboration
across the leadership teams of all parts of the Barts Health group of hospitals.

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B – Belonging 53

For GPs in small practices, team working may be challenging currently, but in primary
care, there are clear links between the quality of team working, quality of patient care,
patient satisfaction and staff wellbeing97-98. Professional forums are also needed to
develop and sustain inter-professional relationships to address difficulties in working
across primary and secondary care. With the advent of primary care networks in
England, it should be a priority to develop supportive teams enabling peer coaching,
social support, mentoring, quality improvement initiatives and action learning groups99.
With the scale that Primary Care Networks will create, it will become easier to build
effective multidisciplinary team working as the Haxby case example in the workload
section below shows.

The new Scottish General Medical Services Contract came into force in 2018 and aims
to reduce GP workload through the expansion of the primary care multidisciplinary
team. This is supported by the Scottish Government’s strategy for primary care. A key
part of this is the introduction of GP clusters – professional groupings of GP practices,
represented by practice quality leads feeding into cluster quality leads. The latter have
responsibility to provide a quality improvement and leadership role, and they will liaise
between practices and the NHS Board on quality improvement issues100. GP clusters
have also been introduced in Wales, supported by Health Boards, and are designed to
enable GPs and others within a locality to collaborate101. Northern Ireland has established
GP Federations with two main aims, to support and protect GP practices and to help
deliver the transformation agenda in Health and Social Care. There are currently 17 GP
Federations owned entirely by GPs and covering all areas of Northern Ireland102. These
changes should be accompanied by the provision of training for leaders in building
effective team and inter-team working at every level.

NHS and primary care working arrangements must develop, prioritise and sustain
effective team working, make provision for it (for example by ensuring high-quality
support for team leaders) and provide areas where regular team meetings can take
place. Teams that regularly take time out to review and improve their performance are
far more effective and innovative – such timeouts increase productivity by an average
of 38% and substantially improve doctors’ health and wellbeing103.

All must rise to the challenge of practising effective team working in medicine, given
the evidence of the enormous benefits for doctors’ productivity and wellbeing and for
their patients.

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B – Belonging 54

Key recommendation four

Team working
To develop and support effective multidisciplinary team working across the healthcare service.

●  ll healthcare organisations should review team working and ensure that all doctors are working
A
in effectively functioning and, ideally, multidisciplinary teams. The teams should have a shared
purpose and clear objectives (one of which is team member wellbeing). Team members should be
clear about their roles and meet regularly to review their performance, including inter-team/cross-
boundary working. Quality improvement should be a core function of all teams.

● The leadership and boards of every organisation employing doctors should establish a key
performance indicator for effective team working and obtain and review feedback to assess if all
doctors are part of a well-functioning team.

● Systems regulators, improvement bodies and partners listedviii should check that employers are
ensuring that doctors are working in well-functioning teams.

● The GMC should work with other professional regulators to develop guidance on multidisciplinary
team working in modern healthcare environments.

● Healthcare systems should develop appropriate support and materials to ensure the continued
development of teams in both primary and secondary care.

Culture and leadership

Evidence from the review
Organisational cultures can have a great impact on the wellbeing of staff104. Changes
to work organisation such as restructuring, staff reductions and the introduction of
temporary work, take their toll on staff105-106. ‘Change fatigue’ has also been highlighted
as work intensifies and increases the risk of burnout that can lead to ‘learned
helplessness’ and feelings of alienation from the healthcare system. The burden of
the requirements of multiple regulators exacerbates this, particularly for GPs.

There are many positives reflecting doctors’ commitment to their work: 65% of doctors
in Wales10 and 59% in Northern Ireland9 reported looking forward to going to work
always or often in the NHS Wales Staff Survey 2018 and HSCNI 2015 Staff Survey.
This was higher than NHS staff as a whole – 60% and 57% in Wales and Northern
Ireland respectively9-10. 73% in both countries were enthusiastic about their jobs.
In the 2018 NHS Staff Survey in England, around two-thirds of doctors look forward
to going to work, three-quarters are enthusiastic about their jobs and their ability to
do their jobs to a standard they are personally pleased with8.

On the other hand, data from these national surveys show concerns from doctors
across the UK about the culture and leadership of their employing organisations.
These findings suggest that the cultures of NHS organisations are not effectively
meeting the needs for autonomy, competence and control among doctors.
viii 
See action plan in Annex 1.

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B – Belonging 55

● Restructuring: doctors in England told us they had concerns about repeated

restructuring and reorganisation of NHS services at regional and national level.

● Organisational values: at the same time, only 62% of doctors in Wales and
56% in Northern Ireland would recommend their organisation as a place
to work in the NHS Wales Staff Survey 2018 and HSCNI 2015 Staff Survey
respectively. Only 65% felt that patient care was their organisation’s top priority
in both countries9-10. Only 36% of doctors in Wales believe their organisation is
committed to helping staff balance their work and home life10.

● Support from senior management: in the NHS Wales Staff Survey 2018,
though 63% of doctors were satisfied with the support they received from
their immediate manager, this still means that more than one in three were
not satisfied10. 54% of doctors in Northern Ireland were satisfied9. In both
countries, fewer than one in three say senior managers appreciate what it is like
to work on the front line, that they lead by example, and that communication
between staff and senior managers is effective9-10.

● Other support: most doctors in Wales complain of lack of timely information

to enable them to do their jobs well and of poor interdepartmental cooperation.
Just over one in three (36%) can meet all the conflicting demands on their
time at work and only 18% say there are enough staff for them to do their jobs
properly10. Doctors in England in the 2018 NHS Staff Survey report a lack of
involvement in changes affecting their work (55%), a lack of adequate materials,
supplies and equipment (50%), and, as in Wales, one third say their teams do
not meet frequently to discuss the team’s effectiveness8.

We heard consistent feedback about environments where leadership was remote from
staff, where pressures fuelled by lack of resources led to bad behaviour that cascaded
down the organisation from the top, and where staff did not feel valued by their
leaders. There was widespread reporting that the standard response to safety failures
was to blame individuals rather than develop systems to avoid recurrence.

For example, Scottish Government brought in the organisational duty of candour,

which came into force in Scotland in April 2018, to implement consistent responses
across health and social care providers to an unexpected event or incident that has
resulted in death or harm107.

These issues also relate to doctors working relationships with each other. In our
engagement across the UK we heard of examples of a minority of doctors treating
trainees and medical students aggressively or rudely. For example, following the
Sturrock review on bullying and harassment at NHS Highland108, the Secretary for
Health and Sport set up a Ministerial Short Life Working Group for the learning to
apply across Scotland to build supportive cultures that engender and encourage the
right behaviours109. The report made specific proposals on leadership; peer support;
and training management and HR work, to achieve a new behavioural and attitudinal
approach. Whatever the pattern in the past, such behaviour is inconsistent with a
modern compassionate healthcare workplace or with good medical and educational
practice and can constitute bullying.

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These are all issues of organisational culture, revealing some positives but many
aspects of culture that undermine doctors’ wellbeing. Changing such cultures is critical
to transforming work environments and improving doctors’ wellbeing.

Good practice and case examples

Doctors who reported feeling empowered and having supportive leaders, being part of
a team, and having adequate job resources had dramatically higher levels of wellbeing.

How can the leadership of NHS organisations nurture such cultures of high-quality,
continually improving and compassionate care and, at the same time, ensure the
wellbeing and intrinsic motivation of all the diverse doctors that they lead (and of
course all staff)? Research within the NHS suggests these are interdependent
outcomes and that there are key cultural elements that must be present110-111.
Compassionate and inclusive leadership are central and these too are described
in Annex 4.

Case study
13
Changing cultures in the NHS
A programme of successful culture change is being implemented across all four
UK countries.

NHS Improvement (NHSI), the Center for Creative Leadership and the King’s Fund
have developed a programme to enable healthcare organisations to develop cultures
that enable and sustain continuously improving, safe, high-quality, compassionate
careix. All the materials are evidence-based, open-source and designed to be
implemented by healthcare organisations rather than external consultants. The
programme provides practical support to help healthcare organisations in primary
and secondary care to diagnose their cultural issues, develop compassionate and
inclusive leadership strategies to address them and implement any necessary
changes. There are currently around 100 trusts and boards across the UK
implementing the programme, including organisations in Wales (Aneurin Bevan),
Scotland (Tayside) and Northern Ireland (Belfast). The resources are also being
used internationally. Similar models have been developed in the US by the Mayo
Clinic (Swensen et al., 2016; Swensen & Shanafelt, 2017). Many of the organisations
involved have demonstrated success in changing culture.

Another example of success is Frimley Health NHS Foundation Trust, rated as good
in 2019 by the CQC. It acquired the struggling Heatherwood and Wexham Park
Hospital and initiated a culture change programme, after carefully assessing the
culture of the new acquisition. The programme involved some 600 line managers
training to focus on high quality, continually improving and compassionate patient
care. More than 700 leaders went through a new training programme. 72% of staff
recommend the hospitals managed under the Trust (Frimley Park, Heatherwood and
Wrexham) as a good place to work.

https://improvement.nhs.uk/resources/culture-and-leadership/
ix

https://improvement.nhs.uk/resources/culture-and-leadership-programme-phase-2-design/

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Case study
14
Developing clinical leadership
The Newly Appointed Consultants (NACs) programme in Manchester University
NHS Foundation Trust started in February 2013, with over 250 consultants attending
the programme. Over 11 months, it provides newly appointed consultants with the
skills, behaviours and mindset to lead and make improvements across the Trust.
The programme is also designed to promote their wellbeing, by supporting their
transition into leadership roles. Participants are encouraged to embark on service
improvement projects, enabling them to directly influence working practices and
implement change. One improvement project introduced new minimally invasive
endoscopy to provide a walk-in-walk-out procedure under local anaesthesia.
For patients, this eliminated the risk of general anaesthesia and enabled them to
return to work and normal life on the same day. It also released beds and theatre
space. The new procedure was recognised through an award and additional funding
at the senior management level in the Trust.

The Clinical Leadership Programme (CLP), started in October 2018, is building

on the principles in the NACs programme. It is aimed at senior clinicians who
are able to shape culture, develop high-performing teams and work across
boundaries. It looks at their approach to conflict and the management of
professional relationships with colleagues. This supports clinicians by building
positive relationships and creating a community of networks long after programme
completion to sustain engagement.

Key recommendation five

Culture and leadership
To implement a programme to ensure healthcare environments have nurturing cultures enabling high-
quality, continually improving and compassionate patient care and staff wellbeing.

● All UK healthcare organisations that have not already done so should commence and implement
a programme of compassionate leadership across all healthcare sectors and obtain feedback from
doctors and healthcare staff to evaluate its effectiveness. It should include mechanisms to ensure
clinical leads and other leaders of doctors at all levels in the healthcare system are recruited,
selected, developed, assessed and supported to model compassionate and collective leadership.

● Leadership and boards of every organisation employing doctors should introduce a key
performance indicator for compassionate leadership and should review feedback from doctors and
other healthcare staff to assess if leadership is compassionate and collective.

● System regulators, improvement bodies and funding and commissioning bodies should check that
employers have in place mechanisms to support compassionate leadership. Regulators and quality
improvement bodies to review how to improve regulatory alignment and ensure compassionate
leadership is sustained in the longer term by integrating it as a priority into their regulatory models.

● The GMC should work with partners listedx to monitor and assess implementation and
maintenance of such changes to cultures and leadership across the system.

x 
See action plan in Annex 1.

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Workload 59
Management and supervision 67
Learning,
Professor training
Michael and
West and development
Dame Denise Coia 70
C – Competence 59

C – Competence
Doctors want to make a positive difference through their work by achieving valued
outcomes, such as delivering high-quality care that improves patients’ lives. The need
for competence is met when workloads do not exceed the ability of staff to deliver this
high-quality, safe and compassionate care. This also involves ensuring that doctors
and students have enabling and supportive supervisory support focused on removing
the obstacles in the workplace, rather than creating directive, controlling cultures that
focus more on blame rather than on learning and accountability. Doctors need to be
continually enabled to grow as practitioners, developing and learning so that their
skills and competence are constantly improving.

We address each of these issues in turn below by reference to the evidence from the
review, good practice, case examples and, finally, our key recommendations.

Workload
Evidence from the review
Excessive workload is the number one factor affecting poor patient satisfaction, low
levels of staff engagement and failure to innovate. It is also the key factor determining
doctors’ stress levels8, 112-113. Previous research30 has identified workload as the most
consistent influence on strain amongst healthcare workersxi.

Our research and the feedback we heard from doctors show that unmanageable
workloads are damaging doctors’ health and exposing patients to potential harm.
The challenges doctors face relate to the pace of work, multiple concurrent demands,
long hours, administrative burdens, role ambiguity and the emotional toll of working
with illness and trauma in unsupportive environments. It is unsustainable to expect
doctors to continue to take on ever-increasing demands when there is consistent
evidence that they (and their fellow healthcare professionals) are, in many instances,
unable to cope with a toxic cocktail of excessive demands and inadequate support.

Of the 4,605 responses to the iMatter staff survey in Scotland from medical and dental
staff, only 37% agreed or strongly agreed they could meet all the conflicting demands
on their time at work and only 31% said that there were enough staff to enable them
to do their job properly114. In the most recent NHS Wales Staff Survey, the respective
figures were 36% and 18%10; in the 2018 NHS Staff Survey in England, 37% and 29%8;
and in the HSCNI 2015 Staff Survey, 33% and 24%9.

Many trainers in the NTS reported heavy workloads, and that they regularly work
beyond their rostered hours. 66.3% UK-wide describe the intensity of their work
through the day as heavy or very heavy. This is twice as many as those who consider
the intensity of their workload to be ‘about right’. There is a strong correlation between
how trainers rate the intensity of their workload and the provision of time to train13.

Although this research was published some 20 years ago, it remains the highest quality study of staff stress in
xi 

the NHS to date. The available evidence suggests that little has changed in that time in terms of levels of staff
stress or the key factors that determine levels of stress.

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The demands on GPs have increased substantially over recent years. They are treating
more people with more complex problems than ever before and the number of GPs
in the UK has has not kept pace with patient demand, 115, 116. We heard repeatedly
that relentless seven to ten-minute consultation times are stressful for GPs and not
productive for patients. The number of sessions that GPs undertake, often with no time
for toilet or other breaks, increases intensity to unsustainable levels and, associated
with the fear of making mistakes, leads to burnout. It has also damaged relationships
with patients, some of whom feel they are being dealt with in a cursory way116.

Around nine out of 10 GP trainers in the UK work beyond their normal hours on at
least a weekly basis and more than half work beyond their hours daily13. This is a much
higher proportion of trainers than in any other specialty. These heavy workloads have a
negative effect on GP trainers’ health and wellbeing. Two thirds (67%) often or always
feel worn out at the end of the working day. Over half (52%) find their work emotionally
exhausting, and over one in five (23.1%) report feeling exhausted at the thought of
another day in work13.

These findings are particularly concerning in the context of recent research by Mind117,
which found high levels of mental health concerns among GPs in England and Wales.
The charity identified excessive workloads and long hours as two of the main drivers of
these concerns.

When asked to rank the top five reasons for why the NHS was having difficulties
retaining medical staff, the most commonly mentioned by doctors was excessive
workload pressures (78%)118. In the 2018 NHS Staff Survey in England, among those
doctors who said they would not always be confident in raising concerns about patient
care, the main reason given was workload pressures making it difficult to find the time8.

While volume of work is a key issue, there are also issues about excessive
bureaucracy, unnecessary administration, unwarranted variation in practices and
processes, and unnecessary hierarchical constraints119. For example, some doctors
told us they were denied time to meet as teams in the fundamentally mistaken
assumption that this will reduce rather than increase their productivity.

In secondary acute care, we heard about doctors being asked to carry multiple bleeps,
cover multiple wards and simultaneously respond to life-threatening issues among
their patients. The level of work overload, stress, anxiety and fatigue combine to
reduce their cognitive function and produce decision fatigue thus further endangering
their wellbeing and patient care120.

