Burnout in the NHS: what happens when doctors become patients?

Dr Kevin Teoh, Lecturer in Organizational Psychology, discusses burnout and mental health trends in NHS consultants – which is the subject of a new paper, co-authored with Dr Atir Khan, Dr Juliet Hassard, and Dr Saiful Islam.

Not many days go by where there isn’t any discussion on the current state of our National Health Service (NHS) – whether it is increasing patient demands and numbers, concerns around funding, patient safety, or Brexit. However, as one of the largest employers in the world, the changes across the NHS can have significant ramifications for its workforce. In the press, there is increasing concern about how healthcare staff are coping in light of these changes.

One of the main topics of discussion is burnout, which consists of three components – emotional exhaustion, depersonalisation, and reduced personal accomplishment.

Emotional exhaustion refers to being emotionally drained and exhausted in the workplace, while depersonalisation is a psychological withdrawal from relationships and the development of negative and cynical feelings towards people. Reduced personal accomplishment represents a lack of work effectiveness due to emotional exhaustion and depersonalisation.

But why is burnout in the NHS so important? And what are the factors in the work environment that precede it? We sought to examine these questions in a sample of NHS consultants drawn from England, Scotland and Wales. Consultants represent the most senior and well-trained doctors in the healthcare workforce. Through their role as supervisors and educators, they are also pivotal in the development of the current and future healthcare workforce. Far less is also known about the working conditions of consultants, when compared to their junior doctor and nursing colleagues.

We focused on two aspects of work – work-related pressure and autonomy. The first reflects the workload and pressure that consultants are under, with considerable evidence from other sectors that link it with the health outcomes of workers. The latter actually reflects a potential positive work aspect as high-levels of job autonomy may be beneficial to consultants (and workers more generally). This is because job autonomy gives consultants the flexibility to manage their workload, work on tasks which they find more interesting and problem solve.

In addition to the working conditions and burnout relationship, we also wanted to see how these linked in with staff outcome measures, including the levels of depressive and anxiety symptoms that consultants were experiencing as well as their intention to retire early from the NHS.

The results paint a worrying picture. Out of the 593 consultants who took part, about a third of NHS consultants had poor-levels of psychological health, including emotional exhaustion (38.7%), depersonalisation (20.7%), anxiety symptoms (43.1%), and depressive symptoms (36.1%). These figures not only highlight that our consultants are struggling; they also suggest that poor mental health among consultants has increased in the years since they were last measured.

As expected, both aspects of work that we measured – (high) work related pressure and (low) job autonomy – predicted adverse psychological health. But what are the implications of poor working conditions and burnout among consultants in the NHS?

Our findings suggest that the impact on both severe mental health issues (i.e. symptoms of anxiety and depression) and an intention to retire early. This means that when consultants in the NHS experience high work-related pressure and job autonomy, the subsequent development of burnout could lead to more severe downstream issues.

From a psychological perspective, this does make sense. Consultants struggling in an environment where they have little autonomy and high work-related pressure requires energy and coping resources. Continual exposure then takes a toll on consultants’ psychological resources, which leads to burnout over time, as doctors feel exhausted and they depersonalise from the people around them. When doctors burn out, it exacerbates even further this demand on their psychological resources. What then happens is the manifestation of further mental and physical symptoms, such as the development of depressive and anxiety symptoms. Also, consultants may choose to leave that difficult work environment to protect their remaining psychological resources – which is why we see that when consultants report higher levels of burnout they are also more likely to intend to retire early.

While it is important to note that we did not diagnose actual anxiety and depression in our sample of consultants, the measurement of symptoms is strongly associated with it. Consultants struggling with such symptoms are more likely to be impaired in their performance, which is consistent with the growing research evidence base linking poor mental health among doctors with lower standards of patient care. Should the prevalence of depression and anxiety among consultants go up, it would inadvertently increase the demands on the NHS as doctors become patients themselves.

The intention to retire early is something that should be of concern to us all, especially as the NHS is currently facing a shortage of healthcare staff, including consultants. If consultants do go on to retire early, this would not only reduce the number of doctors in the NHS but would lead to a skills gap in the healthcare service. This might then generate a continuous downward spiral where consultants experiencing poor working conditions burnout, leading to the development of more severe mental health issues and/or early retirement from the NHS. In turn, this further increases the demands on the health service that impacts the remaining consultants, thereby continuing this cycle.

Managers and policymakers need to be aware of the current state of poor psychological health of NHS consultants. They also need to recognise that decisions and changes made to the working conditions of doctors (and healthcare staff in general) not only impact their burnout levels. Where it is not feasible to alleviate some of the work-related pressures, then ways to increase the level of consultants’ job autonomy should be considered.

