Chief Medical Officer - annual report: 2020 to 2021

Sustainability of our Workforce

Sustainability of our Workforce

We can't begin to recover our health and care system without considering how the pandemic has affected our own physical and mental health. This has been the most difficult year of my career. When I speak to colleagues, no matter where they have been working, or the service they provide, this experience is almost universally shared. We cannot ignore this or fail to proactively seek out those who need support as a consequence of their experiences during the pandemic. This is not only a moral duty to those who have shown such incredible commitment in adversity, but is essential in maintaining high quality, compassionate care for our patients in the future. 

Each of us will have faced varying degrees of issues, concerns for our own health, caring for our families, strain on our important relationships or looking after children during such a heavily restricted time. Some will have sustained trauma to a much greater degree. Recovery must start with acknowledging this, facilitating the means for people to express this and identifying practical means to address it.

There is much discussion of the 'new normal' and how we can shape our health and care system to be a fulfilling place to work where we can practise Realistic Medicine. I don't have all the answers, but I do believe that we can learn from the challenges and successes of this past year. I'm committed to working collaboratively with representatives and organisations from across the professional spectrum to gain better insights of staff experience, and build supportive inter-disciplinary teams that are orientated to provide fulfilling care and support to patients and colleagues alike.

Supporting the Wellbeing of our Workforce

"Health is all about people. Beyond the glittering surface of modern technology, the core space of every healthcare system is occupied by the unique encounter between one set of people who need services and another who have been entrusted to deliver them"
Frenk et al.^[100]

Evidence from around the world has shown that COVID-19 continues to have a significant effect on the wellbeing and mental health of those working in health and care.^[101-102]

In addition to the many personal stories I have heard from colleagues and friends, the Everyone Matters Pulse Survey has allowed the experiences of those working on the frontline in health and care to be understood. This abbreviated version of iMatter was used to gain a better understanding of both the pressures and triumphs which have marked this year. Worry and anxiety are consistent themes expressed in the report. This ranges from work concerns such as patient care, workload, staffing pressures, and PPE, to increased worries about home and personal life, including caring responsibilities, shielding, ill-health, finances and ongoing uncertainty about the future.

In the Scottish Government's Re-mobilise, Recover, Re-design: the framework for NHS Scotland, staff wellbeing has been identified as an essential component. Health Boards have been asked to ensure that their remobilisation plans describe how the physical and psychological wellbeing of staff will be supported.

The burden borne by health and care staff, and the need to support their physical and psychological wellbeing has led to the development of new national resources:

The National Wellbeing Hub: promis.scot was created in partnership with the Rivers Centre for Traumatic Stress in NHS Lothian and the Anchor Psychological Trauma Service in NHS Greater Glasgow & Clyde. The approach is based on the principles of Psychological First Aid, which is recognised internationally as best practice in promoting resilience following trauma exposure.^[103 ]

Since its launch in May up until January, the hub has received over 63,000 visits. The hub is open to all health and care staff, as well as unpaid carers. Additional resources have also been made available through the hub, such as access to apps for staff experiencing sleep disturbance, and online cognitive behavioural therapy. 

Wellbeing Helpline: This was launched in July and provides a 24/7 service to those who need further confidential support with trained Psychological Wellbeing Practitioners, who provide a listening ear and can refer onwards for further support. 

Workforce Wellbeing Champions Network: A total of 84 'Wellbeing Champions' were engaged from Health Boards, Health and Social Care Partnerships, local authorities and the Scottish Social Services Council. Their remit is to promote the psychological wellbeing of the workforce, collect insights, share best practice, and identify workforce needs to inform national policies.

Coaching for Wellbeing: Through NHS Education for Scotland (NES) and the KnowYouMore platform, we have provided bespoke online wellbeing coaching for health and care staff. By January over 1500 people had registered, and over 3000 hours of coaching had been allocated. 

In addition to these national staff wellbeing programmes there have been multiple local initiatives which have been well received, including delivery of 'Comfort Boxes' to NHS wards, departments and care homes across the Grampian region, and the distribution of "You are Appreciated" postcards in Tayside. 

