NHS Staff and Learners' Mental Wellbeing Commission - February 2019
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NHS Staff and Learners’ Mental Wellbeing Commission February 2019
2. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission
Contents
Foreword by Sir Keith Pearson
NHS Staff and Learners’ Mental Wellbeing Commission Chair 4
1. Introduction 8
2. Learning our lessons
The mental wellbeing of young people 17
3. Lessening student stress
The mental wellbeing of healthcare undergraduates 27
4. Mastering mental wellbeing
The mental wellbeing of healthcare postgraduate learners 45
5. Supporting our staff
Mental wellbeing in the workplace 63
Annex
Appendix A: The Commission 90
Appendix B: Useful resources 91
Appendix C: References 92
Disclaimer
In this report the inclusion or mention of any specific service, approach or organisation,
particularly with regard to training package or provider, does not imply endorsement or support.
3. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission
Foreword by Sir Keith Pearson
NHS Staff and Learners’ Mental Wellbeing Commission Chair
people learn by committing to The NHS Long Term Plan,
this Commission. In 2018 we published January 2019, sets
celebrated the 70th anniversary the challenge of establishing
of our National Health Service. a new deal for staff, which
Back in the 1940s as service would see a modern working
personnel returned from the culture where all staff feel
Second World War there supported and respected for
was a widespread feeling of the valuable work they do.
altruism that there needed The Plan aims to build an NHS
to be a reward for the huge where: “the values we seek
sacrifice of lives lost. The NHS to achieve for our patients
was that ‘prize’. Today the NHS - kindness, compassion,
is a much larger and more professionalism - are the
complex organisation, but same values we demonstrate
it is still a people-led health towards one another.” This
service. Seven decades on, we chimes with the views of the
rightly celebrate the NHS and Commission and we feel this
its achievements but must now vision is embodied within our
The NHS is founded on a recognise where we could do recommendations. The Long
common set of principles and better as employers. We must Term Plan wants to see the
values that bind together the put considerable energy and NHS become: “a consistently
communities and people it effort behind making sure great place to work,” where
serves - patients and public - that when we celebrate NHS there is more flexible working,
and the staff who work for 75 there is a recognisable enhanced wellbeing and
it. If we are caring and improvement in the way we career development, and
compassionate, then we look after the wellbeing of greater efforts to stamp out
should be able to our learners and workforce. the scourge of discrimination,
demonstrate those values violence, bullying and
as employers in the way we One in four people in the UK harassment. This again
look after our employees. will experience a mental resonates with the themes
health problem in any given and recommendations of our
We must be able as employers year and mental health Commission. With this shared
to underpin those values with problems are one of the main agenda, we anticipate being
interventions and support that causes of the burden of disease able to advance a range of
are available to all staff for their worldwide. We should be measures that will support
wellbeing needs. If someone concerned about the incidence staff and learners’ mental
is looking to join the NHS, of mental ill health in our wellbeing through the working
whether through education schools, colleges, universities groups implementing the Long
and training, an apprenticeship and the general workforce, Term Plan.
or direct employment, they not to mention the healthcare
should be able to see and workplace. This NHS Staff and Such measures will also build a
feel that the health service is Learners’ Mental Wellbeing more attractive and welcoming
a wellbeing employer and is Commission (the Commission) workplace in which people
bringing to life the statements has sought out evidence of all ages can launch their
expressed in the NHS on causes, interventions, careers. It is clear that our
Constitution. innovations and good practice school pupils and young people
that will shape a healthier who go on to take clinical
It is an opportune time to future for all as part of Health courses at university are a
be looking at the NHS as an Education England’s health and very different group of people
employer and as a place where care workforce strategy. to the generations before.
4. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission
Known as the ‘millennials’ generation of nurses, doctors, the university of choice. But
or ‘Generation Y’, and now health scientists and therapists who has prepared the teenager
being followed by ‘Generation providing healthcare to the to recognise that their fellow
Z’, this demographic appears people of this country. students are almost all ‘A
to be more open about streamers’? Not all can come
emotions than the generations It is hard to imagine the first so some will struggle and
before. They are said to be 13-year-old, currently consumed might experience ‘failure’ in
motivated by different factors with schoolwork, emerging their exams for the first time,
to their older peers and this from medical school in ten possibly ‘failing’ at something
is evident in our schools, years’ time as a doctor. for the first time in their lives.