These findings, along with some of our other research in this area, emphasise the need to address the systematic issues within the work environment that influence the working conditions of NHS consultants. Although more individual-focused interventions, such as resilience training, may have a role to play, on its own this is clearly insufficient. In the UK, there has been limited research looking at interventions to manage the working conditions of doctors. Nevertheless, growing research from elsewhere in the world provide some examples that may be relevant to the NHS here.

Ultimately, as potential users of the NHS, the mental health state of consultants and their working conditions really should be of concern to us all.

The full study, Psychosocial Work Characteristics, Burnout, Psychological Morbidity Symptoms And Early Retirement Intentions: A Cross-Sectional Study Of NHS Consultants In The UK, is published by BMJ Open.

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Contemporary Trotskyism: the resilience of social movements

John Kelly, Professor of Industrial Relations at Birkbeck, discusses the social and political dynamics of Trotskyist organisations – the subject matter of his new book, Contemporary Trotskyism: Parties, Sects and Social Movements in Britain.

Almost eighty years after Leon Trotsky founded the Fourth International, there are now Trotskyist organisations in 57 countries, including most of Western Europe and Latin America. Yet no Trotskyist group has ever led a revolution, won a national election or built an enduring mass, political party. If the Trotskyist movement has been so unsuccessful, then how can we account for its remarkable resilience?

The book argues that to understand and explain the development, resilience and influence of Trotskyist groups, we need to analyse them as hybrid bodies that comprise elements of three different types of organisation: the political party, the sect and the social movement. It is the properties of these three facets of organisation and the interplay between them that give rise to the most characteristic features of the Trotskyist movement: frenetic activity, rampant divisions, inter-organisational hostility, authoritarian and charismatic leadership, high membership turnover and ideological rigidity.

As political parties, Trotskyist groups have always been small, never exceeding a membership of 10,000, and their vote shares in general and European elections have been derisory, rarely exceeding one percent. Yet Trotskyist groups are distinct from mainstream parties because in addition to their search for votes, office and policy implementation, they are also sects. This means they are powerfully wedded to the defence of Trotskyist doctrine, a core set of taken-for-granted beliefs that guide their actions and which are considered to provide the blueprint for ultimate political success. Trotskyist doctrine, like religious doctrine, appears in many different forms and struggles over the proper interpretation of Trotskyist and Leninist texts have splintered the movement into seven competing families.

Yet against this record of failure and division, Trotskyist groups have been assiduous in building a number of broad-based and successful social movements, to campaign on single issues. The Anti-Nazi League, created in the 1970s by the Socialist Workers Party, made a significant contribution to the electoral demise of the far right in that decade, whilst the Anti-Poll Tax Federation, created by the Militant Tendency in the late 1980s, helped destroy that Conservative government tax in the early 1990s.

These isolated success stories provide one element in the explanation of Trotskyist resilience, but an equally important factor is their astonishing efficiency in raising funds and building organisational capacity. The income per capita raised by Trotskyist groups from their members is around ten times greater than that of mainstream parties, an extraordinary achievement that allows them to employ large numbers of staff and to publish a wide range of newspapers, magazines and books. These organisational resources enable them to wield a public presence, on demonstrations and marches for example, out of all proportion to their tiny numbers. The same resources, coupled with their vigorous and uncompromising anti-capitalist message, allows them to recruit hundreds of young people each year, many of whom however quit after a short period.

Drawing on extensive archival research, as well as interviews with many of the leading protagonists and activists within the Trotskyist milieu, this is the first major study for thirty years of this small but vocal movement.

Contemporary Trotskyism: Parties, Sects and Social Movements in Britain is available from Routledge.

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The insecurity cycle

Sue Konzelmann, Reader in Birkbeck’s Department of Management and Founding Director of the London Centre for Corporate Governance and Ethics, discusses the ‘Insecurity Cycle’ – the subject matter of her new book, Labour, Finance and Inequality: The Insecurity Cycle in British Public Policy, co-authored with Simon Deakin, Marc Fovargue-Davies and Frank Wilkinson.

In the aftermath of the most serious financial and economic crises since the Great Depression, the question of why policy doesn’t always change when it looks like it ought to has been a regular topic of debate. This has been especially true of Britain, where the combination of the lack of a fixed, written constitution and the nature of its political and institutional system, in theory at least, make it more prone to change than much of the rest of Europe.

Examination of the major shifts in policy that have taken place since the dawn of industrial capitalism reveals an ‘insecurity cycle’ at work. This policy cycle results from opposing interest groups – working classes on the one side and capitalists on the other – applying pressure on policy-makers to shift the focus of policy towards the support of their own viewpoint and interests.