The Emergency Department, NHS Tayside

The NHS Tayside Emergency Department recognised the importance of staff appreciation following an iMatter report in 2018. This led to the a new approach to feedback and reflection. We initiated a Learning from Excellence (LfE) system, where episodes of excellence were identified and reported, enabling real time positive peer to peer feedback. From here, we were able to understand behaviours that were valued in the team and challenge issues such as incivility. 

When the pandemic struck in March, we recognised that it would have a massive impact on the wellbeing of our team. The LfE system was adapted to reduce the administration burden and changed to 'You are Appreciated' postcards. We created an honesty box and kept it stocked with food and snacks, so that everyone always had something to eat, and a rest room containing a fresh box of toiletries was made available to all staff. Psychological support was sought from the wellbeing team who provided people with regular opportunities to talk and reflect. 

Supporting staff wellbeing has been a real team effort and an ongoing challenge. The team recognises the need to continue to support each other and make sure everyone feels valued at work, but also challenge each other when required, in order to deliver high-quality compassionate patient care.

With unprecedented pressures on our mental health, we need appropriate support to prevent worsening absences from work and to retain staff. A reduced workforce or one experiencing burnout affects the ability to deliver personalised care and the wider aims of practising Realistic Medicine. Work continues to ensure that the wellbeing of our workforce remains a priority. The iMatter Programme will recommence later this year and we are developing a new, complementary Dignity at Work tool, which specifically measures workplace behaviours and culture. By maintaining momentum, I believe that we can truly look after the health and wellbeing of our colleagues, as they continue to provide personalised care. 

COVID-19 and the NHS Education for Scotland Bereavement Workstream

The NHS Education for Scotland (NES) Bereavement workstream has responded to many of the impacts of the COVID-19 pandemic by developing a range of educational initiatives to help support staff to care for for those who are at the end of life, those who are bereaved, as well as support them to look after their own wellbeing.

Early on in the pandemic, visiting rights were suspended in many areas. This led NES to develop guidance on caring for people who are dying and those close to them amidst these restrictions, and on supporting a person's spiritual care needs, in recognition that representatives of belief communities may have been unable to offer their usual forms of support. Additionally, the number of health and care workers contracting COVID-19 and in some cases sadly dying, prompted NES to produce guidance to support teams dealing with the death of a colleague and supporting employees who are bereaved.

NES also launched a short animation that introduced the acronym 'TALK' (Tell, Ask, Listen, Kindness). It was designed to help health and care professionals cope with bereavement. It encourages us to support each other with simple strategies such as talking to colleagues, listening and showing kindness to oneself and others.

A Bereavement Webinar series has been established alongside a virtual peer support network for the NHS Scotland Board Bereavement Strategic Leads and Coordinators. NES also built on the success of its inaugural 2019 bereavement conference with a follow-up event on 24th February 2021. All of these activities support the principles outlined in the first Bereavement Charter for Children and Adults in Scotland which launched in Spring 2020.

@NES_Bereavement         www.sad.scot.nhs.uk       SupportAroundDeath@nes.scot.nhs.uk

Becoming Improvers and Innovators

Throughout 2020, we have seen an unparalleled pace of change, necessitated by the COVID-19 pandemic. Many of the recent changes to the way we work have been in development for a number of years, but the pandemic necessitated a roll-out which was much more rapid than planned. Some situations have required entirely new innovations to solve new problems. I am continually impressed by the creativity, willingness to embrace change and resilience which has been displayed over this past year. 

I am immensely proud of over 12,000 students and returners from health and care who stepped forward to offer their skills during the initial wave of the pandemic. This included more than 2000 final year nursing and midwifery students who joined the NHS Scotland workforce and almost 75% of final year medical students who applied to commence early interim Foundation posts (FiY1) ahead of their usual start date in August. I'd also like to recognise that many other students at earlier stages of their training offered their time as NHS volunteers. Scotland owes a debt of gratitude to the dedication shown by all our students and returners.

The early graduation of medical students and their uptake of clinical duties was well supported by our Undergraduate and Postgraduate Deans, and onsite Educational Supervisors, to ensure that by summer 'new' starts were already well-embedded in their clinical teams. 