colleges, universities and These same teenagers are At all stages of the academic
the NHS workplace. already expressing concerns and professional career there
about the weight of expectation are transitions, as there are
This Commission has heard placed upon them by parents, throughout life. How do we
about how managers and their teachers and their school. best support our school pupils,
leaders working in what is a They feel burdened by this undergraduates, postgraduates
four-generation NHS workforce expectation, knowing that and those progressing through
should ‘learn’ how to get the ‘under performance’ is often the early stages of their careers
best out of colleagues who viewed by their school as a to transition from one phase
are at the beginning of their target missed, a benchmark to another? How are we caring
professional careers. Our moved and a failure to be for their health and wellbeing
young people seek workplace explained. Teenagers talk as they make the steps? What
flexibility and the ability to openly about feeling ‘stressed’ support is in place when those
react to new opportunities, yet and increasingly are seeking steps are ‘mis-placed’?
in healthcare we provide the support from their school
most rigid training programmes pastoral (or wellbeing) While mental health is more
possible. If students on clinical care service, the child and openly talked about; for
undergraduate courses adolescent mental health many pupils, undergraduates,
decide for whatever reasons service, their GP, online postgraduate trainees, and NHS
that their chosen career path in support and their peers. staff, their mental ill health
a health profession is not Stress appears now to be is kept from even the closest
for them, they must be able the norm for teenage years of friends and their family.
to exit the system with dignity. and beyond, and it is these Mental ill health can express
Better still, the NHS should be same stressed teenagers itself in many ways, and in
doing more in partnership with who we are trying to entice the most tragic of cases, we
schools and colleges to better into higher education and discover that the individual has
explain A level (or equivalent) apprenticeships to become our taken their own life. Evidence
subject combinations that future workforce. Stress can be presented to the Commission
lead to clearer apprenticeship, a positive and expectation can appears to show that deaths
university and career choices be helpful, but both should be by suicide among doctors in
that might result in jobs and balanced with realism. recent years are reducing but
careers in the NHS. One in two in other professions, including
staff working in the NHS today Many of these teenagers will female nurses, the figures are
will still be in the workforce in have done well, very well - increasing. Regardless of rate
15 years’ time. More than half a through their school years, trends, behind every statistic is
million of our future workforce ‘A streaming’ through GCSEs an individual person, a grieving
are still pupils in education and A Levels; the teachers will family and friends. One death
today. They are for the most be happy, the school will be by suicide in our workforce or
part, bright and deeply caring. delighted, and the student and among those who are learning
Many will become the next parent will rejoice at getting in the NHS is one too many.
5. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission
There are 1.4 million people in
the NHS workforce. We deploy 1
many of our people to frontline NHS Constitution for England
healthcare and we should want
to be an exemplar when it
We strive to improve health and well-
comes to the support of these being and people’s experiences of
people. There is sufficient
evidence which shows the
the NHS. We cherish excellence and
NHS can do much better. professionalism wherever we find it -
This Commission has looked at
in the everyday things that make people’s
what we are doing currently, lives better as much as in clinical practice,
where there is excellence and
where we could aspire to
service improvements and innovation.
excellence. As a result, a series We recognise that all have a part to play
of recommendations have been
developed. The arm’s-length
in making ourselves, patients and our
bodies of the Department communities healthier.
of Health and Social Care
should work with other key
stakeholders to determine who
will lead on each of these.
Where there are still gaps in
our knowledge we have stated
where more evidence and
insight are needed.
