The big issue: Healers in crisis Ellie Broughton
Therapy Today, December 2023

Talking about COVID, it gives a lot of people flashbacks because people were dying in front of us and our morgue was full. The frightening thing is that no one has addressed the mental health impact which the pandemic has had and continues to have on the staff. No one wants to talk about it.’ This testimony from an NHS nurse is just one of many heard at the recent national inquiry into COVID.¹

The COVID pandemic threw a spotlight on how dependent we are as a nation on the commitment and dedication of NHS workers, many of whom are on low pay and working long hours in increasingly underfunded services. So it’s shocking to read in the latest NHS Staff Survey (2022) that a quarter of the NHS workforce reported being harassed or abused by patients, relatives or other members of the public within the last year, and three in 10 said they often thought of quitting.² The report also found that 34% of the NHS workforce is facing burnout, and 37% feel emotionally exhausted by work.  

The irony is that at the same time the report was released – March 2023 – ongoing Government funding for the NHS staff mental health and wellbeing hubs set up during the pandemic stopped, despite calls for the services to continue. Seventeen hubs out of 40 have already closed or are in the process of closing throughout the UK.  

On World Mental Health Day in October this year, BACP called for all NHS and social care staff to have equal access to dedicated evidence-based mental health and wellbeing support at work, wherever they live in the country. ‘The huge pressure that NHS and social care staff are under is  having a devastating impact on their physical and mental health. It’s vital they have access to timely mental health support from trained therapists,’ said Martin Bell, BACP Head of Policy and Public Affairs. ‘Closing these hubs and denying staff this crucial intervention will have consequences far beyond individual employees, impacting health and social care services, patients and families.’

The authors of a newly published study into the effectiveness of the hubs have called for the services to be continued. ‘The stresses placed on health and social care staff during the pandemic were extreme; providing this additional support was an important step. Many staff continue to experience difficulties and these hubs continue to play a vital role for many,’ says Dr Paul French, co author of the study, funded by the National Institute for Health and Care Research (NIHR).³

Frontline 

Although frontline NHS work has always come with pressure, the widely acknowledged cuts to services of the past decade, layered on top of the challenges presented by the pandemic, have created a perfect storm that is undermining staff resilience at every level. Karen Ledger is a therapeutically trained coach, supervisor and member of the BACP Coaching executive who has worked with NHS senior leadership teams for many years. ‘There has been a noticeable and significant shift in the feelings of powerlessness and hopelessness felt within many teams – not all, but it’s only employees away from the frontline who have held onto a sense of control and job satisfaction,’ she says. ‘The story I hear from those who deal directly with patients or who manage those who deal with patients is one of fatigue, frustration at lack of resources and not being able to retain or recruit staff, and anguish over deteriorating standards of patient care, which can lead to moral injury and vicarious trauma, PTSD and depression in health workers and managers.’

Although NHS workers have access to NHS Talking Therapies like the rest of the population, the success of the staff wellbeing hubs has highlighted the need for specialist support. Working with this cohort can be complex for many reasons, including that ‘clinicians in particular often underestimate how unwell they are’, says Lucy Warner, CEO of NHS Practitioner Health (NHSPH), a free, confidential mental health and addiction service with expertise in treating healthcare professionals. ‘When they register with us, they’ll give the impression on their registration form that they’re not too bad and are probably wasting our time. But then they’ll fill out a PHQ9, GAD7 or CORE10, and actually they score really highly.’ 

Another barrier to seeking help for NHS staff is not knowing who they can trust to talk to about their mental health challenges. When NHSPH was originally set up in 2008 by Professor Dame Clare Gerada, now President of the Royal College of General Practitioners, the aim was to offer mental health support to doctors in England and Scotland because they ‘face a barrier to accessing confidential healthcare’. Since 2021 it has opened up to include nurses and other staff members. NHSPH employs 78 therapists, including 15 BACP members, most on a contracted rather than employed basis. Multidisciplinary teams discuss each referral to agree which treatment plan is best for their condition, which could be individual counselling or group therapy, and is agreed with the client. 