Part of the problem is operational, and researchers have commented that good clinical
workflow is the sum of a multitude of small processes which individually may seem
insignificant or even trivial81. Together, they make the difference between a highly
functional practice model and one that is chaotic, overloaded and stress-inducing.
Clinical excellence depends on operational efficiency. In healthcare environments there
is no team of engineers whose job it is to ensure a ‘manageable cockpit’ for clinicians,
one that is free of information overload, distractions, interruptions, and cumbersome
workflows that cumulatively contribute to a hazardous environment121. No one is
responsible for analysing and minimising the aggregated administrative and cognitive
burdens with the result that though the core work is satisfying, it is often simply
crowded out81, 121.

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Related to work overload is work pace, especially where the clinician has little control
over the number of patients (for example in emergency medicine); or time pressures,
such as having to complete tasks within a specified period. Tasks with high repetition
and short time cycles (as in general practice) are likely to result in high levels of stress
(the combination of high demands and low control is particularly toxic). Other risks are
repetitive strain and musculoskeletal disorders if office ergonomics are neglected122.
What then are the solutions?

Good practice and case examples

A vital element of leadership is addressing courageously and persistently the key
factors impacting upon the core mission of medicine and healthcare. This means
senior management devoting attention to the most significant challenges, like
workload. This will require a fundamental shift in the way we deliver medicine –
transformational and innovative approaches. This is the responsibility not only of
clinical leads but of all leaders and managers.

Case study
15
Jointly reducing workload
East London NHS Foundation Trust (ELFT) is a provider of mental health and
community services, to a population of approximately 1.5 million people. In 2013,
the Trust reviewed all clinical audits with a group of stakeholders, including service
users and staff, to identify which really added value. This allowed it to stop 85% of
all audit activity and led to a broader campaign to encourage people to identify non-
value-adding activity. In May 2014, the Trust invited every team to identify activities
that provided little value to patients or staff. The participation was high, and the Trust
grouped the responses received into three themes: ideas related to duplication of
meetings; unnecessary travel to Trust HQ for training; and duplication of recording
clinical information. The Trust acted on those three areas, trialling combining meetings
or even stopping them all together; having a group work on provision of training; and
absorbing feedback into existing clinical transformation workstreams and systems
configuration. The Trust then further encouraged all teams to have a discussion, using
an introductory podcast from the senior management team to help identify something
they spent time on that added little value. This involved discussing:

● What would you like to stop?

● Would you like to stop this completely, reduce it or change the way you
do this to be more efficient?

● How much time do you estimate you will save (each day / week / month)?

● Have you involved patients and families in thinking about which activity
to stop?

● Have you involved all your staff in thinking about which activity you might
wish to stop?

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In March 2017, a campaign at ELFT encouraged all staff to “break the rules”. Staff
were encouraged to highlight any bureaucratic and unnecessary rules that could
be eliminated to focus more on what was important and valuable to service users,
carers and staff work. Over 100 unique ideas were submitted. All of the ideas
raised were shared with staff on the intranet, who were encouraged to vote for
their favourite. Over 600 members of staff voted for their favourite suggestions
(the biggest response seen in the Trust). The leadership team considered all of the
suggestions and shared responses daily through the intranet on the ideas submitted
and on how the system was being redesigned to make them possible.

Governments throughout the UK have made efforts to recruit and train more doctors
and healthcare professionals. Recruiting more into the system will reduce workloads
and allow greater role variation. This is necessary so that they can undertake the
education, training, teambuilding, supervision, coaching, mentoring and academic
research that is critical to their roles. Variation enhances wellbeing and job satisfaction
and will sustain them in medical practice for the longer term120.

As the think tanks the Nuffield Trust, The King’s Fund and the Health Foundation have
made clear, urgent action is needed to tackle severe staff shortages in the NHS7.
This includes a big expansion in nurse training, deploying other staff to make up for
the existing growing shortfall of GPs and accelerating the recruitment and training of
physician associates.

In England, the People Plan is focused partly on ensuring more doctors are trained
and recruited for primary and secondary care123. Similar efforts are underway in the
other UK countries. For example, in Scotland, the aim of the Health and Care (Staffing)
(Scotland) Act is helping to ensure appropriate staffing. The Act creates a new
statutory duty on the geographical Health Boards, the Common Services Agency for
the Scottish Health Service, and the four Special Health Boards that deliver clinical
healthcare services to ensure that there are appropriate numbers of suitably qualified
staff providing care, alongside guiding principles to be considered when carrying out
this duty124. The Scottish Government’s three-part National Health and Social Care
Workforce Plan (preceding the integrated workforce plan and covering NHS Scotland,
social care and primary care) sets out a range of short, medium and long-term
measures125. And the National Clinical Strategy for Scotland published in 2016 made
proposals for how clinical services need to change in order to provide sustainable
health and social care services fit for the future126.

Increasing the number of medical school places is a core issue being addressed
across the UK. For example, in Northern Ireland, the Review of Medical School Places
was one of the early actions of the Health and Social Care Workforce Strategy 2026:
Delivering for Our People. The intent was to determine the future numbers of medical
education training places that should be commissioned in Northern Ireland127. Wales is
consulting on its workforce strategy until 2030, looking at supply and retention128. Train
Work Live has been a successful campaign in Wales aimed at increasing recruitment
of healthcare professionals129.

Recruitment and retention of doctors is a problem that impacts most healthcare

providers globally130 and the NHS recruits globally to meet its staffing needs – more
than 13% of the 2018 NHS workforce in England were not British131.

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We heard about schemes (Learn Earn Return and the Medical Training Initiative) that
invite doctors from overseas for a specified period to develop key skills and then return
to their country of origin. It is also vital that doctors recruited globally are supported in
a way that enables successful transitions into the NHS and UK cultures.

We also heard about obstacles for doctors in the UK trying to return to work after
a break, particularly for GPs needing a supported return to work after a break from
practice due to ill health or regulatory intervention.

Case study
16
Recruit from other countries
Learn, Earn, Return is a collaboration between Health Education England (HEE),
the Greater Manchester Health and Social Care Partnership, Edge Hill University
and Wrightington, Wigan & Leigh NHS Foundation Trust. Doctors with at least four
years’ experience come to the UK for a master’s degree. The course fee is paid
by the doctor though other arrangements are sometimes available. Doctors will be
employed full-time in NHS Hospitals. At the end of the course, they return to their
country of origin with greater career opportunities. The programme has been
offered since 2006, and the uptake is continuously increasing. Part of why the
programme has been successful is the great attention paid to pastoral and cultural
care of the doctors. NHS consultants, often from the same country, are personally
involved in interviewing, recruiting, welcoming, teaching and looking after the
participating doctors.

Training and recruiting more doctors needs to be supported by changes to the way
medicine is delivered to increase the support for and thereby the productivity of
doctors. There must also be a bolder move towards deploying alternative professionals
in multidisciplinary teams to build a mixed skill set for use on the frontline of medicine,
in both primary and secondary care. Many tasks that are currently done by doctors
can be transferred to other professionals (such as physician associates and advanced
nurse practitioners, pharmacists, physiotherapists, mental health practitioners, social
prescribers, medical assistants and volunteers) working both in specialist units (e.g.
phlebotomy teams) or in multidisciplinary teams132. There are potential benefits for
all from more flexible ways of working, enabling skill development, task variety and
reduced workload133.

We heard about alternative professionals both overseas and in the UK being used
to free up time for doctors by taking notes and preparing referral letters; running
preventive programmes on diet, smoking and exercise; filtering patient requests;
conducting multidisciplinary triage; dealing with normal screening results and repeat
prescriptions; doing pre-appointment work to obtain information on medication,
allergies, care gaps and reason for visit; and nurses treating some problems using
standardised approaches. These changes allowed for longer consultations increasing
doctor satisfaction and patient care.

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Case study
17
Task shifting in primary care
In 2015, three GP practices serving St Austell in Cornwall decided to merge,
absorbing 12,000 patients from the biggest practice in the locality, which had closed
in 2014. The merged practice looked at every element of its work through an audit to
fine-tune the doctors’ workload.

This led to the recruitment of other healthcare professionals, including a community

psychiatric nurse, a physiotherapist and a pharmacist. The merged practice aimed
for people to be seen by the appropriate level of clinician for their concern, to ensure
patients were seen in a timely manner due to lack of GPs in the area.

Recruitment also included administrators who managed its estates and premises,
finances, governance, complaints, the practice website, and communications with
patients and staff.

The wide range of skills among non-clinical staff supporting the clinicians enabled
everyone to specialise in fewer areas of expertise rather than spread themselves
across several roles and responsibilities. As a result, each GP is responsible for
3,800 patients vs. 2,200 patients in the rest of Cornwall.

This redesign process was managed by an executive group with one

partner from each original surgery and the managing partner. Key decisions
were taken at the partners’ meeting once a month. Anyone from the practice could
attend these meetings and the whole process has developed trust and strong
collegiate relationships.

Case study
18
Task shifting in surgery
To combat issues surrounding workload, the Royal College of Surgeons of England
developed the role of doctors' assistants. They successfully piloted the role at East
Sussex Healthcare NHS Trust by employing five doctors’ assistants on six-month
secondments. These individuals, who were previously healthcare assistants,
received a two-week induction, supervision and on going support. They undertook
administrative and basic clinical tasks at the direction of doctors on-call or in acute
clinical areas. Feedback from doctors, doctors’ assistants and other staff was highly
positive, with some doctors saying they would not have coped on a weekend shift
without them.

Mrs Scarlett McNally, Consultant Orthopaedic Surgeon and RCS Council member
who led the pilot, said the important aspects were excellent skills training, a clear task
list, good communication, prior experience in a clinical area and support given for the
change of role.

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Important improvements can be made through clinicians undertaking workflow

mapping, modifying work schedules to increase appointment times and reduce work
intensity. Developing an ability to monitor time, volumes and administration demands
within work processes (sometimes called ‘manageable cockpits’ after similar successful
interventions in the aviation industry) provide a means to monitor workflow and
effectiveness on an ongoing basis121.

At the most basic level, we heard that this requires access to an up-to-date computer
that can run the relevant software; computers on wheels that are working and fully
charged; a system to report IT errors that ensures issues are dealt with promptly; WiFi
without black spots; handheld devices (for observations etc) to be available and charged;
a single sign-on password system; patients’ case notes available; effective electronic
prescribing; relevant stationery available prior to the successful introduction of the
electronic patient record (EPR); equipment needed for clinical examinations such as
tendon hammers, ophthalmoscopes and auroscopes; a desk to write notes and review
test results; and some freedom from non-urgent interruptions from patients, families
and other staff.

This suggests that deploying an administrator in clinical units on all shifts, with
responsibility for these issues would significantly increase productivity and satisfaction
among doctors and other healthcare staff.

Case study
19
Workload in General Practice
The Haxby Groupxii, which cares for 50,000 patients across York and Hull, found
it was overwhelmed by excessive workloads. Its aim was to ensure a sustainable
workload for GPs while maintaining high-quality patient care.

The solution was to develop the GP role to focus on complexity (with the time
to do it) and become effective leaders of multi-disciplinary teams. The large size
of the Group enabled it to focus on the governance required, to allow lower-risk
investment, ensure good HR, finance and business intelligence and release GPs’
time to manage the changes.

The Group now employs eight pharmacists, eight paramedics, five nurse
practitioners and a physiotherapist. The tasks of prescription management, urgent
care, home visits, reviewing letters and results, have been largely transferred to
other professionals. GPs are available to discuss or review patients and provide
mentorship and oversight to the rest of the team.

Quality of care and patient satisfaction is high and GPs now have 15 minutes for
routine appointments.

While the size of the Haxby Group means that it does not reflect the usual UK primary care model, how it has
xii 

tried to address workloads on a scale points to approaches that may be possible by collaborative working
with the scale that Primary Care Networks will introduce in England (practice ongoing in Scotland and Wales
through GP clusters and in Northern Ireland through GP Federations).

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We also heard about innovative uses of technology to free up doctors’ time to support
more sustainable working. These include using automated chat services and phone
and video consultations.

Case study
20
Releasing doctors’ time
University Hospital Birmingham is using new technology to enable patients to
access live and automated chat services, online symptom checkers and video
consultations with doctors and nurses to dramatically reduce the pressure on
services. Patients planning to go to A&E will be asked to do a two-minute online
check of their symptoms before going to hospital. An artificial intelligence triage
system will advise them if they need to seek treatment at A&E. This is intended
to reduce workload in the A&E units at its four acute hospitals in Birmingham, by
dramatically reducing the current 30% of ‘avoidable attendances’. The Trust also
plans to enable patients to talk to their consultant using their phones, and not have
to attend physically for an outpatient appointment. It estimates it can implement
this approach with 70% of its two million outpatient appointments within three
years. Such innovations reflect similar practices in healthcare within the UK
and internationally.

Other changes that appeared to have a great impact were those that enhance
communication between healthcare professionals. Relocation of staff so teams are
co-located, frequent team meetings, leader updates, regular doctor and leader
meetings to discuss concerns and daily multi-professional team huddles to review
the patient list appear to significantly improve productivity, staff satisfaction and
wellbeing81.

In the 2018 RCGP Scotland workforce and wellbeing survey, doctors made many
suggestions for how to tackle GP workload, including improving IT, reducing
bureaucracy, ensuring more time with patients, developing a culture that protects time
for learning, having breaks, improving multidisciplinary team working, having time for
reflective practice and increasing the say GPs have in their local health and social
care system12.

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Key recommendation six

Workload
To tackle the fundamental problems of excessive work demands in medicine that exceed the capacity of
doctors to deliver high-quality safe care.

●  ll organisations that oversee the work of doctors should undertake, in collaboration with doctors,
A
a programme to review workload in their organisations. This will help them to use resources in the
most efficient way, to ensure workloads do not exceed doctors’ ability and capacity to deliver safe,
high-quality care. Initiatives are underway across the UK to increase staffing numbers and this
should be supported by additional solutions including, but not restricted, to:

- A programme to deploy and develop alternative roles to enable doctors to work at the top of their
competence, supported by effective multidisciplinary team working in all areas of healthcare, and
to support doctors to return to work after a break in practice.

- A review of new technologies being used in UK healthcare systems to increase efficiency (see
case studies), working with the voluntary sector, and focusing on preventive care.

- A programme of process improvements that increase productivity especially by supporting

communication in regular team meetings between healthcare staff (see case studies).

- Eliminating tasks and activities that do not add value to patient care or doctors’ wellbeing.

- Engaging communities, community representatives and patients in taking shared responsibility

for their health services.

- Identifying services that cannot be provided in a resource-constrained system and unnecessary

processes that do not add value.

●  he leadership and boards of every organisation employing doctors should review programmes to
T
address excessive workload and monitor their impact.

●  ystems regulators, improvement bodies and partners listedxiii should check that employers have in
S
place programmes to address excessive workloads and to monitor them to ensure improvement.

Management and supervision

Evidence from the review
Unlike other healthcare staff (and people working in organisations generally), doctors
often do not have a line manager. For many doctors, including doctors in training
and some specialty and associate specialists (SAS) we spoke to in England, they are
disempowered within the existing hierarchical system. A picture emerged of isolated
working patterns, not being part of a team, a lack of connection to clinical leads and
seniors, absence of line management and inaccessible rota managers. Consequently,
many doctors have nowhere to go with the day-to-day challenges of their working lives.
This fundamentally weakens their sense of belonging, feelings of competence and their
sense of control.

xiii 
See action plan in Annex 1.

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Doctors’ need for autonomy/control does not imply independence or lack of

accountability. At the same time, being managed by people who are challenging,
aggressive, intimidating and who cause conflict has a detrimental impact on the
mental health of doctors. Compassion and encouragement from clinical leads, line
managers and senior management has direct benefits for the mental health of doctors
and for wise allocation of workload, control of access to resources and the provision
of appropriate supervision133.