Sir Keith Pearson JP DL
NHS Staff and Learners’ Mental
Wellbeing Commission Chair
6. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission
Our mental health environment
tal
1.4 million The cost of poor men A survey of 3,500
workforce in th health in the NHS doctors showed that
e NHS
workforce equates to 73% would choose
£1,794 - £2,1 74 to disclose mental ill
r year
per employee pe health to family or
NHS currently friends rather than a
celebrating its healthcare professional
rs
70th anniversary Three-quaeratlteh
of mental h
problems are One in three
Half of lifetime established b
y
of the NHS workforce
mental ill health, the age of 24 have felt unwell due
excluding dementia, to work-related stress
starts by the age of 14 and one in two staff
The rates of depression
members have attended
among training
work despite feeling
One in 10 grade doctors has
unwell because they
children and young been estimated
felt pressure from their
people have a clinically at about 30%
manager, colleagues
significant mental health
or themselves
disorder and/or
Top four factor
emotional and s
tal
behaviour problems which affect men Ending stigma -
ding years
wellbeing (accor compared to ten
):
Suicide is on to Student Minds ago students en
tering
ed, n are
e fear of being judg higher educatio
three most coomf m the
stress, finding the
causes of de on now five times
people sclose
people - and
ath in young confidence to tell more likely to di
l health
in 15 -19 year
is rising you have a menta a mental health
ng stigma
olds problem, and faci condition
problems
that ‘mental health
kness’
are seen as a wea
Approximately The return on
25% to 35% investment in w
ork-
of young people place mental he
alth
requiring mental interventions is
health or wellbeing £4.20 for every
support are not £1 spent
accessing services
7. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission
1. Introduction
1.1 Our aims The Commission also heard from representatives of
beacons of best practice where colleague wellbeing
This NHS Staff and Learners’ Mental Wellbeing is supported and championed. In addition, visits
Commission has set out to discover and review took place nationwide to find out more about how
evidence of good practice where the mental organisations are valuing, supporting and caring for
health and wellbeing of staff and learners in NHS their staff and for learners on undergraduate clinical
organisations has been made an organisational education placements or receiving postgraduate
priority. HEE recognises its central role in supporting training. We are grateful to everyone who has given
the current and future workforce to deliver high up their time and provided valuable contributions.
quality, safe care and the Commission has examined This final report, written to support the new
successful interventions from around the country, long-term NHS Plan, has been produced for the
to identify what has worked well and what could consideration of the Secretary of State for Health
be adopted widely. Our aim is to see an NHS where and Social Care and thereafter for publication.
staff and learners are happy and feel fulfilled in
their work, where they look forward to going to 1.3 Our key lines of enquiry
work and are proud of the care they provide to their
patients. There is good evidence that happy staff This Commission has examined the culture of
are more compassionate and provide safer care. learning for individuals, from schooldays, through
further and higher education and onto advancing
1.2 About the Commission their professional careers in the health and care
workplace. Each of these stages or transition
The Health Education England (HEE) draft Health points is captured in chapters two to five of this
and Care Workforce Strategy for England to 2027 - report. We have considered various societal
Facing the Facts, Shaping the Future 2 - announced factors, pressure points and specific challenges
a new Commission on the mental wellbeing of NHS at all stages of their educational and career
staff and learners. The Commission has been led by progression. Throughout this journey, we have
Sir Keith Pearson, former Chair of Health Education identified five key lines of enquiry which have
England, and Professor Simon Gregory, Director and influenced our approach. Our key cross-cutting
Dean of Education and Quality, Midlands and East, questions are:
as Programme Clinical Director.
NHS and higher education culture, climate,
HEE clinical fellows undertook an extensive literature context and myths
review, supported by the HEE Kent, Surrey, Sussex
Libraries and Knowledge Services team, and • What aspects of the NHS or university culture
provided invaluable clinical influence on the main might have an impact upon mental wellbeing?
chapters in this report with support from colleagues • Are individuals reluctant to make their mental ill
in and outside the organisation. health known?
• Do individuals fear that disclosure might have a
An interim report was presented to the Secretary of detrimental impact upon their success or career?
State for Health and Social Care in summer 2018, • What might help dispel myths and
and this final report builds on the literature review misconceptions about mental ill health?
and research findings of that interim report working • What can be done to support mental wellbeing
with a Commission panel of subject advisors and of all in the NHS and ensure that we identify
experts meeting during summer and autumn 2018. ongoing support and interventions, and do not
focus solely on the most acute problems
The panel heard from staff working in the NHS
whose wellbeing has been adversely affected by Isolation and lack of support
workplace experiences, and we heard from several
families bereaved by the death of a loved one who • What are the challenges for learners who move
ended their life while in the employment of the NHS. away from their home area to access education
8. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission
and training, working at a distance from family consider the appropriate terminology used in
and friends? describing the concepts of mental health and
• What support is in place for learners both wellbeing. Mental health is defined by the World
clinically and for their personal wellbeing? Health Organisation (WHO) 3 as: ‘A state of wellbeing
• Could this support be improved or delivered in which every individual realises his or her own
differently? potential, can cope with the normal stresses of life,
can work productively and fruitfully, and is able to
High expectations on learners make a contribution to her or his community.’
• Many of our learners will be high academic The positive dimension of mental health is stressed
achievers. On entering clinical training they in WHO’s definition of health as contained in its
may find the continued high expectations constitution: ‘Health is a state of complete physical,
challenging. What could better prepare learners mental and social wellbeing and not merely the
for this at all stages of the transition? absence of disease or infirmity.’
