A better future for healthcare – series

This November (2020) the College of Medicine is 10 years old. We intend to use this as an opportunity for renewal. For some time it has become clear that we need a new medical perspective. Not only to withstand the ever-increasing incidence of long-term disease but also to overcome problems created by our current methods such as increasing antibiotic resistance and addiction to opioids. Covid has further shaken medical complacency.

Consequently, we have brought together some of the best talents and leaders within the College of Medicine to write 15 short chapters on how medicine needs to change in all its various areas from addressing inequalities and developing local communities to improving the lifestyle of our young and the elderly. The five extracts that follow are a preview of a manifesto to be launched later this year. It will not be just another think-piece; it outlines quite specifically how the college and others will extend the reach and effectiveness of medicine over the next 10 years. The time for talking is over and we need to be bold and challenging, which is exactly what we intend to do. You can be the judge of that and this issue of JHH will give you a flavour of our revolution to come.

Michael Dixon

Chair if Council, College of Medicine

The 5 extracts including this one:

1. Reimagining a healthful environment
2. Reimagining medical research
3. Nurturing self-care
4. Reimagining practitioner wellbeing
5. Creating a fairer society and answering the challenges of Marmot

David Peters, Professor Emeritus, Westminster Centre for Resilience, University of Westminster

Published in JHH17.3 – Beyond Covid

The issues

The NHS is Europe’s biggest employer. Under everincreasing pressure to meet the demands of a growing and ageing population its main drivers became the metrics of effectiveness and efficiency. The consequences of this industrial production line thinking is proving to be humanly and economically unsustainable.
Working in healthcare can be hugely rewarding, but continual contact with human suffering, and high levels of responsibility and risk, are emotionally and intellectually demanding. NHS staff wellbeing is in decline: a BMA study in 2019 found that 8 in 10 doctors were at significant risk of burnout and 27% had previously been diagnosed with a mental health condition. Burnout affects decision-making and leads to more errors. Over half of doctors surveyed recently are planning to either retire early or to spend less time in clinical practice.

Today’s young doctors and nurses are the profession’s unhappiest ever. Many are jumping ship. Understandably the newest generation feels entitled to a reasonable work-life balance. Yet despite the ‘modernisation’ of their training and working hours, in 2018 only 37.7% of foundation year 2 doctors continued into specialist training programmes. Although most come back within three years, 5% will never return. Doctors are only human (though many might believe otherwise) and collision can be foreseen between their expectations and an ever-more bureaucratic, hyper-regulated, portfolio and performancemanaged, risk-averse NHS.

We are short of approximately 36,000 nurses in the NHS and around 110,000 nursing staff in social care at a time when new immigration rules may prohibit our ability to recruit nursing staff from overseas. Successive governments have failed to invest in increasing the domestic supply of nurses and much of the growth we have seen in the nursing and midwifery register has been from outside of the European Economic Area (EEA). Brexit has led to a
downward trend in nurses registered from the EEA. If the government is to fulfil its commitment to recruit 50,000 more nurses many of these will be from overseas recruitment. After retirement the top two reasons for leaving the profession are too much pressure from the workload placed on nurses and concerns regarding the ability to provide a good quality of care to patients.

The NHS Plan 2000, aimed to create efficient career paths. But as a result young doctors and nurses with as yet little clinical experience now have to make big choices too early in their career. Training is not supporting the shift to the more agile emotionally intelligent flexible workforce we need if the NHS is to respond creatively to the future’s fast-approaching unprecedented challenges, of which the Covid-19 pandemic may be a harbinger. In the current pandemic emergency many NHS staff, perhaps particularly those deployed outside their specialty, are experiencing traumatic situations whose impact they feel unable to be open about. When they can no longer cope, it’s hard for doctors to admit it: ashamed to ask for help, and perhaps fearing that a mental health problem would lead to their being declared unfit to practice.

The solutions

Nurses and doctors do hard and difficult work. Yet human beings can cope with pressure better and for longer if they have what they need for recovery: safe spaces, a sense of belonging, and a professional identity that is appropriately respected. In the past, to compensate for the stress and long hours, they often had on-site lodging and parking, in hospitals that cultivated a vibrant social life, and they generally worked in ‘firms’ which were stable teams. In the industrial and arguably less personal NHS these supports have vanished and, until the current pandemic, our practitioners’ routine compassion and commitment went unrecognised. Being hailed as a hero might boost morale for a short time, but doctors who have already gone the extra mile would be wise to take a sceptical view of the public’s superhuman expectations.

The 2019 BMA response encourages more favourable working practices and proposes systemic change. Changes in training models, promoting good leadership and carving out longer appointment times, making time for breaks and improving rotas are all necessary. And there is an urgent need to promote self-awareness, self-care and mental wellbeing and to break down personal and cultural barriers to seeking support. encourages more favourable working practices and proposes systemic change. Changes in training models, promoting good leadership and carving out longer appointment times, making time for breaks and improving rotas are all necessary. And there is an urgent need to promote self-awareness, self-care and mental wellbeing and to break down personal and cultural barriers to seeking support.

Yet these are only first aid measures: the loss of morale, rising levels of burnout and growing employment problems are symptoms of a wider malaise. Unmitigated stress is pro-inflammatory. Social inequality, poverty, adverse childhood experiences, poor diet, and environmental pollution amplify this effect. Increasingly, workers in our health and social care systems face an exhausting struggle with the consequently rising tide of chronic disease. In the short term, doctors working with chronic disease will need a wider range of psychosocial tools at their fingertips. In the long term the underlying causes of national ill-being may have to be addressed through holistic and practical grounded action for reducing social inequality, improvements in education and redesign of NHS systems.

Practical action

• Create a Practitioner Wellbeing Faculty in the College of Medicine whose first action will be to produce a short paper on why this subject is so important and why radical action is required.
• Lobby government and ministers to take a more holistic view of the public health to stem the tide of chronic illness and disease.
• Develop whole system test bed sites where practitioner wellbeing can be actively promoted through local systemic changes.
• The College of Medicine to host annual Practitioner Wellbeing Awards.
• The College of Medicine Scientific Advisory Council to make the case for, and enable research into, two promising areas for improving practitioner wellbeing.
• Deliver courses for shifting system change, improving selfcare, and bringing together teachers and influencers for better wellbeing in medical schools.
• Publish an annual report on progress, to launch on the Faculty’s newly created National Practitioner Wellbeing Day.