For example, the system of exception reporting introduced in England after the junior
doctors’ strike in 2015-2016 does not appear to be enabling doctors to manage their
work time effectively. Out of 33,000 exception reports in the year to September 2018,
only 2.5% led to service or rostering changes. Half of these were made at just three
trusts – Barts Health, The Newcastle Upon Tyne Hospitals Foundation Trust and Royal
United Hospitals, Bath134. Exception reporting is a process that exists only in England,
and, while the GMC has consulted doctors in training about rota monitoring in Scotland,
Wales and Northern Ireland, the data demonstrating how it is working in practice isn’t
available. In Scotland, the BMA and the Scottish Government jointly agreed the New
Deal Monitoring Guidance for doctors in training. This aims to implement an accurate,
fair, robust, and consistent approach to monitoring the hours that trainees work135.

In a pressured modern workplace, lack of support of and no access to a line manager

has a negative impact on the work experience of doctors in relation to their core
work needs. As one doctor commented: “…there are times when the senior support
does not exist, and that’s when it can become stressful, when you’re searching for
consultants and registrars you don’t know, and they don’t know you.”

Good practice and case examples

There is considerable evidence of the importance of good supervision for care
quality and for doctor wellbeing136-138. The GMC NTS data reveals that having a good
educational supervisor both in primary care and secondary care buffers the negative
effect of working beyond contracted hours on burnout. Trainees experienced the
least burnout when they worked only their contracted hours and were satisfied with
their supervisor13.

Because many clinicians across the UK reported difficulties in finding the time to fulfil
their supervision roles, supervision time must be allocated in job plans of clinical/
educational supervisors and in the job plans of line managers. Their workloads must
be balanced to ensure that supervision time is not crowded out by other demands.
Effective clinical supervision increases efficiency and productivity and will repay the
time allocated139-140.

In the NHS Staff Survey in England, doctors who reported having supportive line
managers experienced higher levels of work engagement, more satisfaction with their
organisation, and more satisfaction with their immediate work conditions. They were
less likely to be intending to leave their organisations or the NHS8.

Provider organisations (both in primary and secondary care), clinical leads and senior
colleagues must provide supportive and compassionate supervision. This should
include ensuring that local requirements for appraisal are proportionate. There

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also needs to be a close relationship between doctors in training and their clinical
supervisors, involving regular contact so that trainees can get timely, supportive and
helpful feedback, as well as visible and inspirational role modelling.

For example, Project Lift is a leadership programme across health and social care
in Scotland, supported by the Scottish Government, offering multi-professional
development opportunities to established and potential leaders141.

Case study
21 Improving appraisal
The acquisition of new appraisal software allowed all Manchester University
Foundation Trust staff to move to a single appraisal platform, enabling Managed
Clinical Services working across sites to have all their staff within one system.
Medical directors and other clinical managerial staff can view and report on
the staff within their hierarchy level and monitor appraisal progress directly.
The system has allowed Manchester University Foundation Trust to tailor the
system for its specific requirements, providing a tailored appraisal portfolio for
each clinician according to their role and specialty. Moreover, it is designed so
that only the required information is asked to be completed.

Dedicated supervision
NHS Lothian appointed its first cohort of chief registrars in 2018. They have 20%
of their time dedicated to personal leadership and management alongside clinical
commitments. They are a voice for doctors in training across the health board
and are tasked with being a link between doctors in training and management
in the organisation. Chief registrars chair the Lothian Trainee and Management
Forum, the primary purpose of which is to provide a regular forum for two-way
communication between doctors in training and management representatives.
Other activities include co-ordinating a wellbeing survey of all doctors in training
and organising a conference on ‘Being Human: valuing our workforce’.

Poor quality supervision and feedback impacts on both trainers and trainees13.
This can particularly affect doctors from some groups42, 142. It is important that
supervisors, at all levels of seniority, are adequately trained to enable them to
fulfil their roles effectively. This requires evaluation of training to determine its
effectiveness, and regular assessment of the quality of their supervision based
on the principles of compassionate and inclusive leadership.

There is a collective aspiration across the four health systems to develop

compassionate and inclusive/collective leadership. This is done through the
People Plan by NHS England; in Northern Ireland, through the HSC Collective
Leadership Strategy launched in 2017; in Scotland through Project Lift; and in Wales
through the new Health & Social Care Workforce Strategy. The challenge is to ensure
that these commitments are translated into practice. The development of supervision
skills should also be part of continuing professional development throughout the
supervisors’ tenure in the role. Ensuring organisations provide resources (training,
time on schedule etc) for appropriate supervision could be further reinforced via

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systems regulators and improvement bodies, GMC evaluations and reflections by

team members. This is a clear route to enhancing productivity, engagement and
commitment of doctors across our health services.

Key recommendation seven

Management and supervision
To ensure all doctors have effective clinical, educational and pastoral support and supervision to thrive
in their roles

● All organisations that employ doctors should make sure:

- Each has a well-trained line manager supporting them to perform their roles effectively and
ensuring their basic work needs are met. They should also obtain feedback to ensure this is in
place (in primary care, this might be a peer mentor or coach).

- Management, support, educational and clinical supervision are included in the job plans of those in
such roles, and their workloads are balanced to ensure protected time to provide these functions.

●  he leadership and boards of every organisation employing doctors should review feedback to
T
check all doctors have well-trained line managers with protected time to carry out their functions.

●  rganisations responsible for education and training of doctors and medical students should
O
ensure they have an appropriate level of high-quality educational and clinical supervision provided
by well-trained and compassionate supervisors.

● Systems regulators, improvement bodies and partners listedxiv, including postgraduate training
organisations, should work with the GMC to implement and monitor this recommendation, including
via quality management and assurance mechanisms.

Learning, training and development

Learning, training and development are central to a sustained sense of competence
from medical education at undergraduate level all the way through a doctor’s career
journey. The GMC sets the standards for providers of formal medical education and
training, and regularly checks to ensure those standards are met. But, the issues
are wider than only formal development143. We consider these issues in relation to
undergraduate, postgraduate and post-qualification training below.

Evidence from the review

Undergraduate medical education
Our focus groups with UK medical students identified factors similar to those of other
undergraduates, including the transition from home/school to university life; the lack of
a support network (family, friends); fear of disclosing mental health issues; competition
with peers reinforced by social media; and self-care issues (e.g. with nutrition or sleep144).
More specifically, however, medical students said that university-wide support services
xiv 
See action plan in Annex 1.

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C – Competence 71

were rarely tailored to the specific stressors they experience, such as witnessing ill
or dying patients or being part of a serious untoward incident. We heard that in some
circumstances minimum requirements for attendance were too rigid and didn’t allow
for life events during training. We have also received feedback that, for some students,
re-taking a year was in their best interests and meant they were not struggling to keep
up going forward. Although students may not be keen to take time out or re-take
a year, medical schools should be assisting students to consider what is best and
consistent with achieving GMC outcomes and meeting the demands of the course.

Some interactions with other professionals made medical students feel at the ‘bottom
of the ladder’ undermining their confidence and wellbeing. There were anxieties about
the planning of, and the time and cost of travel to placements. Placement providers
were also not always adequately prepared to receive students, and it was difficult
to access consultant time and get exposure to and sign off for competences.

Finally, the combination of tuition fees, university expenses, course length, and limited
ability to work to earn while at medical school can accumulate into financial pressures
affecting students’ wellbeing (many accumulate debts of over £80,000).

Postgraduate training
So far in the report, we have explored factors affecting doctors’ wellbeing at work,
and we want to look at these more specifically in the context of training. Doctors in
training repeatedly expressed frustration at the current approach to training. Doctors’
wellbeing must be supported at the start of their careers, when they face a steep
learning curve. The doctors in training we spoke to described challenges that have the
combined effect of significantly reducing autonomy/control, belonging and competence.
Indeed, the role of doctors in training seems perversely designed to prevent the
fulfilment of all three needs. Doctors in training are also particularly vulnerable to the
workplace factors that impact on all doctors, including workload, poor rota design
and management, inadequate supervision and a lack of basic facilities.

We heard about a tension between the education and training of doctors and the
pressures of service provision with concerns that some employers by default see
trainees primarily as service providers rather than as doctors in training. While service
provision is an important part of training, it can have a negative impact if trainees are
required to undertake high levels of rota gap cover work that may not be educationally
useful or if they are inadequately supervised. While this did not appear to be true for all
SAS doctors, in focus groups we heard from some SAS doctors that the pressures of
service provision also made it difficult for them to access development opportunities.

The rigidity of the training framework itself makes stepping off or getting experience
gained elsewhere recognised, and this does not support doctors in relation to their
wider life circumstances.

Concerns about differential attainment in exams are well known and, while the causes
are complex, we know that some groups are likely to be less familiar with assessment
structures and expectations. This is not only true for those coming from overseas
but also for those who may be the first in their household to go to university/medical
school/become a doctor. Doctors who fail exams face increased financial pressures
from paying for examination retakes.

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C – Competence 72

Some trainers avoid giving feedback, particularly where the person receiving it is
from a different ethnic background to the trainer. Consequently, some doctors miss
out on coaching. These experiences add to the other pressures for those on training
programmes143. They undermine a sense of growing competence and do not suggest
supportive learning environments consistent with the core health service values of
compassion and inclusion.

The frequency of placement changes makes it difficult for doctors in training to build
and maintain supportive relationships with peers and seniors, leaving them isolated
at a time when they are undergoing frequent transitions and need support. Placement
changes also result in repeated changes of employer, causing significant practical
challenges for overseas trainees in relation to visas but also for the wider trainee
population, for example, in relation to repeated mandatory training requirements142.

Remote postings remove doctors in training (usually those who are already struggling
and have failed to get their placements of choice) from their families for prolonged
periods146. This diminishes the extent to which all three core work needs are met –
the needs for autonomy/control, belonging, and growing competence.

Placing doctors with lower attainment, often with the highest need for additional
support, away from their friends and family, leads to difficulties. By creating a hierarchy
of attainment in which there is a small proportion of outright winners and a large group
of relative losers, the system undermines a sense of competence142.

The system of allocating the best performers to their organisations of choice also
tends to strengthen the impact of inverse care trends145 with the areas most in need
being poorly served while the most attractive locations can take their pick from a large
number of well-qualified applicants.

Later career development

Many GPs are planning to retire early, which will increase burden on those that remain
in the profession. The feedback we heard suggests one of the underlying causes
may be the limited opportunities GPs have to learn or develop, particularly when they
wish to reduce their patient-facing roles. GPs are in effect asked to do the same tasks
without opportunities for development for often well over 30 years. Some GPs have
responded by taking part-time or locum positions in other care settings or becoming
educators, leaders or mentors35, 146-147. At the other end of their careers, we heard that
GPs struggle with the transition to the demands of GP practice following postgraduate
training. The First Five programme run by the RCGP, detailed in the below case study,
is a programme to support newly-qualified GPs’ transition to general practice but this
could also be adapted, adopted and extended to include all GPs to allow for ongoing
GP development and training.

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Case study
22
Support for GP development
Organisations representing GPs make clear that those who are newly-qualified
often need support beyond their clinical training to help them transition into their
new role. First Five is an initiative run by the Royal College of General Practitioners
(RCGP) designed to support GPs in their first five years post MRCGP qualification
through to revalidation. The initiative has been warmly welcomed because it helps
GPs develop networks that can provide peer and professional support.

A similar trend is seen in secondary care, with senior consultants planning to take early
retirement. We heard that at the later stages of their career, many wish to stop acting
down to cover rota gaps and to reduce the impact of demanding shift patterns on their
wellbeing. We know that pensions regulations play a part, but many doctors are highly
motivated to stay in or return to the NHS if there were attractive roles that made good
use of their experience and skills.

Good practice and case examples

Undergraduate medical education
Student wellbeing is a shared responsibility of the individual learner, the school, and
the placement providers. It is good practice to provide tailored support services at
medical school level and some schools have implemented student-led peer support/
mentoring programmes and wellbeing elements in the curriculum. They promote
students’ wellbeing through extracurricular activities, and are flexible when students
need time away for health/welfare issues.

Students in the Scottish Graduate Entry Medicine programme (ScotGEM) are

allocated a personal tutor at the school (with a pastoral role) and a General Clinical
Mentor (GCM) who supervises their clinical placements. During the GMC 2018/19
quality assurance review of the programme the students were very positive about
their experience, describing the GCMs as generally approachable and available for
clarification or advice148.

Case study
23
Clinical placement facilitators
Lancashire Teaching Hospitals NHS Foundation Trust introduced clinical
placement facilitators (CPFs), band six – seven nurses, who work closely with
medical students and clinical placement supervisors (CPS) in identifying struggling
students and supporting, guiding and teaching them within each placement.
Students say they are excellent mentors who help organise their placements
based on their needs.

Quotes from medical students about the CPF team at Lancashire Teaching
Hospital NHS Foundation Trust:

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C – Competence 74

“CPFs make a huge difference and invaluable for learning and support. They
go out of their way to make your placement run smoothly. I feel lucky I got a
placement at Preston.”

“Excellent CPFs in organising medical students’ learning, so we can make the

most out of our placement.”

The undergraduate curricula can be designed to ensure that students have the tools
to support their own wellbeing, develop a compassionate approach to care, work
effectively in multidisciplinary teams, and develop their compassionate and inclusive
leadership skills. This could be part of the ongoing review of undergraduate curricula
that will be completed by 2020, to align with the revised outcomes that newly qualified
doctors must meet by the end of their medical degree (Outcomes for graduates 2018).

Education providers can ensure that students, like doctors, have membership of a
stable ‘home team’ that meets regularly and provides the student with a sense of
belonging. Changes in the way clinical placements are run can also help with that.
Placement providers play a key role in ensuring that they support students’ wellbeing
with appropriate cohort sizes, collaboration with other providers to ensure a good
distribution of students, and providing pre-briefings for the teams that students will
be shadowing.

Good education providers work with students to understand their needs and address
them. They provide compassionate and inclusive supervision that offers reasonable
flexibility for students with mitigating circumstances. They also support students and
ensure that the culture enables them to speak up about concerns.

To address the performance pressures on students, good education providers are

seeking to develop a culture of learning that shifts the focus to enabling every student
to become an excellent doctor, rather than competing with their peers to determine
who is best. Conversations with colleagues at the American Association of Medical
Colleges (AAMC) suggested that a pass-fail system where students are encouraged
to achieve a high level, and all are supported to succeed is very successful.

Postgraduate training
In relation to the rigidity of the training framework, the step-on step-off principle
could provide practical solutions to some of the problems identified. The GMC’s
new guidance Excellence by design and the introduction of the General professional
capabilities framework will better enable trainees to switch specialty. The Curricula
Review already underway will also ensure curricula are aligned to assessments and
the reality of medical practice.

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Case study
24
Improving Surgical Training
Improving Surgical Training (IST) is a project led by the Royal College of Surgeons
of England and HEE. It includes a range of evidence-based initiatives to improve the
quality and quantity of training for surgical trainees, following the issues identified
by the Improving Surgical Training report. The pilot is running in several sites to
allow early years trainees to develop competencies at an accelerated pace, with
opportunities to gain skills usually acquired in more advanced training. Pilot training
placements will usually be of twelve months’ duration, to allow the development of
a more settled learning environment, and an improved relationship between trainees
and their supervisors. This will be achieved by:

● Providing training opportunities for approximately 60% of the working week,

often through a minimum 1:10 on-call rota.

● Providing pilot trainees with simulation-based training through dedicated

induction programmes (‘boot camps’) and having specific opportunities
within their posts for both supervised and unsupervised activities.

● Requiring protected supervision time for training in pilot trainers’ job plans
and a minimum of one hour per trainee per week to provide feedback and
reflection. Trainers have been offered additional training and will support
trainees in obtaining the appropriate opportunities to gain the curriculum-
defined skills for their stage.

● Supporting the ‘modern firm’ structure in the working environment,

comprising trainer, trainee, peer colleagues and the surgical care team.
Where present, the latter will work closely with pilot trainees to provide
clinical support and reduce administrative responsibilities.

A key feature of IST is that progression will be based on the acquisition of

curriculum-defined competencies, ensuring the product at the end of training meets
current and future patient needs. The project is being independently evaluated,
where issues including trainee satisfaction and wellbeing will be explored.

Concerns about differential attainment are being addressed in some places by

ensuring early, honest feedback and the use of mechanisms to address diverse needs,
including the use of personal development plans based on formative assessment,
and exam preparation support149.