• What should be put in place to help learners
cope with the high demands of their future It is our view that the mental health of learners and
clinical career roles? staff in the NHS should be viewed as a continuum
just as there is a continuum in a person’s physical
Societal changes health. As Rethink Mental Illness state 4: ‘Mental
health is something we all have, and it’s something
• How do changes affecting the role of healthcare that changes at different times in our lives. We all
professionals over recent decades impact upon have a body and we all have a brain, so we all have
learners? physical health and mental health. Some people
• What changes in societal expectations and think of their mental health as ‘emotional health’ or
behaviours are having an impact upon the ‘wellbeing’.’ It is unfortunate that the term ‘mental
experiences of our learners? health’ may have negative connotations among
• What should we be putting in place to prepare some people, perhaps because they connect it
and support learners with respect to societal to ‘mental illness’. However, when we talk about
changes? ‘physical health’ we do not automatically think of
illness - associations tend to be much more positive.
Generational changes
Dr Stan Kutcher 5 has written about various mental
• What are the challenges that learners face in health states, saying that mental disorders can:
relation to changing perceptions and expectations ‘… exist concurrently with mental wellbeing. None
of lifestyle, careers and working life? of the domains are exclusory to the other domains
• What do we need to do differently to take at one time and a person can be in more than one
account of these changes? domain at the same time. For example, a student
• How do we best manage situations where those can have a mental disorder (such as ADHD), be
teaching and supervising these learners may be experiencing a mental health problem (such as the
from a different generation with differing views? death of a grandparent), be experiencing mental
• What impact on our learners’ experience will the distress (such as an imminent examination); and be
exponential rise in availability and capability of in a state of mental equilibrium (such as spending
technology, including social media, have? time playing a game with their friends).’
• How can we make best use of technology and
social media to improve the learner experience There are various terms used to describe states of
and support wellbeing? poor mental health. The Mental Health Foundation6
talks of people with mental health problems, people
1.4 Mental health and wellbeing terminology with experience of mental and emotional distress,
and people with a mental illness. In this report we
A report such as this gives us an opportunity to have tended to use the term ‘mental ill health’.
9. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission
Whichever term someone in society choses to use, higher education (chapters three and four) and
we are keen to see an end to any stigma around the eventually into the workplace (chapter five). It is
specific words ‘mental health’. We all have mental important how we prepare individuals for the
health as we do physical health. We strive for big changes to come in their lives
mental wellbeing.
• Diverse needs - the difficulty of making life
In this report, we have tended to use the term transitions can be exacerbated for many reasons
‘mental wellbeing’ to describe a state of being that including socio-economic background, cultural
is not only free of mental ill health but encompasses diversity or disability - these challenges need our
a broader context of social, emotional and physical particular attention
wellness. Mind 7 defines this stating: ‘Mental
wellbeing describes your mental state - how you are • Need for self-care - if a person is intolerant
feeling and how well you can cope with day-to-day of their own distress, they may not be able
life. Our mental wellbeing is dynamic. It can change to tolerate the distress of others. We need to
from moment to moment, day to day, month to support a learning and workplace culture which
month or year to year.’ The Government Office encourages compassion to oneself, where self-
for Science (2008) 8 described mental wellbeing as care is ‘normalised’
a: ‘dynamic state, in which the individual is able
to develop their potential, work productively and • Being human beings - some clinicians may
creatively, build strong and positive relationships feel a need to adopt a ‘superhero complex’ to
with others, and contribute to their community. It help deal with the pressure of their role, but we
is enhanced when an individual is able to fulfil their need to acknowledge in healthcare that being
personal and social goals and achieve a sense of a human being and high performing are not
purpose in society.’ As an employer the NHS needs mutually exclusive
to ensure that its managers and leaders are as alert
and responsive to this as they would be to physical • Caring for the carers - the Commission
wellbeing. has considered the question: ‘who cares for
the people who care for the nation?’ We
This change in focus of terminology is vital for staff, must improve the way in which we look after
learners and employers as we switch the focus from ourselves and our colleagues, so they are better
negative connotations to a culture and environment placed to look after the needs of their patients
that supports wellbeing. It should be remembered
that in our many encounters in practices, clinics, • Moral distress - the NHS attracts people of a
wards and departments we find that the majority caring nature but where institutional constraints
of NHS staff are happy, contented and fulfilled and compromise perceptions of the level of care
that staff, students and postgraduate trainees are offered, our staff can develop a sense of
going above and beyond to deliver the best care in personal guilt
often difficult circumstances.