"All five Scottish medical schools demonstrated an impressive agility in pivoting to online education in the early stages of the pandemic. Working alongside the Postgraduate Deans and the GMC, we were able to ensure that as many students as possible graduated months early, providing reinforcement for hard-pressed clinical teams in late Spring."

Professor John Paul Leach, Head of Undergraduate Medicine, The University of Glasgow

As I have outlined earlier in this report, digital technology allows us to continue to practise Realistic Medicine in this 'new normal'. The rapid change in the way we work would simply not have been possible without the willingness and commitment of our workforce to embrace new ways of doing things.

As I mentioned earlier in my report, Attend Anywhere (which powers the Near Me digital consultation service) is transforming the way people engage with health and care services. In Personalising Realistic Medicine, we described how Near Me was starting to be used to enable remote consulting and avoid the need for people to travel to consultations. The advent of the pandemic quickly brought into focus the need to provide safe care through rapid uptake of this technology. Digital Health and Care Scotland and Health Boards worked together to quickly make video consulting available to nearly every GP practise and secondary care team in Scotland. The willingness of the NHS workforce to embrace this new way of working has been simply remarkable. 

The next frontier for digital technology enabling personalised care will be in Social Care, through Scottish Care's Vision for Digital Technology & Digital in Social Care.^{[104 ]}Care staff are already embracing this change with the Care Management (Safety Huddle) Tool being rolled out to all care homes in Scotland.

As well as allowing the continued practise of Realistic Medicine, the use of digital technology can have benefits for staff wellbeing, with the Trickle wellbeing app as just one example.

'An app a day to keep the doctor OK'

Funded by Scotland's Chief Scientists Office, as part of its Rapid Research in COVID-19 programme, the Scottish Medical Education Research Consortium have produced an app for NHS frontline workers to use to help them have a 'good day' at work. 

Dr Kim Walker, project lead, tells us "The feedback we have had challenges the assumption that doctors have undergone a transition into the 'new normal' of COVID-19, when many still feel that their working lives are anything but normal, and the pandemic has magnified already existing challenges to doctors' wellbeing. It is hoped the app will ultimately improve work satisfaction, mental health and resilience in medical personnel who may be struggling to cope with difficult working conditions".

The app will give real-time data on the well-being of Scotland's workforce and will collate the key aspects that contribute to good days – perhaps days where people feel respected, and connected to colleagues, and bad days - perhaps days where people feel they have not been listened to, or didn't get the chance for physical activity. The Trickle app will be piloted in NHS Lothian and NHS Tayside, with plans to roll it out more widely.

The app will provide users with a weekly report encouraging them to focus more on aspects that have previously resulted in good days. It will also provide NHS Boards with a live view of where support and interventions are needed most in response to evolving working patterns and practices, such as the latest COVID-19 constraints.

"The Trickle App has allowed us to attend to our people, to listen to what’s being said, and not said, to understand what’s really important, and ask: How can we help?"
Dr Achyut Valluri, Acute Medical Unit Lead, NHS Tayside

Supporting a Compassionate Workforce

"We are a society which treats all our people with kindness, dignity and compassion, respects the rule of law and acts in an open and transparent way".

The National Performance Framework, Scottish Government

Embedding a culture of compassion and kindness

It is well recognised that when staff working in the NHS are subject to high levels of stress this can result in burnout, one symptom of which is compassion fatigue.^[105] The risks to patient care when health professionals, who are under pressure, lose some of their ability to feel compassion are significant, as demonstrated in the Francis Report.^[106]

If we are to deliver careful and kind care to our patients, we must first show kindness and compassion for each other. Kindness is something that is universally recognised. It cannot be quantified or easily defined, but we all know what it feels like to be treated with kindness. The closely aligned relational values of respect, civility, compassion and kindness are at the very heart of our humanity and have the profound power to enhance our wellbeing and build relationships. 