Placement change problems have been addressed in some areas of the UK through
single lead employer schemes and other positive initiatives150-152. Similar moves
towards supporting placement transitions are being mooted across England and there
are already successful ‘streamlining/passporting’ schemes152.

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C – Competence 76

Case study
25
Integrated foundation training
The North West of England Foundation School piloted several Longitudinal
Integrated Foundation Training (LIFT) programmes in 2016 across eight acute
trusts. The LIFT programme, run by HEE North West, aims to connect several such
integrated placements in a coherent two-year programme. The LIFT programmes
have six, four-month placements in acute specialties with an attachment to a
general practice for the duration of the two years. The latter provides continuity and
a ‘home team’. All the LIFT programmes have the expected standards of teaching
and learning, as well as clinical and educational supervision focused on longitudinal
competency themes such as values, leadership, self-management, patient safety
and quality improvement. Surveys showed that LIFT trainees felt more valued,
supported and satisfied in their roles, had a lower sickness absence rate and tended
towards more compassionate reflections than standard trainees. In the programme
evaluation, doctors in training fed back that the time spent in primary care was one
of the most positive aspects of the LIFT programme. Participants reported improved
communication and consultation skills, a greater ability to deal with complex, diverse
and uncertain situations. Participants reported being better prepared to make an
informed career choice.

Later career development

With the move towards wider role development and task shifting to address workloads,
there will be a significant need for teaching, training, mentoring and support for
multidisciplinary team working. Experienced staff are well-placed to provide this;
newly-qualified GPs also need access to programmes that will support them to
transition into their new role. Some programmes enable experienced GPs to continue
to contribute without doing only patient-facing sessional work, and others in secondary
care enable consultants to continue to contribute in a way that reduces the impact of
shift work and rota gap cover.

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Key recommendation eight

Training, learning and development
To ensure the systems and frameworks for learning, training and development:

● Promote fair outcomes

● Are sufficiently flexible to enable doctors and medical students to grow and develop throughout
their careers and to better manage their wider life circumstances.

Undergraduate medical education

● Medical schools should work collaboratively with students to:

- Get feedback and meet their specific needs.

- Measure and improve student well-being as a routine performance metric.

- Ensure a culture of interdisciplinary learning within the faculty and integrate

wellbeing, compassion and multidisciplinary team working into student training within
ongoing curriculum review.

- Offer confidential services tailored to the needs of medical students and a package of support
for those seeking mitigating circumstances/ taking time out, including additional ways to
complete attendance and curriculum requirements.

- Ensure an effective feedback mechanism for medical students to speak up about concerns
such as bullying and undermining.

- Ensure clinical placement providers are well prepared to receive students and work with other
schools to address issues like capacity.

- Consider benefits of a pass/fail grading system at least for some course components.

● Medical schools should establish a key performance indicator for student wellbeing across all
learning environments and review feedback to assess performance.

● The GMC, through its quality assurance functions, should check and monitor the improvements
made by medical schools on student wellbeing.

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Postgraduate training
● The GMC and system leaders across education and training, including postgraduate training
organisations, should support a review of the impact of the allocation of training placementsxv.

● System leaders across education and training should improve the programme of assessment,
including curricula, to ensure:

- Early and ongoing formative assessment of learning outcomes and provide opportunities to
improve and evaluate performance prior to high-stakes assessment.

- The development of a personal development plan.

● The GMC should continue to monitor differential attainment with a view to achieving continuous
reduction in differential outcomes.

● The organisations responsible for postgraduate medical education and training across the
UK should, where they have not already done so, address administrative burdens placed on
doctors in training such as by establishing a Single Lead Employer (as in Scotland, Wales and
Northern Ireland) or by cross-organisation passporting (where a Single Lead Employer system
is not practicable).

● Postgraduate training organisations should review feedback to assess performance with

addressing administrative burdens placed on doctors in training.

● The GMC, through its quality assurance functions, should check and monitor improvements
made by postgraduate training organisations to address administrative burdens placed on doctors
in training.

Ongoing development
● The GMC should work with UK national governments to develop strategies to better support the
ongoing development of all doctors outside or after formal postgraduate training, and, in particular,
GPs. This should establish new ways of working to improve the capacity and confidence of newly-
qualified GPs and specialists and the retention of experienced doctors in the NHS.

● The GMC to review the findings of its survey of specialty and associate specialist (SAS) and locally
employed (LE) doctors to work with partners to consider what steps need to be taken to better
develop and support this group of doctors and their different challenges across the UK.

This is one of the recommendations in HEE’s report on NHS Staff and Learners’ mental wellbeing in England. The
xv 

GMC’s Promoting Excellence standards give the GMC a responsibility for the fairness of recruitment processes.

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Conclusion

Professor Michael West and Dame Denise Coia

Conclusion 80

Conclusion
Our aim should be to ensure that the UK’s health services are a model for the world
in creating work places that promote doctors’ wellbeing, through meeting their core
work needs. This is a moral issue but is also consistent with the core purpose of the
service to ensure the health of our population. Doctors’ health and wellbeing is critical
to the quality of care they can provide for patients and communities.

We have repeatedly referred to compassion or kindness in interactions with those

we work with, those we lead and those for whom we provide services. There is
a convincing evidence base for the beneficial effects of compassion on patient
outcomes and the wellbeing of health and care professionals. Neglect, incivility,
bullying and harassment of staff have quite opposite effects154. Lawrence and Maitlis
(2012) describe an ethic of care in effective teams and organisations, which is more
likely to occur in those 'that foster integration, nurture trust and respect the emotional
lives of members, and where members have the opportunity to become competent
carers'155. When our focus is on understanding and helping others in service of the
healthcare systems' shared vision, collaboration and teamwork will be much more
effective, productivity markedly higher and patient safety and satisfaction
much improved.

Our call to action is for all health service leaders to practise the skills of
compassionate and inclusive leadership to create the cultures that the health service
needs for the future. Where organisations are founded on values and cultures of
compassion and inclusion, they will foster individual, team, inter-organisational,
and community wellbeing characterised by fairness, trust, thriving and wellbeing.
In that way, we will effectively meet doctors’ needs for autonomy, belonging and
competence at work and thereby better serve the wellbeing of the patients and
communities we serve. That is not only our challenge, it is our imperative.

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Annex 1 –
Action plan

Professor Michael West and Dame Denise Coia

Annex 1 – Action plan 82

Action plan
The General Medical Council (GMC) should work with UK national governments and
those coordinating and leading the following programmes to ensure collaborative
action to guarantee the wellbeing of the medical profession as a priority:

● The NHS People Plan in England

● The Health and Social Care Workforce Strategy 2026: Delivering for Our People
in Northern Ireland

● The Ministerial Short Life Working Group on Culture and Project Lift in Scotland

● Health and Social Care Strategy and the Health and Social Care Leadership
Framework in Wales

This action plan sets out detailed recommendations. It also highlights potential
partners and proposes some practical solutions.

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Annex 1 – Action plan 83

Autonomy and control

Aim: to give doctors control over their work lives

Potential partners – national and local organisations across the four countries of the UK including:

● National Health Service (NHS) organisations

● Employers - including local health service Trusts, Boards and primary care providers

● Employers - representative organisations

● Systems regulators and quality improvement bodies

● Postgraduate medical education and training organisations

● The GMC

● Doctor representative organisations – including the

British Medical Association (BMA)

● Medical royal colleges and faculties

● Medical leadership organisations

1. V
 oice, influence and fairness – to introduce mechanisms for
doctors to influence the culture of their healthcare organisations
and decisions about how medicine is delivered.

Clinical leaders and managers should consult doctors (and other healthcare staff)
and gather feedback about how healthcare teams are established and maintained, how
their work is organised and delivered and the response to concerns to ensure a focus on
learning not blame.

Approach and practical solutions to include:

● Employers making sure concerns are listened to and addressed by working with doctors to:

- Encourage and gather feedback from all healthcare staff via psychologically safe mechanisms,
including staff working in isolated roles or at risk of being perceived as ‘outsiders’.

- Assess and identify concerns, including the extent to which teams and organisations are
working in ways that are fair and just. This should be part of the core work of any environment
that doctors work in.

- Continuously develop and deliver an action plan to address concerns and suggestions.

- Prioritise time and resources to deliver culture transformation programmes and training
as required.

- Provide timely feedback on if and how concerns have been addressed.

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Annex 1 – Action plan 84

1. V
 oice, influence and fairness – to introduce mechanisms for
doctors to influence the culture of their healthcare organisations
and decisions about how medicine is delivered (continued)

 he leadership and boards of every organisation employing doctors should establish a key
T
performance indicator for voice and influence and review feedback to assess performance.

 ystems regulators, improvement bodies and suggested partners should check that
S
employers have and are using mechanisms for obtaining and reviewing feedback from
doctors about their work.

The GMC should work with partners listed to:

- Support monitoring and assessment of engaging leadership, and just and fair cultures.
- Assure progress across healthcare teams and organisations in both primary and
secondary care.

Approach and practical solutions to include:

● Monitoring using established (academic, peer-reviewed) measures of voice, influence, justice and
fairness.

● Improvement, development and implementation of the following to ensure high-quality

measurements across all areas:

- The GMC’s national training surveys (NTS)

- NHS staff surveysxvi

- National surveys of primary care staffxvii

Healthcare providers should promote a workplace in which discrimination of any form is not
tolerated, by ensuring prompt identification and addressing of issues.

Approach and practical solutions to include:

● Employers ensuring quality, positive diversity and inclusion across all areas of healthcare by:

- Providing a timely and sensitive engagement or feedback process that staff can use to report
concerns or issues.

- Taking appropriate steps to address any issues identified.

xvi 
Such as the NHS Staff Survey in England, Health and Social Care Northern Ireland Staff Survey and
Scotland Dignity at Work Survey, NHS Wales Staff Survey
xvii
Such as the National GP Worklife Surveys in England and RCGP Scotland Workforce and Wellbeing survey

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Annex 1 – Action plan 85

1. V
 oice, influence and fairness – to introduce mechanisms for
doctors to influence the culture of their healthcare organisations
and decisions about how medicine is delivered (cont.)
The GMC should work with partners listed to confront divisive cultures in healthcare
organisations by reporting on progress with implementing the recommendations of the
‘Fair to refer?’ report.

Approach and practical solutions to include:

● Progress reporting to include the proportionality of referrals by employers to the GMC.

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Annex 1 – Action plan 86

2. Work conditions – to introduce UK-wide minimum standards for

basic facilities in healthcare organisations.
All healthcare employers should provide all doctors with places and time to rest and sleep,
access to nutritious food and drink, the tools needed to do their job and should implement the
BMA’s Fatigue and Facilities charter.

Approach and practical solutions to include:

● Ensuring basic facilities include, but are not limited to:

- Removing barriers to and promoting the importance of taking breaks.

- Physical spaces to take breaks.

- Access to nutritious food and drink for all shifts.

- Suitable places to rest.

- Lockers to secure belongings.

- Effective IT systems and support with using them.

- Time to take breaks and undertake essential activities such as appraisal, training
and supervision.

● Employers to seek feedback from staff on any obstacles to the access to basic facilities and to
address concerns raised.

● Employers, where necessary, to reinforce the importance of accessing basic facilities, rests and
breaks to those responsible for day-to-day supervision of medical staff:

- Through the delivery of culture transformation programmes and training.

- By promoting the importance of breaks and time for essential tasks, such as supervision, line
management and appraisal.

The leadership and boards of every organisation employing doctors should review facilities
to ensure compliance with the BMA’s Fatigue and Facilities charter.

Systems regulators, improvement bodies and partners listed should check that employers have
implemented the BMA’s Fatigue and Facilities charter in all working environments.

 he GMC should continue to work with partners via the insights and data obtained through
T
their NTS to monitor, assess and support implementation. Where issues are identified, the GMC
should work with postgraduate deans, medical royal colleges and employers to ensure they are
promptly and fairly addressed.

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Annex 1 – Action plan 87

3. Work schedule and rotas - To introduce UK-wide standards for

the development and maintenance of work schedules and rotas
based on realistic forecasting that supports safe shift swapping,
enables breaks, takes account of fatigue and involves doctors
with knowledge of the specialty to consider the demands that
will be placed on them.


NHS England, NHS Wales, NHS Boards in Scotland and the Department of Health (Northern
Ireland) should fully implement the BMA’s and NHS Employers’ Good Rostering Guide (see
new deal monitoring guidance in Scotland) in all healthcare environments.

Approach and practical solutions to include:

● Ensuring doctors’ work schedules enable them to be:

- Well

- Healthy

- Effective in their work

- Able to sustain their contribution to high-quality patient care.

● Healthcare organisations to ensure that rotas are designed and managed based on
accurate data, taking account of the available staff rather than being designed on the basis
of a notional workforce.

 ealthcare organisations across the UK should develop and maintain mechanisms to enable
H
doctors to report rotas that are not compliant with the BMA’s and NHS Employers’ Good
Rostering Guide (see new deal monitoring guidance in Scotland). Guardians of safe working
hours in England should encourage doctors in training to raise exception reports about
rostering issues and should monitor such exception reports and take steps to address the
issues raised.


Systems regulators, improvement bodies and partners listed should check employers have
implemented the BMA’s and NHS Employers’ Good Rostering Guide (see new deal monitoring
guidance in Scotland).


The GMC should work with partners listed above to monitor implementation of the BMA’s and
NHS Employers’ Good Rostering Guide (see new deal monitoring guidance in Scotland)

Approach and practical solutions to include:

● Undertaking monitoring until good practice is standard practice within all healthcare organisations
in the UK, with the aim to achieve this within 12 months.

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Annex 1 – Action plan 88

Belonging
Aim: to help doctors be connected to, cared for and caring of others around them, so they
feel valued, respected and supported

Potential partners – national and local organisations across the four countries of the UK including:

● NHS organisations

● Employers - including local health service Trusts, Boards and primary care providers

● Employers - representative organisations

● Systems regulators and quality improvement bodies

● Healthcare professional regulators

● Postgraduate medical education and training organisations

● The GMC

● Doctor representative organisations – including the BMA

● Medical royal colleges and faculties

● Medical leadership organisations

4. Team working – to develop and support effective multidisciplinary

team working across the healthcare service.

All healthcare organisations should review team working and ensure that all doctors are
working in effectively functioning and, ideally, multidisciplinary teams. The teams should have
a shared purpose and clear objectives (one of which is team member wellbeing). Team members
should be clear about their roles and meet regularly to review their performance, including
inter-team/cross-boundary working. Quality improvement should be a core function of all teams.

Approach and practical solutions to include:

● Employers working with clinical leads to ensure doctors are working in such teams and that these
are working cohesively, supportively, inclusively and compassionately.


The leadership and boards of every organisation employing doctors should establish a key
performance indicator for effective team working and obtain and review feedback to assess if all
doctors are part of a well-functioning team.

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Annex 1 – Action plan 89

4. Team working – to develop and support effective multidisciplinary

team working across the healthcare service (continued)

Systems regulators, improvement bodies and partners listed should check that employers are
ensuring that doctors are working in well-functioning teams.

Approach and practical solutions to include:

● Monitoring to include using established (academic, peer-reviewed) measures.

● Improvement, development and implementation of the following to ensure high-quality

measurements across all areas:

- The GMC’s NTS

- National staff surveysxviii

- National surveys of primary care staffxv


The GMC should work with other professional regulators to develop guidance on
multidisciplinary team working in modern healthcare environments.

Approach and practical solutions to include:

● Guidance that is evidence-based, appropriate and developed in a way that:

- Improves team and inter-team working.

- Improves healthcare for the communities the NHS serves.

- Improves staff wellbeing.

- Is focussed on clinical effectiveness, innovation and quality improvement.


Healthcare systems should develop appropriate support and materials to ensure the
continued development of teams in both primary and secondary care.

Approach and practical solutions to include:

- Materials that are evidence-based, appropriate and developed in a way that:

- Improves team and inter-team working.

- Improves healthcare for the communities the NHS serves.

- Improves staff wellbeing.

