Sep 1 / Dr Tom Ratcliffe

Surviving in a failing system

I have worked in the NHS since 2008. The summer of 2023 is the first time in my career that I have stepped back from clinical practice in 15 years, thanks to a 3 month sabbatical.

This month I have rejoined the fray and wanted to share a few reflections whilst I retain the sense of perspective that this break has bestowed. In particular, I want to talk about the wellbeing of the clinical workforce.

The typical clinician

Clinical medicine is inherently stressful. Most clinicians will be hovering somewhere in the mild to moderate range on standard burnout scales, even in the best of times (see the Maslach Burnout Inventory).

Clinicians' work is innately traumatic and the NHS environment itself can further traumatise staff. However, frontline workers receive little space, help or support to process all that is happening to them and their patients and deal with this trauma.

These are emphatically not "good times" in the NHS and clinicians are emerging from a once in a century pandemic. Current levels of stress and burnout among clinicians are not sustainable. The majority of people I speak to about emotional wellbeing, including many seasoned colleagues, are struggling or have recently struggled. I have had some time off due to stress myself in the last 2 years – experiencing burnout was a scary and unpleasant experience.

Some statistics:

A fundamental problem is the mismatch between personal characteristics that make for good clinicians and the traits required to survive the NHS in its current state. The majority of clinicians have a desire to control their environment so that they can provide high quality care, fix problems and derive order from chaos. This is what treating illness and disease well is all about.

Clinicians have very high standards and a strong predilection to perfectionism. Alongside this are the twinned emotions of guilt and shame, which are frequently part of clinicians’ psyches and way of thinking (perhaps exacerbated by trauma): "if things aren’t working, then it must be because I am not working hard enough to fix things, I must see that extra patient, get this bit of work done before I go home," are common refrains.

These characteristics of the typical clinician drive them to provide great care in favourable environments but can be seriously problematic for them personally when practicing within a failing system.

The system: set up to fail

The NHS environment is increasingly volatile, unpredictable, complex and impossible to control.

This is a result of the shortage of staff, the often appalling state of infrastructure (estates and technology) and the austerity-driven loss of crucial services that support people and prevent the NHS being overwhelmed.

When there is too much work, healthcare workers remain accountable for the outcomes of the life and death decisions they make. This can be extremely stressful when key parts of the system are under such strain that they can no longer be trusted (i.e. ambulances taking too long to attend life-threatening emergencies, delays for outpatient care, over-stretched child safeguarding teams etc.).

Clinicians can only operate in a resource poor environment for prolonged periods by lowering  their standards ("better that the patient gets some medical care at an okay standard than no medical care at all"), which causes moral injury - the utilitarian mindset is hard to reconcile with the obligation to do the best for every patient.

In leadership and management roles clinicians are often unable to what they have taken on these roles to do: strive for higher standards and fix problems they encounter in the system. Frequently, they break themselves trying to achieve the unachievable. Or are just left with a deep and, perhaps, well founded cynicism.

This can manifest as a general demotivation, a widespread sense of hopelessness and endemic burnout. This is compounded when frontline NHS workers are denigrated by those in power (I used to regard this as meaningless froth but, increasingly, I have seen the negative impacts on staff and how this denigration changes some patients' attitudes to healthcare staff). Examples include Secretaries of State suggesting that ‘junior’ doctors lack a sense of vocation, nurses accused of messing about making TikToc videos at the onset of the Covid-19 crisis rather than treating patients or GPs being accused of ‘hiding’ due to the implementation of virtual / telephone consulting as part of crucial pandemic control measures.

This comes at the same time as many health professionals are experiencing lower material rewards for their labour (real terms pay cuts for many groups of staff and inflation to living costs and housing).

What keeps clinicians working in frontline healthcare?

A good question! The answer is generally: a commitment to medicine as a worthwhile intellectual and practical challenge, the opportunity to improve peoples’ lives, the ability to contribute to delivery of universal healthcare as a force for good in the world and, especially in the case of general practitioners, a desire to serve their communities. Medicine remains a well respected profession and there is inevitably a sense of self-esteem arising from professional identity. Without these factors, and if other opportunities were on hand, a mass exodus would be inevitable. The current reality is partial exodus – with early retirement, career transfers, increased part time working and/or emigration becoming more common.

What can clinicians do to get through this?

A few things are needed:
  1. The system needs to be fixed, which is about massive investment in workforce and infrastructure and prioritising improving health across all of public policy (note: this is going to take at least a decade to achieve)… with this in mind, items 2-7 are probably they need to do now…
  2. Clinicians need to find personal strategies to survive – avoiding the “all or nothing” thinking trap that comes with perfectionism and remind themselves that they are doing an incredible job on the back of a global pandemic and a manufactured crisis in universal healthcare, neither of which is their fault!
  3. Be clear about what they can control and focus on these things (the first four lines of the oft quoted serenity prayer are helpful here: “grant me the serenity, to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference.”)
  4. Accept that it is “okay not to be okay”, get support, help each other out and remind each other what a great job they are doing
  5. Look out and support colleagues who are struggling: accept that an active strategy to stave off burnout is a requirement of the job at the current time and is likely to fail some of the time for most people
  6. If you are a leader, make sure your organisation invests in support and staff wellbeing – through measures like coaching, mentoring, good occupational health and psychological care and support, which should be a core part of what healthcare organisations do to help staff.
  7. Make sure that your organisation is as well run  as it can be under the circumstances, with controllable inefficiencies removed and colleagues clear about what they need to focus on.
  8. Fight back! The NHS is not in crisis by accident. It has been systemically undermined for over a decade and sits on the shaky foundations of an ailing, austerity society. Shout about this situation, hold the yes men and women who have facilitated this accountable and make sure that the general public know who is to blame for the calamity (clue: it is not the NHS staff breaking themselves to keep the show on the road).

A personal reflection

Despite everything I have written above, after a few months away from NHS primary care, I was looking forward to returning to work when my sabbatical ended.

I love what the NHS stands for, I feel proud and honoured to work with some of the best people you could imagine: caring, passionate, creative and altruistic. Most importantly, I still feel I can make a difference.

It is early days in my return but I am trying not to get angry or worry about things I cannot control or change, trying to focus on changing the things likely to have the greatest impact and remind myself of the value of just being there, every day, under very challenging circumstances.

I am trying to do my best to tell my colleagues how wonderful they are and thank them for their hard-work as often as I can.

As of September 2023, I am positive that things will change for the better.

The darkest hour comes just before the dawn...

You can find our more about coping with the pressures of NHS primary care in our learning module on "surviving and thriving at the deep end".