Research from The Carnegie Trust refers to 'Radical Kindness', for it demands institutional change and challenges long established norms.^[107] It requires moving the dominant focus of our organisations from process, performance targets and close scrutiny, towards a balanced approach that emphasises relationships, connections and trust. It requires incorporating qualitative values-focused measures alongside quantitative measures.^[107] Cost effectiveness, evidence-based practice and productivity remain vitally important, however there is a pressing need for the values we hold dear to complement the rational aspects of healthcare. While this will not be without its challenges, we must find better ways of working that focus on our shared humanity.

Compassionate and Kind Leadership 

We must focus on creating the conditions that allow kindness and compassion to flourish at work. The concept of psychological safety, where staff are listened to, feel included and of worth, creates a culture where successful innovation and improvement are more likely to happen.^{[108 ]}Having engaged staff is the single most predictive factor for higher productivity, improved health board financial performance, quality of patient care (and reduction of medical errors) and workforce recruitment and retention.^[109-110]

Compassionate, inclusive and multi-professional leadership has the potential to bring wide-ranging benefits across health and care.

Project Lift, an integrated leadership programme, is dedicated to talent management and leadership development. It offers multi-professional development opportunities for current and future leaders. The programme organises free online events for attendees of all levels of seniority to come together and explore collaboratively how to tackle the most urgent issues in health and care. The programme also looks at how we can create a more sustainable way of working. The values of kindness and compassion​, humility and curiosity​, inclusivity and diversity​ are at the heart of this programme. We aim to make it part of how we foster a culture of compassionate and inclusive leadership at all levels, and at all stages across health and care in Scotland.

The busy and complex environments in which we work, mean we often find ourselves working with people we do not know. Compassionate leadership is essential to fostering positive inter-personal relationships and supported team working. It also requires personal commitment. Consider for a moment the best team you've been a part of. What made it such a great team to work in? Was it the mutual understanding, respect, civility or kindness you showed each other? Connecting with each other can improve our job satisfaction and the care we provide. What can you do to connect with the people around you?

We must continue to learn from instances of reported incivility and negative behaviours, as represented in the Sturrock Report . It contains valuable lessons we must learn from if we wish to establish a collective, collaborative, and cooperative culture, where people feel valued. In the wake of the report, a Ministerial Working Group was convened, to examine and explore measures that support open and honest workplace cultures and deliver sustainable behavioural changes to leadership and management across NHS Scotland. We want to build a national conversation about compassionate leadership, to make culture our first resort and, in time, to create a self-sustaining 'ecosystem' where one generation of generous, compassionate, inclusive leaders inspire the next.

Supporting a Diverse and Inclusive Workforce

"In diversity there is beauty and there is strength."
Maya Angelou

At the heart of NHS Scotland sits the vision that all staff and patients are treated with care, compassion, dignity and respect.^[111] The pandemic has exposed and exacerbated deep-rooted health and social inequalities in our society and highlighted racial inequalities in our health and care workforce which must be addressed.^[112]

During the pandemic we have all become used to dealing with uncertainty in the midst of incomplete evidence, and I have listened to the concerns from staff from minority ethnic communities, particularly those from Black or Asian backgrounds, about the potential increased risk of COVID-19 to them and their families.

In light of the growing UK and international evidence of this disproportionate risk to patients and staff ^[113], an Expert Reference Group on COVID-19 and Ethnicity was established. This group have provided wide ranging recommendations on gathering data and evidence to inform our response to these risks, as well as responding to more systemic issues which perpetuate inequalities.  In response to this the Scottish Government has published an individual occupational risk assessment tool to help consider the risk of COVID-19 in the workplace. Further to this the Scottish Government has committed to: ^[114]

• establishing a national Race Equality Network to produce an action plan with annual progress targets for health and care employment at all levels of seniority in relation to minority ethnic groups;
• increasing the numbers of minority ethnic staff in senior and executive team roles through our Leadership and Talent Management Programmes;
• ensuring new and existing minority ethnic staff networks in health and care have a voice and influence to drive change, by introducing clear lines of governance and accountability, up to Board level;
• working with staff networks and health and care employers on a campaign to improve the accuracy of workforce ethnicity data.

This work would not be possible without committed networks of staff in our Health Boards promoting a diverse workforce. I am hopeful that with increased support and with shared learning across health and care, we can move towards a more inclusive and diverse workforce. 