- Team development to be focussed on clinical effectiveness, patient experience, team member

wellbeing, innovation and quality improvement, and quality of inter-team working.

xiv 
Such as the NHS Staff Survey in England, Health and Social Care Northern Ireland Staff Survey, Scotland
Dignity at Work Survey and NHS Wales Staff Survey
xv
Such as the National GP Worklife Surveys in England and RCGP Scotland Workforce and Wellbeing survey

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Annex 1 – Action plan 90

5. C
 ulture and leadership – to implement a programme to ensure
healthcare environments have nurturing cultures enabling high-
quality, continually improving and compassionate patient care
and staff wellbeing.


All UK healthcare organisations that have not already done so, should commence and
implement a programme of compassionate leadership across all healthcare sectors and obtain
feedback from doctors and healthcare staff to evaluate its effectiveness. It should include
mechanisms to ensure clinical leads and other leaders of doctors at all levels in the healthcare
system are recruited, selected, developed, assessed and supported to model compassionate
and collective leadership.

Approach and practical solutions to include:

● Leaders across all healthcare organisations reviewing their organisational cultures using the
evidence-based resources available for the four UK countries. The key leadership and cultural
development programme, being implemented in around 100 Trusts and Boards across the UK, is
the open source culture and leadership programme developed by NHS Improvement in partnership
with The King’s Fund. The King’s Fund is leading also on developing compassionate leadership
with national partners in all four UK countries.

● These steps should help the development of high-quality care cultures and the modelling of
compassionate and collective leadership in every part of the healthcare system. This will support
high-quality, continually improving and caring approaches for doctors and patients.


Leadership and boards of every organisation employing doctors should introduce a key
performance indicator for compassionate leadership and should review feedback from doctors
and other healthcare staff to assess if leadership is compassionate and collective.


Systems regulators, improvement bodies and funding and commissioning bodies should check
that employers have in place mechanisms to support compassionate leadership. Regulators
and quality improvement bodies to review how to improve regulatory alignment and ensure
compassionate leadership is sustained in the longer term by integrating it as a priority into their
regulatory models.

Approach and practical solutions to include:

● Monitoring using established (academic, peer-reviewed) measures.

● Improvement, development and implementation of the following to ensure high-quality

measurements across all areas:

- The GMC’s NTS

- National staff surveysxx

- National surveys of primary care staffxxi

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Annex 1 – Action plan 91

5. C
 ulture and leadership – to implement a programme to ensure
healthcare environments have nurturing cultures enabling high-
quality, continually improving and compassionate patient care
and staff wellbeing (continued)


The GMC should work with partners listed to monitor and assess implementation and
maintenance of such changes to cultures and leadership across the system.

Approach and practical solutions to include:

● Monitoring bodies to assess implementation of initiatives and monitor improvements to culture

and leadership across the system. All four UK countries to ensure that this is a central element of
performance management frameworks.

● Monitoring bodies to ensure their own organisations are exemplars of such healthy cultures.

xx 
Such as the NHS Staff Survey in England, Health and Social Care Northern Ireland Staff Survey, Scotland
Dignity at Work Survey and NHS Wales Staff Survey
xxi
Such as the National GP Worklife Surveys in England and RCGP Scotland Workforce and Wellbeing survey

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Annex 1 – Action plan Belonging / Competence 92

Competence
Aim – to improve doctors’ ability to experience effectiveness and deliver quality care

Potential partners – national and local organisations across the four countries of
the UK including:

● NHS organisations

● Employers – including local health service Trusts, Boards and primary care providers

● Employers – representative organisations

● Systems regulators and quality improvement bodies

● Healthcare professional regulators

● Postgraduate medical education and training organisations

● Medical schools

● The GMC

● Doctor representative organisations – including the BMA

● Medical royal colleges and faculties

● Medical leadership organisations

6. Workload – to tackle the fundamental problems of excessive

work demands in medicine that exceed the capacity of doctors to
deliver high-quality safe care.

All organisations that oversee the work of doctors should undertake, in collaboration with
doctors, a programme to review workload in their organisations. This will help them to use
resources in the most efficient way, to ensure workloads do not exceed doctors’ ability and
capacity to deliver safe, high-quality care. Initiatives are underway across the UK to increase
staffing numbers and this should be supported by additional solutions including, but not
restricted, to:

- A programme to deploy and develop alternative roles to enable doctors to work at the top
of their competence, supported by effective multidisciplinary team working in all areas of
healthcare, and to support doctors to return to work after a break in practice.

- A review of new technologies being used in UK healthcare systems to increase efficiency

(see case studies), working with the voluntary sector, and focusing on preventive care.

- A programme of process improvements that increase productivity especially by supporting

communication in regular team meetings between healthcare staff (see case studies).

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Annex 1 – Action plan 93

6. Workload – to tackle the fundamental problems of excessive

work demands in medicine that exceed the capacity of doctors to
deliver high-quality safe care (continued)
- Eliminating tasks and activities that do not add value to patient care or doctors’ wellbeing.

- Engaging communities, community representatives and patients in taking shared

responsibility for their health services.

- Identifying services that cannot be provided in a resource-constrained system and

unnecessary processes that do not add value.

Approach and practical solutions to include:

● Healthcare systems and bodies to work collaboratively with staff across all working environments,
including primary care, to address issues of excessive workload and identify appropriate solutions.
This includes close communications between employers, leaders in primary care, system bodies
and staff to ensure prompt identification of issues and potential solutions.

● Integrated approaches to ensuring doctors’ workloads do not exceed their ability and capacity to
deliver safe, high-quality care to be collaboratively and continuously developed.

● Identifying activities that do not add significant value in doctors' work and eliminating them.

● Increased use of quality improvement approaches to reduce work that does not add significant
value to the core mission of healthcare.

● Effective use of new technologies to reduce excessive, chronic workload.

● Multi-disciplinary team-working and appropriate task-shifting across all environments to support

more effective role development and task allocation making the best use of team skills.

● Governments and healthcare organisations in the four countries to facilitate national conversations
to engage the community about priorities for the NHS. This must include a focus on the workload
burden on the NHS and the need for systemic prevention and for better healthcare self-
management in communities.

The leadership and boards of every organisation employing doctors should review
programmes to address excessive workload and monitor their impact.

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Annex 1 – Action plan 94

6. Workload – to tackle the fundamental problems of excessive

work demands in medicine that exceed the capacity of doctors to
deliver high-quality safe care (continued)
Systems regulators, improvement bodies and partners listed should check that employers
have in place programmes to address excessive workloads and to monitor them to ensure
improvement.

Approach and practical solutions to include:

● Monitoring using established (academic, peer-reviewed) measures.

● Improvement, development and implementation of the following to ensure high-quality

measurements across all areas:

- The GMC’s NTS

- National staff surveysxxii

- National surveys of primary care staffxxiii

xxii 
Such as the NHS Staff Survey in England, Health and Social Care Northern Ireland Staff Survey, Scotland
Dignity at Work Survey and NHS Wales Staff Survey
xxiii
Such as the National GP Worklife Surveys in England and RCGP Scotland Workforce and Wellbeing survey

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Annex 1 – Action plan 95

7. M
 anagement and supervision – to ensure all doctors have
effective clinical, educational and pastoral support and
supervision to thrive in their roles.
All organisations that employ doctors should ensure:

- Each has a well-trained line manager supporting them to perform their roles effectively and
ensuring their basic work needs are met. They should also obtain feedback to ensure this is
in place (in primary care, this might be a peer mentor or coach).

- Management, support, educational and clinical supervision are included in the job plans of
those in such roles, and their workloads are balanced to ensure protected time to provide
these functions.

Approach and practical solutions to include:

● Management for doctors focussed on better meeting their basic work needs for autonomy and
control, belonging and competence. Such management should model compassionate and
inclusive leadership.


The leadership and boards of every organisation employing doctors should review
feedback to check all doctors have well-trained line managers with protected time to carry
out their functions.


Organisations responsible for education and training of doctors and medical students
should ensure they have an appropriate level of high-quality educational and clinical
supervision provided by well-trained and compassionate supervisors.

Approach and practical solutions to include:

● Quality and accessibility of education and clinical supervision ensuring training and working
environments are safe for patients and supportive for learners and educators. They should adhere
to the GMC’s ‘Promoting excellence – standards for medical education and training’.


Systems regulators, improvement bodies and partners listed , including postgraduate training
organisations, should work with the GMC to implement and monitor this recommendation,
including via quality management and assurance mechanisms.

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Annex 1 – Action plan 96

8. Training, learning and development – to ensure the systems and

frameworks for learning, training and development:
● Promote fair outcomes.
● Are sufficiently flexible to enable doctors and medical
students to grow and develop throughout their careers and
to better manage their wider life circumstances.

Undergraduate medical education

Medical schools should work collaboratively with students to:

- Get feedback and meet their specific needs.

- Measure and improve student wellbeing as a routine performance metric.

- Ensure a culture of interdisciplinary learning within the faculty and integrate wellbeing,
compassion and multidisciplinary team working into student training within ongoing
curriculum review.

- Offer confidential services tailored to the needs of medical students and a package of
support for those seeking mitigating circumstances/ taking time out, including additional
ways to complete attendance and curriculum requirements.

- Ensure an effective feedback mechanism for medical students to speak up about concerns
such as bullying and undermining.

- Ensure clinical placement providers are well prepared to receive students and work with
other schools to address issues like capacity.

- Consider the benefits of pass/fail grading system at least for some course components.

Approach and practical solutions to include:

● Supporting supervisors to give prompt, tailored and ongoing feedback to all learners. Exam
preparation support should particularly provide candidates less familiar with assessment structures
and expectations or candidates who have failed an exam with additional support.


Medical schools should establish a key performance indicator for student wellbeing across all
learning environments and review feedback to assess performance.


The GMC, through its quality assurance functions, should check and monitor the improvements
made by medical schools on student wellbeing.

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Annex 1 – Action plan 97

8. Training, learning and development – to ensure the systems and

frameworks for learning, training and development:
● Promote fair outcomes.
● Are sufficiently flexible to enable doctors and medical
students to grow and develop throughout their careers and
to better manage their wider life circumstances (continued)

Postgraduate training

The GMC and system leaders across education and training, including postgraduate training
organisations, should support a review of the impact of the allocation of training placementsxxiv.


System leaders across education and training should improve the programme of assessment,
including curricula, to ensure:

- Early and ongoing formative assessment of learning outcomes and provide opportunities to
improve and evaluate performance prior to high-stakes assessment.

- The development of personal development plans.


The GMC should continue to monitor differential attainment with a view to achieving a
continuous reduction in differential outcomes.


The organisations responsible for postgraduate medical education and training across the
UK should, where they have not already done so, address administrative burdens placed on
doctors in training such as by establishing a Single Lead Employer (as in Scotland, Wales and
Northern Ireland) or by cross-organisation passporting (where a Single Lead Employer system
is not practicable).


Postgraduate training organisations should review feedback to assess performance with
addressing administrative burdens placed on doctors in training.


The GMC, through its quality assurance functions, should check and monitor improvements
made by postgraduate training organisations to address administrative burdens placed on
doctors in training.

Approach and practical solutions could include:

● Monitoring using established (academic, peer-reviewed) measures.

● Improvement, development and implementation of the GMC’s NTS to ensure high-quality

measurements across all areas.

xxiv 
This is one of the recommendations in HEE’s report on NHS Staff and Learners’ mental wellbeing in
England. The GMC’s Promoting Excellence standards give the GMC a responsibility for the fairness of
recruitment processes.

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Annex 1 – Action plan 98

8. Training, learning and development – to ensure the systems and

frameworks for learning, training and development:
● Promote fair outcomes.
● Are sufficiently flexible to enable doctors and medical
students to grow and develop throughout their careers and
to better manage their wider life circumstances (continued)

Ongoing development

The GMC should work with UK national governments to develop strategies to better support
the ongoing development of all doctors outside or after formal postgraduate training, and,
in particular, GPs. This should establish new ways of working to improve the capacity and
confidence of newly-qualified GPs and specialists and the retention of experienced doctors
in the NHS.


The GMC to review the findings of its survey of specialty and associate specialist (SAS) and
locally employed (LE) doctors to work with partners to consider what steps need to be taken to
better develop and support this group of doctors and their different challenges across the UK.

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Annex 2 –
Approach
to review

Professor Michael West and Dame Denise Coia

Annex 2 – Approach to review 100

Approach to UK-wide review of doctors’

and medical students’ wellbeing
At the start of 2018, the GMC commissioned a UK-wide review of doctors’ and
medical students’ wellbeing. The review, which forms part of the GMC’s wider
Supporting a profession under pressure portfolio of work, considered the wellbeing
of all medical students and doctors in the UK across all specialties, grades,
employment arrangements and demographics.

The findings from the review have been fed into the report and recommendations.
They will enable the GMC to work together with organisations across the UK to agree
priority areas for collaborative action, to tackle the causes of poor wellbeing and
improve support for doctors and medical students.

The review was co-chaired by Professor Michael West and Dame Denise Coia.
Unfortunately, in May 2019, Dame Denise Coia had to step down due to ill-health.
Professor Michael West continued to chair the review.

For Professor Michael West's and Dame Denise Coia's biographies see page 10.

Evidence based approach to research

and engagement
The review was based on a research and engagement strategy designed to ensure
a robust evidence base.

Engagement
As part of the engagement strategy, a detailed stakeholder mapping exercise was
carried out. Dame Denise Coia, Professor Michael West and the GMC review team
supporting them with their work (‘the review team’) met with a wide range of external
stakeholders. These included organisations within the healthcare system and others
with an interest in the wellbeing of people at work. A full list of the organisations
involved with the review is included at the end of this annex.

Awareness of the review was raised through a number of channels, including

engagement events, meetings with stakeholders and social media.

The review team also used these channels to undertake an initial exploration of
possible partnerships and sought to establish whether organisations held any
information and/or data that could be useful for the purposes of the review. This
resulted in an overwhelmingly positive response from organisations and individuals
who offered to share data and their support. A number offered to pilot interventions
as part of the review.

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Annex 2 – Approach to review 101

The review team worked with the Scottish Wellbeing Advisory Group, co-chaired by
Dame Denise Coia and David Garbutt at NHS Education Scotland, to support early
intervention pilots in two Scottish health boards. Further information can be found
in a case study on the work in Annex 3. The review team also worked with groups in
Northern Ireland and Wales who were linked with the Scottish working group.

A number of events were held with doctors and medical students across all four
countries of the UK. The groups included medical students across all year groups,
doctors in training across different specialties and grades, general practitioners,
specialty and associate specialists (SAS) and consultant grade doctors working in
community settings, mental healthcare and acute hospitals.

These events were designed to obtain doctors’ and students’ feedback in relation to the
emerging evidence and recommendations in the review, in advance of the final report
being published. The sessions lasted between one and two hours, and were informal
in order to encourage participants to speak freely. Participants were given background
information on the review and asked to discuss the three themes identified in the review
(autonomy/ control, belonging, competence). They also discussed potential solutions to
issues raised and offered feedback on emerging ideas for recommendations.

The engagement activities provided opportunities to compare this feedback and seek
input and learn from doctors and medical students directly.

Research methodology
Aims and objectives
The aim of the research component of the review was to build a structured evidence
base to inform the review’s conclusions and key policy recommendations on the
mental health and wellbeing of medical students and doctors in the UK. The focus
was to build a comprehensive picture of the key issues, using a range of sources of
evidence given the time and resources available.

The review chairs asked four research questions:

● What is the prevalence and incidence of adverse mental health among medical
students and doctors in the UK, and how does this compare with other
countries, others in the working population and others working in health and
care services?

● What is the impact of poor wellbeing on medical students and doctors and
on quality of care?

● What factors have most influence on the wellbeing of people at work, and
specifically on medical students and doctors?

● What primary interventions (focused on workplace factors identified in the

above) are effective for ensuring medical students’ and doctors’ health and
wellbeing?

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Annex 2 – Approach to review 102

Methods
To answer the four research questions, the review involved qualitative and
quantitative research:

Qualitative research
1. The chairs and the review team held meetings with individuals working
in universities, hospitals, general practices and in each of the national
organisations within the four countries of the UK holding relevant data.
The meetings focused on gathering their views on the mental health and
wellbeing of medical students and doctors and identifying information they
could share with the review team. The review team kept written notes of the
meetings, which were analysed using inductive and deductive content
analysis with the QSRI NVivo 12 Pro software.