As well as a rise in the number of staff members seeking help from NHSPH – a 77% increase since March 2021 – there has been an increase in the severity of presenting issues. At the end of last year, around one-third of clients presenting to NHSPH reported that they had thought about or made plans to end their lives before seeking help. The incidence of suicidal thoughts and planning among referrals rose from around 28% in October 2021 to almost 36% a year later.⁴

Burnout 

Although every suicide is a tragedy, what is perhaps of more concern is the growing rate of burnout among NHS staff, not least because of the increased pressure this places on an already struggling health service. Some six million working days were lost to mental ill health in the NHS workforce last year, according to the Nuffield Trust.⁵ Emerging research also suggests that burnout increases the risk of errors. Last year The BMJ published a systematic review that found that, overall, doctors’ burnout doubled patient safety incidents.⁶ A 2023 NIHR study found that GP burnout was linked to higher opioid and antibiotic prescribing.⁷ 

Switching to the ‘other side of the desk’ can make the therapeutic process a struggle for many doctors. ‘They find it hard to adjust to being a patient rather than a clinician,’ says Warner. ‘Part of what we’re doing in the service is giving people permission to take off that metaphorical white coat and adapt to the role of patient. What our clinicians and therapists are so skilled at is allowing them the freedom to ask questions, adopt that patient mentality, and not make assumptions that they know things already.’ 

Another challenge is fitting therapy around work, particularly for junior doctors on rotation, although the transition to online therapy has helped. ‘Although not ideal, they can literally go and lock themselves in a cupboard or sit in their car and do a therapy session,’ Warner says.  

Broken

It’s impossible to ignore the ongoing pressure on nursing staff, and two in five nursing staff polled by Nursing Times in January 2023 say their mental health is worse now than during the pandemic.⁸ A report in The Independent newspaper described nurses as saying they are ‘truly broken’ and that 42,400 staff voluntarily quit their NHS jobs in one quarter of last year – higher than any quarter over the past decade.⁹ 

Midwives are also under pressure – a recent study by Dr Sally Pezaro and colleagues found that they are at greater risk of problematic substance use than doctors or paramedics, but they have no access to confidential support for drug and alcohol addiction.¹⁰ Pezaro and colleagues have another study under peer review that demonstrated that while problematic substance use itself did not increase intention to leave the profession, it reduced emotional health, which did. ‘We know retention is a huge problem in midwifery, and we need to support more of them to stay, so it’s important that we try to understand the mechanisms behind them wanting to leave, or leaving, following problematic substance use,’ she says. 

Paramedics are also suffering – a 2021 study in the Journal of Paramedic Practice found that more than 50% of ambulance staff were experiencing burnout.¹¹ During the strikes of December 2022, many spoke out about the impact of burnout, workforce shortages and the cost of living on the profession.¹² The Care Quality Commission, an NHS watchdog, warned that harm to patients is becoming ‘normalised’ as paramedics now routinely work without breaks.¹³ Outside of hospitals and GP surgeries, dentists are also struggling. Earlier this year, a small study published in the British Dental Journal on dentists in Wales found three-quarters of respondents had gone to work without feeling mentally well enough.¹⁴ Before COVID, a 2019 paper in the same journal found almost a fifth had had suicidal thoughts.¹⁵ And ironically, counsellors and therapists working for NHS Talking Therapies and other services are reported to be ‘stretched to capacity with many now under crippling and unsustainable pressure’.¹⁶ 

Specialist support 

Many of the charitable initiatives that have been set up, such as the well-respected charity Doctors in Distress (www.doctors-in-distress.org.uk) and the Laura Hyde Foundation (www.laurahydefoundation. org), are focused on crisis management and reducing suicide. And for good reason – the Laura Hyde Foundation estimates that there is a death by suicide among UK doctors every three weeks.¹⁷ Death by suicide among nurses is also on the increase – a report from the Laura Hyde Foundation found that 366 nurses who had contacted the charity’s services in 2022 had attempted suicide, up from 319 in 2021.¹⁸ 

But the options for those staff who are not suicidal but are significantly impacted emotionally, psychologically and psychically by the pressures of working for the NHS are limited. In September a new trial began for a depression and PTSD treatment tailored to nurses and healthcare workers – Supporting Hospital and Paramedic Employees (SHAPE) Recovery.¹⁹ First trialled during the pandemic, CBT-based therapy sessions are offered online and over the phone. In its first clinical pilot it returned a 91% recovery rate for PTSD and 71% for depression for 300 participating health and social care workers; results are now under peer review. 

Warner says many of NHSPH’s clinician clients respond well to the short-term CBT work it offers, as it teaches them tools they can then use themselves. A recent report from the Society of Occupational Medicine (SOM) also recommended CBT, along with coaching and positive psychology interventions.²⁰

But for some NHS staff members, the work needs to be longer term – particularly those suffering from moral injury, a specific emotional response that is triggered when people are forced to act in a way that goes against their ethical and professional values. As well as the frustration of not being able to provide an adequate level of care for patients in a service that is commonly described by the media as ‘broken’, many frontline staff are still processing the impact of denying patients visits from family members while they were dying or seriously ill, and witnessing colleagues lose their lives due to lack of proper PPE. More recently, the conviction for murder of paediatric nurse Lucy Letby offered a snapshot into deeply embedded systemic challenges faced by staff at some NHS trusts, including the culture of silence around whistleblowing.