• Bereavement by exposure - every clinician
1.5 Our key themes carries with them a lifetime experience of upset,
trauma, death and dying; professionals working
For the benefit of those reading this report, we in healthcare have very different emotional and
have picked out some key themes and discussions psychological needs to those working in other
that have emerged during the course of the sectors
Commission.
• Bereavement by suicide - has been shown
• Preparing for transitions - a constant an identifiable factor for self-harm, and suicide
theme throughout has been the importance for those who have a close connection with the
of transitions, as an individual progresses deceased. We have heard that this could well
through school (chapter two) towards further or apply to clinical and educational colleagues,
10. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commissionnot least due to the often devastating effect 1.6 Our approach
of colleague suicide and the guilt many health
professionals feel about colleagues’ death This Commission was charged with addressing
both staff and learner mental wellbeing. To do so,
• Looking after loved ones - healthcare we have divided our consideration into four key
practitioners do not work in isolation in the chapters. These are:
world - we need to consider how their wellbeing
at work is affected by and affects family and Chapter 2. Learning our lessons -
friends/colleagues, particularly in the most tragic here we briefly consider the mental wellbeing of
cases where people are bereaved by suicide young people and in particular their routes into
the NHS workforce and what the NHS needs to
• Take a break - often under pressure from understand about them and offer to them.
colleagues or the accepted workplace culture,
staff can feel pressurised to work long shifts We then subdivide learners into undergraduate
without breaks, come to work when ill students and postgraduate learners.
(presenteeism) and even skip annual leave,
particularly where staffing is under-resourced Chapter 3. Lessening student stress -
the mental wellbeing of undergraduates who
• The simple things - wellbeing at work needs are learning in the NHS is a key issue for this
to be addressed strategically across the NHS but Commission with the majority of such students
often it is the simple things in the workplace based in educational institutions but placed in
that can make a real difference: staff lockers, multiple healthcare settings.
showers, a quiet room, the availability of
nutritious food, a good coffee, a psychologically Chapter 4. Mastering mental wellbeing
safe space to get together with others to talk - postgraduate learners are both trainees and
and debrief, or just a colleague taking the time employees. This leads to significant overlap with
to say ‘thank you’ the issues for undergraduate learners, yet these
postgraduate learners are also NHS staff. We have
• Role of technology - technology has been put therefore, focused on the mental wellbeing of
forward as both the likely cause and possible postgraduate learners in the NHS as a separate
solution to some wellbeing issues - we need chapter. While this includes postgraduate medical
to consider more the role of tech gadgets and trainees about whom much is known there are
social media. many other postgraduate learners included in
this category including nurses, psychologists and
healthcare scientists.
Chapter 5. Supporting our staff -
there are 1.4 million people in the NHS workforce
across clinical and non-clinical careers ranging
from porters to engineers, from chief executives to
cleaners, all are vital to good running of the NHS and
to high quality service. The NHS employment culture
is key to supporting these staff and therefore here
we focus on mental wellbeing of the workforce.
Throughout these chapters we have found
common themes and much overlap. We have
sought to minimise duplication but we encourage
consideration of the findings and recommendations
in all chapters.
11. Health Education England - NHS Staff and Learners’ Mental Wellbeing CommissionWe have broadly categorised the 33 of non-clinical staff and 35% of postgraduate
recommendations into three groups that address trainees. While working patterns have changed
the NHS culture, the mental wellbeing of NHS staff over recent years with larger numbers of the non-
and those learning in the NHS, and the support the NHS workforce choosing not to take lunch breaks
NHS provides to them. (reportedly 35% of office workers regularly do not
take lunch breaks), the opportunity to access food,
The recommendations in this report are grouped and provision of an appropriate environment in
under the following headings but we appreciate which to eat, must be of paramount importance
that some might fall under more than one category: and the NHS should be a model employer.