2. The review team reviewed a series of reports and articles focusing on mental
health and wellbeing. The material was identified by the chairs of the review,
the engagement meetings, and through correspondence with individuals with
a specialist interest, knowledge or expertise in the field. These publications
were also analysed using inductive and deductive content analysis using with
QSRI NVivo 12 Pro in relation to the four research questions.

3. The review team conducted a literature review, focusing specifically on primary

interventions to support medical students’ and doctors’ wellbeing. Primary
interventions were defined as interventions that are aimed at modifying or
eliminating stressors in the work environment which could impact on an
individual’s health and wellbeing. Three databases were searched for published
literature on mental health and wellbeing of doctors and medical students,
primary interventions for medical students' and doctors’ wellbeing: MEDLINE/
PubMed, CINAHL Plus, and PsycINFO. The specific databases were chosen
because of their international coverage and their relevance to healthcare;
PsycINFO was selected because of the relevance of organisational psychology
to the review. It did not involve a systematic literature review or broader
coverage of databases due to the limited timescale for the review.

The search concepts used were intervention; wellbeing and doctor/medical

student. In addition to the database searches for published literature, a number
of internationally recognised experts in the field were contacted for advice on
publications they were aware of that focused on primary interventions.

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Annex 2 – Approach to review 103

Inclusion / exclusion criteria

The review focused on publications that discussed a specific intervention

meeting our definition of ‘primary’ intervention. The intervention had to be
directed at students or healthcare professionals, but not exclusively medical
students or doctors. Papers had to be published in the English language,
within the last 10 years (2009-present), to capture more recent developments
in the field. Papers discussing secondary (e.g. mindfulness training) and
tertiary interventions (e.g. counselling services) were noted (since some were
tangentially relevant) but generally not included.

Data extraction

The articles identified through the database searches and correspondence

with experts were critically appraised by two members of the review team
through a screening process. This was necessary because of the very large
number of entries found in the database searches, (the terms ‘doctor’ and
‘wellbeing’ frequently appeared together). The first stage involved reading the
publication titles and/or abstracts to determine relevance to the topic. The
second stage involved reading the abstract / summary or specific sections
of publications (introduction, results and discussion / conclusions) selected
through the first stage, to determine whether the inclusion criteria had been
met. All publications screened in the second stage of the process were
recorded in Microsoft Excel with a brief explanation of the reasons why the
inclusion criteria were or were not met.

The two researchers met three times to discuss the papers they had selected,
which led to a final list of publications. The full text of publications meeting the
screening criteria was retrieved and saved, and documents shared from the
organisations contacted were added to the list. The publications in the final
list were divided between three members of the review team, and information
recorded in a Microsoft Excel template, using key fields that had been agreed
between the review team and Professor Michael West. A summary of the
interventions discussed was extracted from the template, and categorised
according to the three themes governing the review; autonomy/ control,
belonging and competence. The relevant interventions were incorporated into
the rest of the research findings to inform the final report. The process followed
is shown on Figures 1 and 2.

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Annex 2 – Approach to review 104

Literature search on physician wellbeing

Records identified through Additional records identified

database searching through other sources
858 32

Records selected from 1st

Other records
stage screening (title / abstract)
did not meet
Researcher 1 – 238
inclusion criteria
Researcher 2 – 274

Records selected from 2nd stage

screening (abstract / text)
Researcher 1 – 112
Researcher 2 – 110

Articles selected Records after

to access full text duplicates removed
94 84

Full text unavailable

15 (pay wall/ no academic
access)

Studies included in qualitative synthesis

100 (incl. 68 from database searching and 32 from additional resources)
(full text read: 50; key sections read: 50)

Figure 1: Flow chart for literature review component (doctor wellbeing).

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Annex 2 – Approach to review 105

Literature search on medical student wellbeing

Records identified through Additional records identified

database searching through other sources
457 1

Records selected from

1st stage screening (title / abstract)
Researcher 1 – 179
Researcher 2 – 184

Records selected from 2nd

stage screening (abstract / text):
Researcher 1 – 56
Researcher 2 – 60

Records after
Articles selected
duplicates
to access full text
removed
52
42

Full text unavailable

7 (pay wall/ no academic
access)

Studies included in qualitative synthesis

36 (incl. 35 from database searching and 1 from additional resources)
(full text read: 10; key sections read: 26)

Figure 2: Flow chart for literature review component (medical student wellbeing).

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Annex 2 – Approach to review 106

4. Members of the review team attended two international conferences on the

mental health and wellbeing of doctors that took place during the initial stages
of the review; the WellMed Conference in Thessaloniki, Greece (9-13 May 2018);
and the International Conference on Physician Health in Toronto, Canada (11-
13 October 2018). The review team contacted the conference organisers after
the events, and requested copies of the presentations given on initiatives to
support doctors’ and medical students’ wellbeing. Three review team members
read through the presentations and populated a standardised Excel template
with key information on the initiatives.

Quantitative research
5. The national training surveys (NTS) are the GMC’s annual surveys of doctors
in training and trainers. They are used to monitor and report on the quality
of postgraduate medical education and training in the UK. In 2018 the GMC
introduced new questions on wellbeing and burnout into the surveys, and
analysis of this data has been used as a key evidence source for this review.
The questions were taken from the Copenhagen Burnout Inventory section
on work-related burnout. Responses from the 2018 NTS were used in three
strands of analysis:

a. To measure the prevalence of burnout within the UK trainee and trainer
populations – from an overall perspective, but also between different
groupings of the population, including medical specialty, training level,
age, ethnicity, and gender.

b. To explore associations between burnout and other measures within the
NTS. An independent researcher, Dr Pascale Daher, was commissioned
to look at relationships among factors associated with doctors’ reporting
of stress and burnout, using structured equation modelling. Factors
included workload, whether doctors in training and trainers felt supported
or prepared for their role, or whether their training was disrupted by work
environment factors.

c. To understand what factors in the workplace impact on doctors’ wellbeing

(burnout and overall satisfaction), Dr Daher tested a series of models that
looked at the impact of a set of job demands. This included workload,
working hours and rota design and job resources such as teamwork,
supportive environment and educational supervision on doctors’ wellbeing.
Dr Daher also tested models that explored whether the association
between these job demands and wellbeing is contingent on the availability
of job resources and, when there was an association, probed the nature
of the relationship.

6. The review team accessed publicly available data from NHS England’s 2018
National Staff Survey; the 2018 NHS Wales’ Staff Survey; and the Scottish
Government’s iMatter Staff Experience Continuous Improvement model.
The GMC also entered into a data sharing agreement with NHS England
which enabled the team to analyse anonymised raw data from NHS England’s
National Staff Survey.

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Annex 2 – Approach to review 107

a. Publicly available data: The surveys were used, dependent on what was
publicly available in each, to compare results between medical staff groups
and other NHS staff groupings. Changes in responses for the medical staff
group’s results across multiple years were also examined to identify trends.

b. The review team used the anonymised raw data from NHS England’s
National Staff Survey from 2014 to 2018 to explore the factors that impact
on doctors’ wellbeing. The team also set out to understand how workplace
factors might affect doctors’ wellbeing both positively and negatively. Two
main indicators of wellbeing were used – the first looked at positive forms
of wellbeing, namely engagement and satisfaction. The second indicator
focused on turnover, physical health, stress, and presenteeism. As in the
NTS, Dr Daher explored the impact of a range of factors including workload,
working extra hours (paid and unpaid) and a bundle of workplace support
factors such as teamwork, leadership, and the availability of job resources
on each of the indicators of wellbeing. To better understand how these
factors interact in the workplace, Dr Daher tested
a series of moderation models and where a significant interaction was
found, probed for the direction of the interaction.

The GMC review team

Tom Bandenburg – Head of Quality Assurance (Reporting), Data, Systems and Quality
Nathan Booth – Policy and Research Officer
Alexandra Blohm – Strategic Lead
Professor Sue Carr – Deputy Medical Director
Eleanor Davy – Project Officer
Dr Salma Eltoum Elamin – GMC Clinical Fellow 2018-19
Dr Cat Harley – GMC Clinical Fellow 2018-19
Dr Madhu Kannan – GMC Clinical Fellow 2018-19
Kerry Kilby – Project Officer
Nico Kirkpatrick – Assistant Director
Dr Robert Manton – GMC Clinical Fellow 2018-19
Ioanna Maraki – Policy Manager
Professor Colin Melville – Medical Director and Director of Education and Standards
Dr Latifa Patel – GMC Clinical Fellow 2018-19
Emma Reuben – Project Manager
Anna Rowland – Assistant Director
Dr Alice Rutter – GMC Clinical Fellow 2019-20
Adam Troughton – Data Reporting Officer
Nilla Varsani – Project Manager
Dr Catherine Walton – GMC Clinical Fellow 2019-20

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Annex 2 – Approach to review 108

Organisations the Chairs and GMC

review team met with and attendees of
relevant events held during the review
Academy of Medical Royal Colleges
Academy of Trainee Doctor’s Group
Associates of Surgeons in Training
Black and Minority Ethnic Forum attended by:
● Association of Pakistani Physicians and Surgeons of UK
● Association of Pakistani Physicians of Northern Europe
● Jewish Medical Association UK
● British International Doctors Association
● British Association of Physicians of Indian Origin
● Pakistan Medical Association
● British Islamic Medical Association
● Muslim Doctors Association
British Industrial Design Association
British Medical Association (BMA)
BMA’s Staff, Associate Specialist and Speciality Doctors (SAS) Committee
British Orthopaedics Trainees’ Association
Care Quality Commission
Care Under Pressure
Chartered Institute of Personnel and Development
Confederation of Health and Social Care
Conference of Postgraduate Medical Deans
Doctors in Distress
Doctors in training roundtable event attended by:
● Chair of the BMA’s Junior Doctor’s Committee
● Chair of the RCGP’s Associates in Training Committee
● Co-chair of the BMA’s Medical Schools Committee
● Co-chair of the RCP London Trainees Committee
Doctors Support Network
Faculty of Leadership and Management
Faculty of Intensive Care Medicine
Family Doctor’s Association
Government departments throughout the UK and devolved countries
KPMG
Medical Schools Council
Medical Women’s Federation
MIND

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Annex 2 – Approach to review 109

NHS Confederation
NHS Employers
NHS Improvement
NHS Practitioners Programme
NHS Providers
Royal College of Anaesthetists
Royal College of Emergency Medicine
Royal College of General Practitioners
Royal College of Obstetricians and Gynaecologists
Royal College of Paediatrics and Child Health
Royal College of Pathologists
Royal College of Psychiatrists
Royal College of Radiologists
Royal College of Veterinary Surgeons
Society of Occupational Medicine
The Association of LGBT Doctors and Dentists (GLADD)
The Kings Fund

England
Association of Surgeons, England
BMA England
Charlie Waller Memorial Trust
East Lancashire Hospitals NHS Trust – focus group
Health Education England
Lancashire Teaching Hospitals NHS Foundation Trust – focus group
Leicester Medical School – focus group
Liverpool Medical School – focus group
Manchester Medical School – focus group
NHS England
NHS Practitioner Health Programme
Northamptonshire Healthcare NHS Foundation Trust – focus group
Royal Blackburn Hospital – focus group
Royal College of Physicians of London
Royal College of Surgeons of England
University Hospital Coventry & Warwickshire NHS Trust – focus group
University Hospitals of Leicester NHS Trust – focus group
Warwick Medical School – focus group
Wrightington, Wigan and Leigh NHS Foundation Trust

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Annex 2 – Approach to review 110

Northern Ireland
Department of Health Northern Ireland
Northern Health and Social Care Trust – focus group
Northern Ireland Medical and Dental Training Agency
Public Health Agency (NI)
Regulation and Quality Improvement Authority

Scotland
Academy of Medical Royal Colleges, Scotland
BMA GP Committee
BMA Junior Doctors Committee
BMA Scotland
Health and Safety Executive in Scotland
Healthcare Improvement Scotland
NHS Education for Scotland
NHS Greater Glasgow and Clyde
NHS Lothian, Edinburgh – focus group
NHS Tayside, Dundee – focus group
Royal College of General Practitioners, Scotland
Royal College of Physicians of Edinburgh
Royal College of Physicians of Edinburgh Trainee Committee
Royal College of Psychiatrists
Royal College of Surgeons of Edinburgh
Royal College of Surgeons of Edinburgh Trainee Committee
Scottish Academy Trainee Doctors Group
Scottish Association of Medical Directors
Scottish Clinical Leadership Fellows
Scottish Deans Medical Education Group
Scottish Directors of Medical Education
Scottish Government
Scottish Medical Students Committee

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Annex 2 – Approach to review 111

Wales
Academy of Medical Royal Colleges Wales
BAPIO Wales
BMA Cymru
Cardiff Medical School – focus group
Community Health Council in Wales
Healthcare Inspectorate Wales
Health Education and Improvement Wales
NHS Wales
NHS Wales Confederation
NHS Wales Employers
Powys Community Health Council
Public Health Wales
Royal College of Psychiatry, Wales
Swansea Medical School – focus group
Wales Audit Office
Welsh medical students committee

Overseas
Mayo Clinic, USA
National Academy of Medicine
The Cleveland Clinic

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Annex 3 –
Additional
case studies

Professor Michael West and Dame Denise Coia

Annex 3 – Additional case studies 113

Multiple themes
Case study
i
Scottish wellbeing advisory group
The Scottish wellbeing advisory group, co-chaired by Dame Denise Coia and David
Garbutt, has coordinated a large programme of work focused on promoting doctors’
wellbeing. The group has provided leadership, built a community of good practice,
and created influence and collaboration between Territorial Health Boards, NHS
Education for Scotland (NES), professional bodies and the Scottish Government to
bring about change across NHS Scotland.

The group’s aim has been to deliver change across all Health Boards in NHS
Scotland, in order to promote and improve doctors’ wellbeing, system productivity
and patient experience. The work is consistent with the Scottish Government’s
workforce strategy of a ‘once for Scotland’ approach, where changes are consistent
within Scotland and learning is shared across geographies.

Current initiatives include:

Developing and testing early intervention pilots in two Scottish

Health Boards
The GMC review team has worked with Scottish colleagues on early intervention pilots
in NHS Lothian and NHS Greater Glasgow and Clyde, involving testing of interventions
designed to support doctorsxi and improve their wellbeing. With the support of senior
leaders in the Boards, doctors’ accounts of their working lives were mapped using a
consistent survey instrument. Survey data (across domains of engagement, stress/
burnout, workload) revealed that younger doctors (aged between 20-24) were more
burnt out on average than older colleagues; this was also the case for Foundation Year
1 (FY1) trainees, whether this was due to FY1 doctors more likely being in the 20-24
age group, or vice versa is difficult to determine. Both surveys also showed that males
in general were less burnt out than their female colleagues, significantly so when
it came to personal burnout. Working nights was also shown to have a significant
negative impact on results across all domains in both Health Board pilots.

The surveys undertaken in the two Health Boards included qualitative questions on
workplace factors that positively contribute to wellbeing and those that could be
changed to improve wellbeing at work.

Themes emerging from NHS Lothian following analysis of the qualitative responses
included:

● Colleagues and teams were the most mentioned factor contributing to their
wellbeing at work, followed by ‘interesting work’, ‘time on rota’, ‘saying thank
you’ and ‘rest’.

The NHS Lothian pilot surveyed only doctors in training. The NHS Greater Glasgow and Clyde pilot surveyed
xi 

all doctors below consultant grade.

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● Respondents often used the terms ‘friendly’, ‘supportive’, ‘caring’, and

‘approachable’ to describe their colleagues.

● Positive feedback from colleagues and patients, including patients saying

‘thank you’, boosted respondents’ wellbeing and made them feel valued.

● Respondents highlighted ‘facilities’, ‘peer and senior support’, ‘rota planning’,

‘staffing’, ‘task shifting and appropriate escalation’, ‘time for other activities
including family life’, ‘shifts’ and ‘training’ as areas that could be changed to
improve wellbeing at work.