We want to increase diversity and inclusion across our health and care system, not just because it is the morally right thing to do, but because the evidence clearly shows that a diverse workforce improves not only engagement and wellbeing for all staff, but also innovation, and the quality and safety of patient care.^[116] This is imperative if we are to realise the aims of Realistic Medicine. 

I am clear that we need to talk about, and live out, the values we champion in our society. We must value and promote an inclusive culture with a diversity of race, age, gender, sexual orientation, religion, and disability. We need to continue to challenge ourselves to learn, to engage in sometimes difficult conversations and listen to those who are experiencing inequalities for any reason. To be a workforce that practises Realistic Medicine and who are passionate about equity, we need to appreciate the strength in our diversity and have compassionate leaders, drawn from a broad pool of talent.

As challenging as it has been, we have continued to make progress, rolling with rapid change, leading on innovation and championing the wellbeing of our workforce. Imagine how much more we can achieve once the acute phase of this pandemic is over. 

Reducing Differential Attainment in Medical Education

Reducing differential attainment in medical education, and ensuring a fair training experience for all, is one of the key equality outcomes for NHS Education for Scotland (NES). Significant differences in outcomes, termed differential attainment, in College examinations and in training progression between international medical graduates (IMGs) and UK graduates (UKGs) has been widely recognised. The reasons are multifactorial, and are seen in other professions and areas of education. 

The Scotland Deanery welcomes IMGs and is committed to acknowledging and reducing the differential attainment gap. Recognising the challenges of integrating into a new country and a new healthcare system, the Scotland Deanery established an IMG induction day, and IMG buddy system, and promotes an IMG doctors support network. In 2020, pre-induction webinar sessions were established in collaboration with the International Recruitment Team which provided specific answers to IMGs' questions. IMGs from 27 countries linked into these sessions, with excellent feedback. Other initiatives include the Scottish Trainee Enhanced Programme (STEP) developed in General Practice and currently being expanded into Psychiatry. These programmes aim to welcome IMGs to UK training and to help improve outcomes through improvement in the trainee/trainer working relationship. Uniquely, STEP brings IMGs and their educational supervisors together, for a day of shared learning and development of a new understanding about cultural differences communication skills, and learning techniques. 

Advancing Equity in Medical Education

In the GMC National Training Survey^{[115 ]}an important theme this year has been the difference in experience for those in postgraduate medical training from minority ethnic groups, particularly those from Black or Asian backgrounds. These colleagues were less likely to report positive experiences through the pandemic in terms of experience of teamworking, sharing of knowledge and a supportive training environment, compared to the experience of white trainees. According to GMC figures nearly 40% of UK registrants are from a Black, Asian or other minorty ethnic background and there are acknowledged longstanding issues of discrimination and disadvantage. 

The Scotland Deanery have held webinars to listen to the concerns of our trainees and have set up an Under-Represented Minority Staff Network. This joins the new Disability and Long-Term Conditions Network and LGBT+ Staff Networks. Nevertheless, advancing equity in medical training is an area which requires continued focus over the next year and beyond.

Conclusion

I know that many of you are feeling weary and for some it goes beyond that. Some of you will feel burnt out. Many of you are continuing under severe pressures due to the unrelenting pace of the pandemic, staff shortages and increasing workload. As we strengthen our efforts to address these challenges at an organisational and policy level, I firmly believe that kindness and compassion towards each other has a vital role to play in improving our wellbeing and our working lives. As we recover, restore and renew our health and care system, with our workforce at front and centre, we can make Scotland an even better place to work. 

I have outlined just a fraction of the good practice to support our workforce that's taking place across Scotland, but by working together we can go further. We must continue to focus on providing kind and compassionate leadership, developing diverse, inclusive and positive workplace cultures and supporting our people to deliver the careful and kind care we strive for. 

Considerations:

• To provide the best possible care, we need to look after our own wellbeing. How can we look after ourselves and each other better? 
• How can we create and foster a positive and inclusive workplace culture that values respect, civility, kindness and each other? 
• What can we do to encourage development opportunities at work and ensure we have multidisciplinary leadership in the workplace?