The insecurity cycle

Following periods of market liberalisation, in response to the resulting insecurity associated with rising unemployment, poverty and inequality, those affected can be expected to put pressure on policy-makers for social intervention and protection. However, this soon triggers a counter-response by capital and those in upper segments of the distribution of income & wealth – pressuring policy-makers to scale back social protections and liberalize markets. The perceived ‘zero-sum’ nature of this ongoing contest usually means that a gain for one side is seen as a loss by the other – resulting in a continuation of the cycle.

It is not, however, a contest of equals. Historically, the significant asymmetry of power between the forces of free-market capitalism and those of the social welfare state has meant that movement towards social interventionism has typically been long and drawn out, whilst shifts towards market liberalization have been relatively abrupt.

Winds of change

Our research on the dynamics of major policy shifts – from the industrial revolution to the present – suggests that four main factors produce the conditions for change. These include:

1) Crisis – usually of considerable duration; but such a ‘chronic’ crisis may be exacerbated by shorter, ‘acute’ crises.

2.) Democratic pressure, often at its greatest during elections, can also be highly influential in between. Over the years, it has resulted in the emergence of trade unions, pressure for expansion of the franchise and, more recently, socially based movements – such as Momentum – on the social welfare side of the insecurity cycle. But not all democratic pressure is on this side of the cycle, with the 1978-79 ‘winter of discontent’ producing a tide that swept Margaret Thatcher into office – and illustrating the two remaining factors:

3) New – or different – policy ideas; and

4) Credible political backing. Both of these were present in 1979, adding to both the chronic crisis of the 1970s, generally, and the acute crisis of the winter of discontent.

Combined with the resulting democratic pressure, change was almost as inevitable in 1979 as it had been less than four decades earlier, with the combination of the chronic crisis of the interwar years, the acute crisis of World War Two, the new ideas of John Maynard Keynes and the Labour Party, plus a highly ‘electable socialist’ in the form of Clement Attlee in 1945. The policy changes implemented after the elections of Attlee and Thatcher represent the two complete turns of the insecurity cycle so far, with the move to the left taking over 150 years to come about, and that to the right a scant 35. There have, however, also been many smaller shifts, that could be accommodated within the existing policy paradigm.

Axis of anger

The insecurity cycle is also a useful way to help make sense of events both in Europe and on the other side of the Atlantic. This is a policy cycle that is not primarily driven by numbers and data, so much as by feelings of unfairness, hopelessness, and in some cases, anger and fear. As the Brexit campaign revealed, such feelings are difficult to dissipate by politicians citing indicators such as GDP or ‘happiness’ coefficients in defence of the status quo, rather than implementing substantive changes in policy. From this perspective, the sharp polarization between support for the UK’s continued membership of the European Union, and those who feel it is damaging, as well as that between President Trump’s supporters in the US, and those who feel that they’ve lost out as a result of globalization, begin to make considerably more sense.

Is the insecurity cycle an inevitable part of policy-making? Perhaps – and if both sides continue to see it as a zero-sum game, almost certainly. However, what if the relationship between labour, finance and the social welfare state could be fundamentally changed? Continued technological change, as well as expanding populations – both in a context of finite resources – would suggest an uncomfortable intensification of the insecurity cycle if this is not at least attempted.

The links between social movements like Momentum in the UK, and Our Revolution, which has grown out of Bernie Sanders’ presidential campaign in the US, offer the intriguing possibility that politicians like Jeremy Corbyn and Sanders – who are articulating an alternative vision of society and politics – may produce an axis as influential as that of Reagan and Thatcher during the 1980s. This, of course, would also mark a third complete movement in the insecurity cycle.

Labour, Finance and Inequality: The Insecurity Cycle in British Public Policy is available from Routledge. 

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Examining the class system in British museum employment

Sam Evans, a PhD researcher at the Department for Organizational Psychology, is leading a series of focus groups which will ask participants to reveal what it takes to get in and get on in the museum sector, and how social class shapes career chances and experiences.

I’m interested in how inequality is reinforced in the workplace. Class, until recently, has been surprisingly absent from the debate. Research into diversity or equality, often overlooks class, as does occupational psychology in general. Part of the reason for this absence is that class is not a legally protected characteristic, like age or gender, but also it is argued that there has been a more fundamental ‘individualisation’ of Western culture.

Class identities have become more difficult to see or express in the workplace. Our careers are thus seen as our responsibility, and we don’t often think or talk about the structural inequalities that might frame this. However, there is research suggesting inequality at work is increasing, professions are becoming more not less exclusive, and social mobility is declining.