● Several suggestions were made to improve facilities ranging from improving

technology systems to dedicated rooms to enable private conversations
when seeing patients.

● Despite identifying colleagues and their teams as positive influences to

wellbeing at work, respondents also gave several constructive examples of
helpful improvements to peer and senior support, including acknowledging
the pressure more junior staff were under, prioritising breaks, speaking to
colleagues respectfully and giving motivational and positive feedback.

The Scottish wellbeing advisory group has worked with NHS Lothian senior leaders,
chief registrars, departmental teams and doctors in training to co-design an
improvement programme and interventions based on the survey findings.
This has included:

● Further development of local peer mentoring programmes.

● Personal wellbeing and resilience workshops in association with local experts.

● Tests of change to facilities provided including access to hot food out of

hours, rest facilities and transport solutions.

● Rota management and monitoring masterclasses to support shared

understanding and engagement of managers/ senior medical staff/ doctors
in training with this core process.

● Access to group structured reflective practice in more clinical areas like

psychiatry, medicine of the elderly, acute medicine and the emergency
department, including testing of Balint groups.

● Increasing use of positive event (e,g, GREATix and Learning from Excellence)
reporting and culture change around adverse event reporting in service of
a just culture.

● A full day conference organised by the chief registrars focused on

supporting and valuing the medical workforce aligned to the principles
of realistic medicine.

● A quality improvement showcase to value and promote the input of doctors

in training in improving clinical services.

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Engagement conversations have also been held with clinical teams and system
leaders to facilitate change and ensure team understanding. This has included:

● Informal and formal feedback conversations with clinical teams using the
data from the wellbeing survey.

● A trainee-management forum facilitating two-way communication between

doctors in training and site and system management.

● Teaching fellow and chief registrar involvement in end of rotation feedback

and listening conversations.

● Introduction of an electronic engagement platform for all doctors in training

to allow sharing of concerns, ideas for change and facilitate open and
transparent communication.

● A network of medical education coordinators that engaged formally

and informally with all doctors in training, to promote engagement and
highlight concerns.

The same qualitative questions were included in the NHS Greater Glasgow
and Clyde survey, themes emerging following recent initial qualitative analysis of
responses included:

● ‘Colleagues and teams’ were again by far the most mentioned factor
contributing to their wellbeing at work, followed by ‘saying thank you’,
‘working atmosphere and culture’ and ‘interesting work’.

● Respondents highlighted ‘rota planning’, ‘peer and senior support’, ‘staffing’

and ‘facilities’ as areas that could be changed to improve wellbeing at work
the most.

The Health Board will be developing a similar programme following analysis of the
qualitative responses to offer a complete picture along with the quantitative findings.

●  roviding support for doctors who are facing work-related mental

P
health and wellbeing problems, by developing a specialist practitioner
health programme.
Scottish Clinical Leadership fellows, with the support of the advisory group,
have proposed that a doctors’ specialist health service should be developed
in Scotland.

● Enhancing educational governance for doctors in training as valued

members of clinical staff.
A review of educational governance has been undertaken by NHS Education
Scotland and is being incorporated in the new NHS Scotland Blueprint
for Governance, with the support of the group. They are in the process of
drawing up development packages that fit under the theme of governance
in general.

The Scottish wellbeing advisory group has brought together stakeholders

and the Scottish Government with a desire to influence change. The group
has focused on providing leadership, a mechanism for community building
and helped create a critical mass to build internal momentum and external
negotiating power across NHS Scotland.

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Team working
Case study
ii
Wellbeing and peer support
WARD (Well and Resilient Doctors) is an organised peer support group, comprised
of registrar and above doctors in training.

WARD teams host education workshops to improve wellbeing on topics such as

mindfulness, sleep and fatigue and physical health. The team currently work with
foundation doctors but hope to support all doctors in training in the future.

WARD teams are placed in eight trusts in Severn at the moment, and they wish to
expand the service so that it is available in every trust in the deanery. Beyond the
central service, each trust has a dedicated local team who also highlight other support
services offered by the trust on their website.

Voice, influence and fairness

Case study
iii
Listening to doctors in training – University Hospitals
of Leicester (UHL) NHS Trust
In November 2017, an online survey was sent to 943 junior doctors working at
UHL, with 402 doctors responding. The Trust designed the survey to produce a
comprehensive picture of junior doctor morale. The results highlighted many factors
influencing morale, including team working and relationships, feedback, training
and workload. The findings sparked a dialogue between doctors in training, senior
clinicians and managers. This led to the development of a Junior Doctor Morale
working group, formed in January 2018, to improve the working lives of both doctors in
training and locally employed junior doctors at the Trust.

The working group introduced a number of changes, including:

● Guidance for raising concerns while on shift.

● Interventions to recognise doctors’ efforts, for example monthly local junior

doctor awards, and annual trust-wide educator awards.

● Workshops on having challenging conversations, to improve feedback from

consultants to trainees.

● Free post-shift rest facilities for junior doctors, when they feel too tired to travel
home safely.

● Allocation of 100 extra car parking passes for junior doctors.

● Creation of divisional / local junior doctor forums to give junior doctors an

opportunity to express their views.

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Training
Medical students

Case study
iv
Inter-professional education and team-based
learning – King’s College London Medical School.
King’s College London has a range of inter-professional workshops for medical
students and other students from King's faculties as part of their curriculum. This
inter-professional programme provides learning opportunities throughout students'
training, and encourages the multi-disciplinary team working expected by many
professional bodies.

Year 1 medical students join students from dietetics, midwifery, nursing, pharmacy
and physiotherapy in learning about patient safety and team behaviour. They also
undertake a programme of clinical skills simulations (involving recognition of an
unwell patient) with nursing and midwifery students.

Year 2 medical students report (as part of their portfolio assessment) on their
observations of inter-professional team working and communication encountered
on placement.

Year 3 medical students (brought together with Year 2 nursing, midwifery and
pharmacy students) complete an inter-professional education workshop on
pain assessment and management, to consider how effective inter-professional
collaboration enhances patients’ pain management.

In Year 4 of the programme, medical students take part in an inter-professional

simulation session (involving a mannequin) and de-brief to improve patient safety
and care through awareness and reflection on practice with adult/child nursing
and midwifery peers.

In Year 5 the students participate in a medication error prevention workshop

to discuss individual and team responsibilities in the delivery of safe medicines
management with colleagues from other disciplines. They also participate in a
multi-disciplinary Schwartz Round during their Transition to Practice module.

Further, medical students can sign up voluntarily to take part in a half-day workshop
on collaborative teamwork in mental health where medical students form small
groups. They work in partnership with a patient educator and clinical psychology,
mental health nursing, pharmacy and occupational therapy students. This workshop
aims to develop the skills required for person-centred care planning within a mind-
body approach.

There are also several inter-professional learning programmes in development,

including medication review, e-prescribing, and experiential learning in maternity care.

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Workload
Case study
v
Workforce initiatives – Royal College of Emergency
Medicine (RCEM)
RCEM has highlighted evidence that working in highly pressurised healthcare
environments damages the health and wellbeing of clinical staff. Emergency
physicians are amongst those at the highest risk of mental ill health, compassion
fatigue and career burnout. The College also highlighted the imbalance between
consultant numbers and the growth in attendance at the Emergency Department.

The College has provided guidance on system design, job planning and wellbeing
strategies for emergency medicine. The key principles from this guidance are to:

● Maximise safe working practices for emergency medicine consultants

working a significant part of their time out of hours to allow more
proportionate time off, so that they have time to rest, recover and recuperate
from the intensity of the working environment.

● Actively support the development of portfolio and less than full time (LTFT)
working careers, where appropriate.

● Develop job plans for the older emergency physicians, so that they can
balance their clinical and non-clinical work. The proposals should allow for
opting out of onerous on call and night time clinical duties.

The College also made staffing recommendations in relation to size of service and
shift. It defined the desirable ratio between a consultant and new attendances
as one whole time equivalent (WTE) Consultant to between 3,600-4,000 new
attendances. This would depend upon the complexity of workload and associated
clinical services for which an Emergency Department is responsible.

The College also published a workforce plan with several commitments, including:

● Increased growth and recruitment into the specialty, through ‘expansion

cohorts’ with Health Education England (HEE), the defined route of entry
into emergency medicine (DRE-EM) training programme, international
recruitment, particularly as part of ‘earn, learn and return’ schemes, and
other routes.

● Investment into the growth of the advanced clinical practitioner (ACP)

workforce in emergency care.

● Investment in a leadership/personal development training programme for

every emergency medicine trainee.

● Providing funding to and working with a third of the trusts highlighted in the
GMC's NTS as having the biggest problems with their training environment,
to develop and implement clinical educator strategies.

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● Piloting LTFT training for all higher specialty training year 4 (ST4) and above
trainees in emergency medicine.

● Development of post Certificate of Completion of Training (CCT) fellowships.

● Joint publication of a best practice guide with NHS Improvement, that

trusts will be expected to use to improve their recruitment and retention in
emergency departments.

These commitments have been designed to address the issues of growing a multi-
professional workforce, reducing attrition in medical training, and improving retention.

Culture and leadership

Case study
vi
Buddying agreement between organisations –
Guy’s and St Thomas’ Hospital NHS Foundation
Trust and Medway NHS Foundation Trust
Buddying was introduced in 2013 by the Department of Health to support NHS
organisations in special measures. These partnering arrangements differ from other
regulatory measures, in that they embed a team of senior clinicians and managers
from a high performing organisation into a struggling hospital. A 2014 review by the
Foundation Trust Network has suggested that buddying arrangements are well-
received by most organisations, with clear opportunities for peer-based learning.

Senior clinical and managerial teams from a high-performing organisation, Guy’s

and St Thomas’ Hospital NHS Foundation Trust (GSTT), provided buddying support
to colleagues from an organisation in difficulty, Medway NHS Foundation Trust
(MFT). This was to rapidly improve safety and quality of care and help a recently
appointed management team to improve performance. In March 2015, a buddying
partnership was agreed for 18 months, subsequently extended to 28 months.

The aim was to promote close working partnerships, compassionate leadership

and improve patient quality of care, safety and efficiency. Equally important was the
emotional and pastoral support for staff at the trust in difficulty, which helped them
enact change during periods of scrutiny, perceived failure and low team morale.

A review published on the programme† cites the beneficial impact of two interventions:

● Firstly, the value of a buddying arrangement, in which staff from GSTT

provided advice, operational assistance, compassionate leadership and
pastoral support to colleagues at MFT during planning and implementation
of a new medical pathway.

● Secondly, the effectiveness of a whole system medical pathway

transformation, in which physical estate (i.e. ambulatory emergency care,
acute admissions wards) and medical processes (i.e. medical rotas, staffing,
handovers, board rounds and specialist referral) were changed.

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GSTT appointed project managers and clinical leads with defined responsibilities
and seconded nursing, medical and managerial staff to provide targeted input (e.g.
leadership support) and mentoring for MFT staff. In total, 113 GSTT staff contributed
to the buddying programme, of whom 19 (including three contract managers) were
involved in the medical pathway. The buddying team worked closely with MFT’s
local improvement programme, operational teams, NHSI and the Emergency Care
Improvement Support Team (ECIST). Progress was communicated to MFT’s board,
external agencies (ie NHSI) and operational managers at regular team meetings.

The authors of the programme review noted the programme demonstrated that
significant improvement in performance, safety, quality of care and patient/staff
experience can be achieved at pace (<10 weeks) if supported by effective team
working and appropriate external and regulatory input. The authors also noted
their experience suggests that buddying can be an effective way to promote
change and support a trust in difficulty, when included within a comprehensive
improvement programme.
†
Leach R, Banerjee S, Beer G, Tencheva S, Conn D, Waterman A et al. Quality Improvement: Supporting
a hospital in difficulty: experience of a ‘buddying’ agreement to implement a new medical pathway.

Case study
vii
Leadership interventions – Mayo Clinic
The Mayo Clinic is a non-profit integrated multi-specialty group practice in the
US which has 4,500 physicians (242 of them are in titled leadership positions).
It has developed and validated two leadership interventions that led to significant
increases in professional satisfaction and reductions in professional burnout.

‘Listen-ask-develop’
The practice of ‘Listen-ask-develop’ is a team-based approach to eradicate
the root causes of professional burnout. It works in teams of doctors and with
integrated care teams. The model directs the removal of frustrations one at a
time and engages professionals as partners in co-creation activities to identify
and solve problems. The technique begins with the assumption that systems and
behaviours are the problem, not people.

The ‘Listen-ask-develop’ model is intended to:

● Identify drivers of burnout.

● Foster healthy clinician-leadership relationships.

● Engender teamwork and camaraderie.

● Support development of clinician leaders.

● Alleviate burnout by improving team dynamics, processes, and systems

of care.

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The work unit leaders ensured action was taken in partnership with members to
address points raised by doctors following the ‘listen’ stage of the model to ensure
its success. Issues outside of the control of the work unit were communicated to
appropriate leaders in the organisation and timely feedback was given regarding
the action plan (Swensen et al, 2017).

Using the technique to identify and remove local frustrations, teams at Mayo Clinic
reduced burnout and improved satisfaction. In 217 clinical units with approximately
11,000 staff, satisfaction improved by 17%, burnout decreased by 21%, and
teamwork increased by 12% (Swensen et al, 2016).

‘The Leader Index’

A team at the Mayo Clinic has identified five Leader Index Behaviours that
positively impact physicians’ professional fulfilment, satisfaction and burnout.
These are:

● Include: Nurture a culture where all are welcome and psychologically safe.

● Inform: Transparently share what you know with the team.

● Inquire: Consistently solicit input and ideas of associates.

● Develop: Support professional development and career aspirations of staff.

● Recognise: Express appreciation and gratitude in a meaningful way to

colleagues.

The team at the Mayo Clinic has developed a way to evaluate these behaviours,
and develop and select leaders for them. The leadership qualities, behaviours and
actions are also teachable.

The Clinic formally assesses the performance of physician leaders each year
through the Leader Index, using a 12-question staff-wide survey evaluating the five
key leader behaviours (Swensen et al, 2016). The results are shared with leaders,
who are supported to improve with workshops, training and dedicated coaching
sessions. If leaders could not or did not wish to improve, they were moved on from
their positions because of the degree of impact on the morale of their workforce.

The Mayo Clinic has succession pools for all leadership positions, which are rated
for readiness, competence, and ethnic and gender diversity. Individuals holding
these positions rotate after two four-year terms so no leader is in position longer
than eight years.

Based on the success of the work with physicians, the Clinic scaled the
Leader Index management to include all (over 3,300) point of care leaders
such as nurse managers and social worker supervisors.

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Case study
viii
Collective Leadership project – Belfast Health
and Social Care Trust
The Collective Leadership project at the Belfast Trust started with a new structure
aimed at creating high levels of medical participation and medical and clinical
engagement. The new triumvirate structure means each division is led by a team
of three, chaired by a doctor. This aims to give formal senior leadership roles to
doctors, makes doctors professionally accountable for the medical leadership in
the division, drives multi-disciplinary working at senior levels and encourages
medical involvement in decision making. In 2018, the Trust started its culture
programme to create a baseline of the current culture and change culture. By the
middle of 2019, when the Change Team presented its results to the Board, 2,000
staff had participated.

Other organisational development approaches are aimed at creating the behaviours

and culture needed for collective leadership to be effective. A culture in which
people relate to each other differently and with more compassion. Of these, staff
report that they value:

● Role modelling a more intentional, compassionate, appreciative and visible

leadership by senior leaders, including the Chief Executive and Medical
Director.

● Development of a medical engagement strategy focusing on quality

improvement. Care was taken to implement it thoughtfully in such a way it
was clear thought had been given to reducing the extra burden. For example,
during out of hours QI training doctors were encouraged to bring their
children if they wished. QI programs have given doctors the skills to create
a positive sense of influence over the quality of the service.

● Embedding a different style of leadership through a medical development

programme through The King’s Fund and increasing doctors’ voice through
focus groups and open sessions.

● Creating a more compassionate culture through the adoption of Schwartz

Rounds, listening events which tackle fear cultures where they exist in
pockets or are created by changes in the wider context, and workshops on
just culture.

● Encouraging team-based working across the integrated care model.