• NHS culture - recommendations: Of particular concern, 40% of our postgraduate
1, 2, 12, 15, 16, 17, 18, 20, 21, 23, 27, 33 learners and one-third of clinical and non-clinical
staff did not feel able to disclose mental ill health
• Staff wellbeing - recommendations: or distress to line managers or peers. This suggests
7, 8, 13, 14, 22, 24, 25, 26, 30 an unknown level of mental distress among our
workforce that we must address. Over 45% of
• NHS support to staff and learners - clinical, non-clinical and postgraduate respondents to
recommendations: the online engagement identified that their wellbeing
3, 4, 5, 6, 9, 10, 11, 19, 28, 29, 31, 32 is best supported by their peers. In this case, we need
to ensure that we are providing appropriate resources
1.7 Online engagement to staff to enable them to support colleagues.
We say later in this report that for the most part, This online engagement has provided a new
people enter healthcare employment because they dimension of feedback from staff and those learning
want to care and heal or because they simply like in the NHS that is not currently captured through
working with people. Work is good for us and other mechanisms such as the NHS staff survey. It
the vast majority of people who come to work in gives sufficient new insights that we have agreed
the NHS every day do so because they love their with NHS Employers that they will look further at
job, they enjoy the people they work with and the results including the free text comments and to
take great pride in knowing they are there to help consider whether engagement such as this should
and support patients, carers and families. This be conducted further in the future.
was reflected in an online survey carried out for
the Commission and it was encouraging to have 1.8 Investing in wellbeing
received confirmation that some respondents
reported good, progressive and supportive At a time when the NHS is struggling to balance
workplace wellbeing initiatives. However, early the books, it would be easy to question if now is
findings from the Commission’s online engagement the time to ‘invest’ in wellbeing for staff and those
show that only 40% of our clinical staff (48% for learning in the NHS. But if we question the cost of
learners) reported that their wellbeing at work investment in wellbeing let us not overlook the cost
was good, and 76% reported having experienced of not doing so.
mental distress or ill health. For our non-clinical
workforce respondents, the figures were similar, Set out here are examples of the costs that could be
with 46% reporting good wellbeing at work reasonably reduced if the recommendations in this
and 72% having experienced mental ill health or report are given sufficient priority:
distress. Over a quarter of respondents felt that
their wellbeing was ‘not important’ to the NHS. • NHS sickness absence rates are reported to be
at least 4.5% per annum and estimated to cost
We found that 60% of our clinical staff reported £1.1 billion. The NHS Long Term Plan workforce
missing meals at work on at least a weekly basis workstream has set the ambition to reduce this
over the last six weeks, compared with 38% by 1% (to 3.5%) by 2020. If this releases savings
12. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commissionin the same proportion as current estimated 2018, which aims to tackle mental health issues
costs, then savings could exceed £120m in the workplace. The Duke of Cambridge served
as a pilot at the East Anglian Air Ambulance and
• In so far as staff retention is concerned, 350,000 worked alongside doctors and paramedics providing
people left the NHS for reasons other than age emergency medical cover in eastern England.
retirement over the past five years with leaver
rates rising from 5.7% in 2012-13 to 6.7% in This report references the importance of
2017-18. The additional cost of this deterioration promoting and supporting the wellbeing of NHS
in retention is considered to be as much as staff and those learning in NHS settings. We will
£100m per annum say that working and learning in the healthcare
sector is like no other employment environment.
• Work-life balance is reported as a factor in 13% Daily, our staff are confronted with the extremes
of NHS leavers (45,000 people over five years) of joy, sadness and despair. We repeatedly heard
that this emotional labour is often exhausting.
• If working lives were extended by a year this The Commission heard described how many of
could over time represent a supply boost of our clinical staff retain a collection of curated
between 3% and 5% (assuming average service traumatic memories of death and dying. Many
of 20-30 years with breaks) with perhaps £30 of our staff, often young staff, see the horrors of
million in avoided agency costs over five years. extreme trauma; they see the aftermath of major
road traffic accidents, suicide, and they see children
1.9 Wellbeing in distress or dying and they help families cope
with the loss of a loved one. They see the effects of
“I worked several times on very traumatic jobs deprivation and many see, what they described to
involving children. After I had my own children, I us as ‘life in the raw’. These memories, like ghosts
think the relation between the job and the personal from the past may return at unexpected times.
life was what really took me over the edge, and I The emotional labour required to manage this
started feeling things that I have never felt before … rollercoaster for NHS staff and those learning in
Talking was really important, but even that wasn’t the NHS is often taken for granted by the individual
quite enough for one particular incident for me.” and by the NHS itself, but the Commission found
that there are dangers to this which can profoundly
HRH Prince William, quoted in the media 9, speaking impact upon the wellbeing of staff and those who
at the This Can Happen conference in London, are learning in the NHS.
13. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission1.10 Recommendations
Recommendation 1:
The NHS Workforce Wellbeing Guardian
As we have reviewed the academic literature and taken evidence, it has become clear that as in many
other non-healthcare sectors there is a need for board-level leadership to be responsible for the mental
wellbeing of their staff.