I want to explore these issues in-depth in my research project, The Museum of Them and Us; I am interested not just in how people are classed, but also occupations, roles and organisations. I am particularly interested in why some careers and types of work favour some groups of people and not others. We assume anyone can get in and get on, no matter how tough, given they have the right personal qualities. But what is this really like for people from different backgrounds? I have chosen to look at museums, partly because I am familiar with the field, but also because visiting and working in museums is described as middle class. But why is this, does this account for all types of work, and what does this mean for people who might not be from middle-class backgrounds.

I don’t have a fixed definition of the term ‘class’ (this is a subject that has been debated for 150 years and most researchers recognise there is no one single definition), but am using Pierre Bourdieu’s concept of capital of class. This involves looking at the types of economic, social or cultural capital that are valued within different types of museum work and how this relates to the type of capital people actually have, or are able to acquire. Cultural capital is particularly important as this relates to accent, dress, education and knowledge of particular types of culture, and is often highly valued in cultural work.

I have already conducted interviews with representative bodies, trade unions and membership bodies as well as analysing reports and websites to look at how ‘getting and getting on is described’. I have found that, as with other research, museum work has become less secure and more competitive. The onus seems to be on the person to develop themselves as specialist and professional, and yet also flexible and versatile. This potentially makes it riskier and less beneficial for anyone entering the field. Class was talked about but was often described as difficult to see or measure, and most diversity initiatives were aimed at developing the individual to fit the required ways of working, rather than look more closely at how ways of working might be creating inequalities.

With the focus groups and interviews, on the one hand, I am asking people to talk about their work – what it takes to get in and on, how this might have changed, how this might be different for different roles, are some roles held in higher esteem than others and why. On the other hand, I want to talk about social class – what does it mean to people, do they think class matters and if so, how? I am also asking people to contribute images or photos that they think represent their work.

Take part in the focus groups:

If you have worked or volunteered for a museum you can take part in a focus group or an interview. If people think that class has mattered to them in particular, I am also conducting private interviews.

Taking part is confidential, enjoyable and you will be helping the sector. To take part in a focus group or an interview and for further information, please contact me or visit my website.

Thursday 5 April
6PM – 7.30PM, Birkbeck Main Building, Room MAL 420, Malet Street, WC1E 7HZ  

Wednesday 11 April
6.30PM – 8PM, Birkbeck Main Building, Room MAL 420, Malet Street, WC1E 7HZ.

Thursday 26 April
6PM – 7.30PM, Museums Association Offices, 42 Clerkenwell Close, London, EC1R 0AZ

Friday 18 May
2.30PM – 4PM, Birmingham Museum and Art Gallery, Chamberlain Square, Birmingham B3 3DH

Wednesday 23 May
6PM – 7.30PM, Museums Association Offices, 42 Clerkenwell Close, London, EC1R 0AZ

Thursday 7 June
4PM – 5.30PM, Whitworth Gallery, The University of Manchester, Oxford Road, Manchester, M15 6ER

Thursday 14 June
5.30PM – 7PM, M Shed, Princes Wharf, Wapping Road, Bristol, BS1 4RN

Or schedule an interview:
If you think social class has mattered to you personally in your work or career then you can take in part in an individual interview, by email, Skype or face to face (depending on your location).

If you are interested in finding out more, please contact Sam directly.

About Sam:

I studied History originally, and then spent about 25 years working in marketing in the museum, cultural and public sectors. A lot of my work was really about understanding people and organisational cultures as much as ‘doing’ marketing, hence my interest in studying organisational psychology.  I started studying part time about 8 years ago, first obtaining a degree in psychology at OU, then moving on to the MSc in Organisational Psychology at Birkbeck.

About the same time as graduating, I was made redundant, which forced a decision – stick to the marketing “battleship” I knew, or jump onto the less stable “raft” of psychology. I had already met some PhD students and Dr Rebecca Whiting who became my supervisor, and thought I would really like to study for a PhD here. So when I was offered a studentship, I took the leap. It’s been one of the best decisions I’ve ever made!

From Dr Rebecca Whiting, a lecturer in the Department of Organisational Psychology and Sam’s PhD supervisor:

Sam brings a wealth of experience to her research from working in this sector and an intellectual rigour from her academic training. Class is a challenging concept to research because of the many and sometimes conflicting ways in which its conceptualised and measured.

Many definitions reflect the relationship between class and socio-economic and cultural status. However, since class is not a ‘protected characteristic’ under the Equality Act 2010, it doesn’t always appear as an aspect of diversity in organizations, so is ripe for critical investigation. Museums are key locations of our socio-cultural heritage but are an under-researched context in organizational and occupational research.

This highlights the importance of Sam’s research which brings together this topic and context to explore how class impacts on museum work.

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