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Case study
ix
Wellbeing initiatives – The Cleveland Clinic
The Cleveland Clinic is a non-profit, multi-specialty academic medical centre, which
provides clinical services and conducts academic research. The Clinic has taken
multiple approaches to improve the wellbeing of their clinicians and staff, including:

● Communicating vision and leadership principles by expressing to staff

that they are part of a team of compassionate caregivers that aim to transform
healthcare. This is also expressed through the values of the organisation that
every person has to meet: quality, safety, empathy, innovation, teamwork,
inclusion and integrity.

● Running town hall meetings, where senior leaders from the Clinic spoke
to staff using a standardised toolkit to understand their perspective on the
Clinic’s strengths and deficits. This effort ran with leadership support across
60,000 members of staff and a key goal was to create a culture of safety and
an environment of listening and respect. The feedback from the town hall
meetings allowed leaders in each department to identify three or four things
to tailor. A key characteristic was the ‘strength and deficit approach’, where
departments focus was not just on improving deficits, but also concentrated
on enhancing strengths.

● Conducting an engagement survey achieving staff engagement of 68%.

● Running a learning academy in the Clinic’s Global Centre for Learning.

This includes a healthcare leadership course, a management programme,
and a course on empathy and its importance in clinicians’ roles. Every doctor
in the Clinic went offline for half a day to attend a communications course on
how to interact with patients and make sure that interactions are meaningful.
The management programme also asked managers to go to lunch together
once a month to share their experiences and learning.

● Running a coaching and mentoring programme, which included training

for staff on how to be coaches and mentors. The programme started with an
orientation at the beginning of the year where staff could approach potential
mentors. In addition to affecting the sense of belonging to the organisation,
mentors can help their mentees with specific advice for career development
and fulfilling their goals.

● Providing mindfulness resources to staff and a wellbeing day once a year.

● Addressing the ‘pebbles in the shoes’ to remove small frustrations that can
have a big impact, and enable staff to fully concentrate on supporting patients:

- Conscious efforts to make Electronic Medical Records (EMRs) easier for

doctors, including creating a secure app to put EMRs on doctors’ phones.

- Developing a ‘tap and go’ option to sign into systems in the clinic instead
of entering a password. This saves time as it needs to be done multiple
times each day

- Giving the ability to park near to the ward where doctors’ patients are located.

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Case study
x
Professional Compliance Analysis Tool (PCAT) –
Scottish Government Health Workforce and Strategic
Change Directorate
The Scottish Government Health Workforce and Strategic Change Directorate
developed a quality improvement framework: the Professional Compliance
Analysis Tool. PCAT was designed to improve working patterns, quality of training,
clinician wellbeing and patient safety. It offers a way for teams and departments
to celebrate good practice and identify areas for improvement. PCAT is locally
owned and led by those who experience and see its impact directly. Local teams
are able to tailor questions asked in surveys, this has helped participation levels
and recipients remain anonymous. Combined with quantitative data collected,
PCAT has provided a robust tool that accurately reflects trainees’ views of their
experiences, which can then inform meaningful discussions around potential
areas of improvement. Entire teams discuss findings to agree on QI processes,
accountabilities and timelines. Trainees have reported this process has engaged
and empowered them as it has allowed them to see real changes being
implemented as a direct result of their feedback.

PCAT has been successfully rolled out across Scotland, providing whole-system
data collection but also offering in-depth and specific analysis of individual
departments’ strengths and opportunities. Using locally owned data to inform QI
conversations can effect genuine improvement and enhance staff experience in
a way that may be unachievable by centrally administered surveys.

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Management and supervision

Case study
xi
GP appraisal report
The focus of the Medical appraisal: Feedback from GPs in 2018-19 report by NHS
England and NHS Improvement was to look at GPs’ perspective of their annual
appraisal across different areas of the country, to understand whether it’s necessary,
offers value for money and is beneficial to doctors and patients. Feedback was
provided by a total of 13,440 GPs (estimated 30% of the GP workforce in England),
supplied by 10 of 16 NHS England Local Offices. The feedback was very positive,
with 88% of respondents agreeing that their appraisal contributes to improvements
in patient care, and 91% agreeing it was useful for promoting quality improvement.
Many GPs commented specifically about being supported by their appraiser
through difficult times. The results were more positive than the equivalent results
in the 2017 survey by the Royal College of General Practitioners (RCGP), which
had a smaller sample (1,100 respondents). Despite the positive feedback on annual
appraisals in this report, areas for ongoing improvement were minimising the burden
of less valuable activities for doctors, and optimising the platform or product used
for recording supporting information for appraisals.

The Royal College of General Practitioners in Scotland surveyed its members in

2018, in relation to how they felt about working in general practice, what motivated
them, what worried them, what impact working had on their wellbeing, and their
views on the future. The survey received 355 responses from practising GPs
and those who had recently left the profession, representing a cross-section of
approximately 8% of Scotland’s GP workforce. Almost 70% of GPs reported
spending time face-to-face with patients, working as part of a team and improving
patient outcomes as their primary motivations. At the same time however:

● 57% said they think working in general practice will get worse over the
next few years and 26% said that they’re unlikely to be working in general
practice in five years’ time.

● 37% feel so overwhelmed by their daily tasks that they feel they cannot cope
at least once per week.

● 44% said stress had impacted their mental health and 29% their physical
health. 39% of respondents thought stress had impacted their decision
making and patient care, and 35% reported it impacted their personal life.

GPs considered more opportunities for team building and learning within their
practice and longer consultation times as the most attractive approaches to address
the issues.

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Case study
xii
Supporting doctors in difficulty – Wrightington,
Wigan and Leigh NHS Foundation Trust
In recent years Wrightington, Wigan and Leigh NHS Foundation Trust has worked
jointly with other trusts to offer remediation services. The services supported
doctors encountering difficulties with their clinical competencies, communication,
behaviour or relationship difficulties with their colleagues. This has involved the
development of an intensive remediation plan, the establishment of supervision
and mentorship support, and the direct involvement of the Medical Director to
oversee the process. A clinical supervisor was appointed in each case to support
the doctor.

Interventions to support staff mental health

The Trust has brought in initiatives to support staff mental health, including:

● Development of the Critical Incident Stress Management service (CISM).

This is a coordinated response to support staff following a distressing
incident, offering debrief sessions to support staff with the after effects,
their stress reaction and levels of resilience.

● Power Pause – an emotional first aid kit to support staff during times of
high pressure. It is designed to help staff to rest, as and when they need
to, throughout their working day and recharge through taking breaks.

● Take 10’s – to reflect on stress levels and the impact on health and
wellbeing. The Trust takes this proactively out to staff, establishing a
temporary base when required, to encourage people to attend.

● Giving staff the 'gift of time' on their birthday – with a complementary

day off work.

● Running a range of financial wellbeing schemes to ease the stress of

money worries, including debt consolidation, loan services, pay advances,
savings through payroll and support and advice.

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Case study
xiii
Medical Peer Support – NHS Ayrshire & Arran
A medical peer support program for consultants and SAS doctors was launched
in NHS Ayrshire & Arran in spring 2018 as a result of a self-directed initiative.
Trained consultants and SAS grade clinicians (peer supporters) offer support to
colleagues who struggle from the emotional impact of an adverse event or a difficult
professional or personal experience. Reactions can include sadness, shame,
anger, fear, guilt and isolation. Unresolved these can result in depression, anxiety,
burnout, sickness absence and suicide. The adverse effect on others such as family,
colleagues, team and the quality of patient care can be significant. A prevalent
culture of invulnerability and perfectionism makes it very difficult for clinicians to
share their emotions. Evidence, however, suggests that senior grade doctors prefer
to talk with a peer. Peer support is not therapy but offers temporary social support
as empathic and non-judgemental listening from a colleague in a safe space. It is
entirely confidential and voluntary.

A lot of evidence about medical peer support originates from Jo Shapiro, an

Otolaryngologist at the Brigham and Women’s Hospital in Boston who initiated
a peer support programme††. The NHS Ayrshire & Arran peer support group
was inspired by that programme to implement the model. There are now 14 peer
supporters offering support to consultant and SAS doctor colleagues. In the first
year, 23 one-to-one peer support conversations took place. A confidential system
of self-referral or referral by clinical or associate medical directors offers any senior
clinician direct access to peer support. Contact can also be made via a confidential
mailbox. A list of all 14 peer supporters and details of the program are available
on the Ayrshire & Arran internal website. Close links exist with mental health,
psychology and occupational health for advice and onward referral if necessary.
The peer supporters meet every two months for mutual support and updates.
A twice-yearly training day maintains and enhances peer support skills. To ensure
utmost confidentiality no paper or electronic records are kept. An annual activity
report without any personal details is generated. Local management has been
very supportive of the program. A need to expand peer support to senior specialist
trainees in NHS Ayrshire & Arran has been identified.

Other health boards in Scotland are now developing peer support programs.
Plans are also afoot to create a Scottish peer support network.

In times where social interaction at work has diminished as a result of changes in

work patterns in healthcare, peer support offers a safe space for conversation and
listening for clinicians who struggle to go through a difficult period. According to Jo
Shapiro, peer support is ‘one way forward toward a culture of community that truly
values a sense of shared organisational responsibility for clinician wellbeing and
patient safety’††.
††
Shapiro J, Galowitz P. Peer Support for Clinicians. Academic Medicine. 2016;91(9):1200-1204.

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Annex 3 – Additional case studies 128

Case study
xiv
Learn Not Blame Campaign – Doctors’
Association UK
Doctors’ Association UK’s ‘Learn Not Blame’ campaign aims to empower
individual doctors to be part of a transformational change process working
towards a revolution in the culture of the NHS. The campaign encourages
individuals to commit to action within their own sphere of influence, and join
together as a movement to put pressure on NHS leadership to mirror that change
and commit at a Trust or Health Board level to an open, learning and just culture.

Caring for doctors Caring for patients

Annex 3 – Additional case studies 129

Equality, Diversity and Inclusion

Case study
xv
Ethnic Minority Network – North East London
Foundation Trust
North East London NHS Foundation Trust has been making continued
improvements for BME doctors alongside the wider organisation. The Trust’s
ethnic minority network (EMN) ambassadors include representatives from
medical staffing, to ensure issues affecting medical colleagues are included
in the implementation of the EMN’s strategy.

This has involved adopting an NHS Equality Delivery System, a framework to help
them continually improve their performance on equality. Actions have included:

● Development programmes for BME staff.

● Developing more targeted adverts to attract under-represented sections

of the community.

● Rolling out ‘fair treatment’ panels to triage disciplinary cases.

● Appointing another BME-origin member to the Trust’s board voting

membership.

● Appointing a medical consultant EMN network ambassador, who works

directly with the executive medical director to raise any issues.

● Planning to deliver a ‘cultural intelligence’ training session for all medical

staff across the trust.

● The Trust’s focus for the EMN Strategy is to have a key objective to support
medical staff around formal disciplinary processes.

Caring for doctors Caring for patients

Annex 4 –
Compassionate
and inclusive
leadership

Professor Michael West and Dame Denise Coia

Annex 4 – Compassionate and inclusive leadership 131

Compassionate and inclusive leadership

There is a collective aspiration across the four UK health systems to develop
compassionate and inclusive/collective leadership. This is done through:

● The People Plan by NHS England;

● The HSC Collective Leadership Strategy in Northern Ireland;

● Project Lift in Scotland and

● A Healthier Wales, the new Health and Social Care strategy in Wales.

The challenge is to ensure that these commitments are translated into practice.

Compassionate leadership comprises four elements:

Attending: The first element of compassionate leadership is being present with and
attending to those we lead. Leaders who attend will model being present with those
they lead and ‘listening with fascination’ (Kline, 2002).

Understanding: The second component involves leaders appraising the situation those
they lead are struggling with to arrive at a measured understanding. Ideally, leaders
arrive at their understanding through dialogue with those they lead and perhaps have
to reconcile conflicting perspectives rather than imposing their own understanding.

Empathising: The third component of compassionate leadership is empathising.

Compassionate leadership requires being able to feel the distress or frustration of those
we lead without being overwhelmed by the emotion and therefore unable to help.

Helping: The fourth and final component is taking thoughtful and intelligent action
to help the other. Probably the most important task of leaders in healthcare is to help
those they lead to deliver the high-quality, compassionate care they want to provide.

What compassionate leadership does not mean is:

● loss of commitment to purpose, high-quality performance or good

performance management

● difficult conversations being labelled as bullying

● always taking the easy, consensus way forward rather than putting patients
and communities first

● not being able to challenge the status quo and make the radical changes
patients and communities need or

● team work and system working being controlled by whoever has the most
power and is most ruthless (see https://www.kingsfund.org.uk/blog/2019/05/
five-myths-compassionate-leadership).

Caring for doctors Caring for patients

Annex 4 – Compassionate and inclusive leadership 132

If we are to create compassionate cultures in organisations it is also vital to have

inclusive leadership. The Fair to refer? report identified steps that need to be taken to
ensure that the needs of all doctors, including those in isolated roles or perceived as
‘outsiders’, are understood and addressed. Without shifts in power, compassionate
leadership could be a fig leaf for controlling others.

Compassionate leadership can be seen as including key aspects of leadership in

our national health services.

Compassionate leadership
Attending Understanding Empathising Helping
Effective leadership Inclusive leadership Collective leadership System leadership
● 
Direction A clear, shared, ● Clear, shared, inspiring ● Everyone has leadership ● Shared vision and values
inspiring purpose or vision purpose or vision responsiblity ● Long term objectives
● 
Alignment Clear goals ● Positively valuing difference ● Shared leadership in teams ● Frequent face to
for people and teams ● Frequent face to face ● Interdependent leadership face contact
aligned and springing from contact = working together across
the vision ● Constructive and ethical
● Continuous commitment to boundaries conflict management
● 
Commitment Developing equality and inclusion ● Consistent leadership style
trust and motivation ● Mutual support and altruism
● Clear roles and strong across the organisation across organisational and
amongst all
teams sector boundaries

In more detail, attending includes:

● noticing suffering at work

● inquiring about suffering or distress

● recognising time pressure, overload and performance demands that distract us

from noticing suffering

● challenging policies, rules, and norms of conduct oriented to blame and

punishment

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Annex 4 – Compassionate and inclusive leadership 133

Understanding includes:

● seeing that suffering is often masked by missed deadlines, errors or difficult

work situations

● learning to be curious about the causes of difficult or ambiguous work situations

● cultivating the default assumption that others are good, capable and worthy
of value

● withholding blame by focusing on learning

● giving others dignity and worth whatever their role or difference

Empathising includes:

● being present

● remaining calm and steady in the face of suffering

● developing empathic listening, allowing leaders to be present without needing

to fix, solve or intervene necessarily

● identifying with others by feeling similar

Helping includes:

● focusing on what is most useful for the other

● taking action that addresses suffering

● creating flexible time to cope with suffering, buffering others from overload

● avoiding legalistic approaches that deny human connection

● addressing corrosive politics, toxic interactions, underperformance via ‘fierce

compassion’

● empathising, integrity and confidentiality

● recognising that compassion is neither weak nor vulnerable

For more detail, see:

West, M. A. & Chowla, R. (2017). Compassionate leadership for compassionate health

care. In Gilbert, P. (ed.). Compassion: Concepts, Research and Applications. (pp. 237-
257). London: Routledge.

West, M., Collins, B., Eckert, R. and Chowla, R. (2017). Caring to change. [online]
Available at: https://www.kingsfund.org.uk/publications/caring-change [Accessed 24
Oct. 2019].

Caring for doctors Caring for patients

Annex 5 –
Sources
of support

Professor Michael West and Dame Denise Coia

Annex 5 – Sources of support 135

Sources of support
During the review we identified a number of excellent services providing support and
advice to doctors and medical students.

The British Medical Association have compiled a list of support services that doctors
and medical students may find useful. This includes a directory of wellbeing support
services around the UK, specifically for those looking for local support.

This list can be accessed at www.bma.org.uk/advice/work-life-support/your-wellbeing/

sources-of-support.

Caring for doctors Caring for patients

Bibliography

Professor Michael West and Dame Denise Coia

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