‘It is challenging – I’ve sat there wondering, what option is there? They have very little control over their workplace,’ says Rachel Morris, a former NHS GP and burnout survivor, now a coach specialising in working with doctors along with running the podcast You Are Not a Frog (www.youarenotafrog.com). ‘Practitioners may be thinking: “This job is killing you. Why don’t you leave?” But it’s hard for doctors to leave. They don’t want to. They’ve trained for years, so often they’ll opt to stay in much, much longer than other people would. You need to get creative about clients’ options; there is always a choice – just because I can’t immediately see the options doesn’t mean there aren’t any there.’ All practitioners working with this cohort must bear in mind the ‘medical identity’ can be a very strong one that is difficult to leave behind, says Clare Gerada, in Beneath the White Coat: doctors, their minds and mental health (Routledge): ‘The “medical self” acts as a necessary and mature defence mechanism but can, and often does, get out of hand, especially when not counterbalanced by a healthy working environment or personal support.’ 

Coaching works well with frontline staff as the emphasis is on hope and empowerment, says Karen Ledger. ‘There is always something they can do,’ she says. One of her current contracts is providing leadership coaching within midwifery services, supporting staff to take on and stay in leadership roles which have been difficult to fill. ‘I focus on awareness building in leaders to recognise what autonomy they do have even in a difficult working context, the strength of pulling together and drawing on each other, and by doing so making their working lives being more sustainable collectively. Leaders are not familiar with thinking about themselves and can be resistant to not looking at emails in the evenings, or saying no to extra hours when exhausted, and it’s always “what about the staff caring for patients”, but when staff are at burnout or simply tired, mistakes get made. I have years of medico legal work as an expert witness of medical negligence and worst-case scenarios to draw on to help communicate the importance of self-care.' 

She says any skilled practitioner who can truly listen to the experiences of staff will be of help, but contextual knowledge of the environment and cultural challenges they face is a bonus. ‘General psychoeducation and work around emotional and psychological management is key, but if there is a sense that you do understand what they are going through, the work may be more effective as the therapeutic relationship will be stronger. My background is in social and health care so I have had personal experiences of the frustrations of being impacted by board-level decisions that you know are not in staff or patients’ best interests. Although people like myself on a small scale and Professor Michael West on a larger scale have been working for decades to change the nature of NHS leadership, compassionate leadership is still only practised in more socially aware and open-minded pockets of the NHS.’ 

Concessions 

In the absence of adequately funded services, many private practitioners have responded to the growing crisis by offering concessions to NHS staff, or volunteering their time for free to services such as Frontline19 (www.frontline19.com). ‘Sometimes the best we can do is bear witness as we help the staff member face and process their feelings,’ says Penelope Campling, psychiatrist and psychotherapist, and author of Don’t Turn Away: stories of troubled minds in fractured times (Elliott & Thompson), who supported clinicians on the frontline during the pandemic. She also advises recognising the systemic conditions, acknowledging the erosive effect of moral injury and validating trauma, while helping clients regain some sense of agency.²⁰ 

Navneet Singh MBACP, an integrative therapist who works for NHSPH, has around 20-25 online sessions with NHS medical staff a week. ‘Most of the medics who were in the frontline during the pandemic have faced and seen things that you’d expect in a war or in less developed nations,’ he says. ‘Now younger trainees are starting to say, “If we don’t take care of ourselves, who will?”’ 

He has noticed common patterns of engagement in this cohort, including ‘intellectual defences, especially in doctors, rationalising and justifying issues that are going on,’ he says. ‘Psychotherapeutic theories are not absolute, as they are in the medical or physiological world, and that can be something that doctors hide behind – seeking proof that this would work as a way to disconnect from their pain.’  

Solutions 

In the long term, it’s clear that systemic change is needed – as SOM CEO Nick Pahl said, ‘While individual focused solutions are undoubtedly important, they will not be effective in isolation unless organisational interventions are also embedded in policy and practice. The NHS Long Term Workforce Plan aims to reduce the overall leaver rate for NHS-employed staff from 9.1% (2022) to between 7.4% and 8.2% over the next 15 years. This can only occur by investing in reversing burnout, tackling root causes, so that NHS staff can return to work well.’ ²⁰ 

Change has to be top down, says BACP’s Martin Bell: ‘Whoever forms the next UK Government must invest in counselling and psychotherapy and the skills of our members, so more people – including NHS workers – can access therapy.’