The evidence for board-level leadership is in the following chapters but the role is so central to all the
recommendations in this report, in particular the culture of the NHS, that our primary recommendation
is the creation of board-level NHS Workforce Wellbeing Guardians.
Therefore, the first recommendation of the Commission is the introduction of this role in every local,
regional and national NHS organisation. We anticipate this board-level role being an existing executive
director who would be aligned with a non-executive director. The NHS Workforce Wellbeing Guardian
will seek to assure and continue to re-assure the board that their organisation is a wellbeing organisation
and a healthy workplace in which NHS staff and learners can work and thrive. The role will ensure
that sufficient information is being provided to the Board, so it can benchmark, set organisational
expectations and monitor performance in this regard. This will help provide a lens on learner and staff
mental wellbeing in each and every NHS organisation, seeking continual improvements in how those
who care for the nation’s health are indeed cared for themselves and supported in their working lives.
The ways in which the NHS Workforce Wellbeing Guardian will work would be for determination by the
individual organisation but should be within a common NHS framework, allowing for local best practice
in supporting learner and staff mental wellbeing. However, it is envisaged that at an organisational level,
the Workforce Wellbeing Guardian will be aligned with a Workplace Wellbeing Leader.
It is recommended that the NHS should establish an NHS Workforce Wellbeing Guardian in
every NHS organisation (where appropriate such as primary care this may be at a locality level)
and that the Wellbeing Guardian should be authorised to operate within the nine principles
set out on the following page:
14. Health Education England - NHS Staff and Learners’ Mental Wellbeing CommissionThe NHS Workforce Wellbeing Guardian Principles:
Principle One: The mental health Principle Five: The death by suicide
and wellbeing of NHS staff and those of any member of staff or a learner
learning in the NHS should not be working in an NHS organisation will
compromised by the work they do for be independently examined and the
the NHS. findings reported through the
Wellbeing Guardian to the board.
Principle Two: The Wellbeing Guardian
will ensure that where there is an Principle Six: The NHS will ensure
individual or team exposure to a clinical that all staff and learners have an
event that is particularly distressing, time environment that is both safe and
is made available to check the wellbeing supportive of their mental wellbeing.
impact on those NHS staff and learners.
Principle Seven: The NHS will ensure
Principle Three: The Wellbeing that the cultural and spiritual needs of
Guardian will ensure that wellbeing its staff and those learning in the NHS
‘check-in’ meetings will be provided are protected and will ensure equitable
to all new staff on appointment and and appropriate wellbeing support for
to all learners on placement in the overseas staff and learners who are
NHS as outlined in the Commission working in the NHS.
recommendations.
Principle Eight: The NHS will ensure
Principle Four: All NHS staff and those the wellbeing and make the necessary
learning in the NHS will have ready adjustments for the nine groups
access to a self-referral, proactive and protected under the Equality Act 2010.
confidential occupational health service
that promotes and protects wellbeing.
Principle Nine: The Wellbeing
Guardian, working with system
leaders and regulators, will ensure
that wellbeing is given equal weight
in organisational performance
assessment.
15. Health Education England - NHS Staff and Learners’ Mental Wellbeing CommissionRecommendation 2:
The NHS Workplace Wellbeing Leader
The ability to address staff and learner wellbeing issues that may be either, ‘critical’ at first contact, or
may ‘slowly’ be contributing to an unhealthy culture would be dependent upon hearing from staff at
their level. Such contact would need to be conducted in a manner that was supportive and did not pose
a risk to the individual(s). This requirement indicates that there must be an active ‘listening’ component
and to this end, a Workplace Wellbeing Leader is envisaged for all NHS workplaces.
It is recommended all NHS organisations appoint a Workplace Wellbeing Leader to work
with and report to the Workforce Wellbeing Guardian.
In early 2019 consideration will be given to the guidelines for both of these roles.
16. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission2. Learning our lessons
The mental wellbeing of young people
2.1 About this chapter
For the most part, our future nurses, allied
health professionals, scientists, doctors, dentists,
pharmacists and the wider healthcare workforce,
are currently doing their SATs, GCSEs and A levels
(or equivalent). We know that school age children As a society, we are very good at
begin to forge views about what kind of person helping our young people talk about
they are developing into, where their strengths mental health - we are, however, less
lay, their evolving personality and the academic good at helping them to know what
subjects they enjoy at an early stage in their school to do about it.
life. Certainly, by the age of 11 or 12 years, pupils
are narrowing down their possible broad areas of Professor Louis Appleby, lead for the
interest and how this might influence their choice of National Suicide Prevention Strategy
subjects to be taken at a later stage. for England, personal communication
The modern NHS is one which recruits for values
and trains for skills, and therefore, we need to be
playing our part in ensuring that pupils, schools
and parents have access to the most up-to-date
information about the NHS, careers in the NHS
and where entry routes into healthcare can offer
a variety of alternatives. It is timely that Health
Education England has recently launched a new
online guide to health service careers -
www.healthcareers.nhs.uk/FindYourCareer It is easier to build strong children,
than to repair broken men.
As the NHS is likely to be the largest employer in
many communities, we have a legitimate concern Frederick Douglass, 1817-95,
for the education and mental wellbeing of young an African-American statesman
people, many of whom will soon be advancing
their learning or stepping into the NHS workplace.
The starting point for considering the future
mental wellbeing of our health service staff and
those learning in the NHS is therefore, not in our
universities or hospitals but it is with school pupils in
their classrooms and in their homes. It is here that
the next generation of healthcare professionals will
have spent their formative years, gaining academic,
personal and life skills. It is also here that the effect
of life’s expectations starts and where its first
impact upon their mental wellbeing can be found.
17. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission18. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission
2.2 Key Questions less severe problems that interfere with their
development and learning
In this report section we are seeking to answer • One in 25 children are affected by anxiety and
four key questions relating to the mental wellbeing depression
of secondary school-age pupils who may be • Suicide is one of the three most common causes
considering entry routes into a future career in the of death in young people - and is rising. Suicide
NHS: is the biggest killer of young people aged 20 to
34 years
1. What are the risk factors (personal, family, social, • Adolescent self-harm and eating disorders are
societal and educational) for mental ill health in a growing problem
adolescents? • Approximately 25% to 35% of young people
2. What early factors associated with planning requiring mental health or wellbeing support
for a future career in healthcare may affect an are not accessing services, and
individual’s mental wellbeing? • 60% to 70% of children do not receive
3. How can we best support the transition of appropriate interventions at a sufficiently early
future healthcare professionals from school or age.
college to apprenticeships, further education,
higher education and beyond? These issues do not seem to be confined to the
4. What can we learn from the evidence base that UK, an important factor as the NHS has a multi-
enables schools and colleges to better support national workforce. Bodies such as WHO are
pupils, improving the mental wellbeing of increasing global awareness of the unacceptably
adolescents planning for careers in the NHS? high incidence of youth mental health problems,
although there is still much work to be done.14
2.3 Mental wellbeing of young people
Adolescence is a period of transition that poses a
Mental wellbeing is integral to human health and risk to mental wellbeing. Growing up involves often
happiness. The positive consequences of improving unpredictable emotional and physical transitions
children and young people’s mental wellbeing that are stressful for all young people.15
are numerous, but encompass better cognitive
development and learning, physical and mental Even routine and predictable processes such as
health, and social and economic prospects in progressing through school and college years can
adulthood.10 prove challenging.16 Adolescence brings hormonal
shifts that result in emotional, intellectual and
Young people with better mental wellbeing recover physical changes - these changes can influence
more quickly from illness, are less likely to engage and challenge the senses of self, identity and
in behaviours which may put their health at risk relationships.
and appear to cope better with stressful events.11
Conversely, young people with mental ill health are 2.4 Support in schools and colleges
at increased risk in later life of issues including poor
educational attainment, anti-social behaviour, and As well as striving to support their pupils’ and
drug and alcohol misuse.12 students’ wellbeing, career decisions and transition
to employment or further study, schools and
In the UK research literature, we have found that:13 colleges are embarked on a major series of changes
to the courses and qualifications that they offer.
• Half of lifetime mental ill health starts by the Some are already well underway, such as the
age of 14 years reform of GCE A Levels, bringing back two-year
• One in 10 children and young people have a programmes, with final written examinations as
mental health disorder and/or emotional and the norm, rather than the modular structure, with
behaviour problems significant coursework and an intermediate AS
• One in seven children and young people have Level, that was introduced in 2000-01. A radically
19. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commissionnew approach to technical, professional and young people’s mental health is still to be fully
vocational education is also beginning, following a understood and is rapidly changing. There is a
major review led by Lord Sainsbury and embodied generation-defining change in its availability, use
in the Government’s Skills Plan. This will introduce and acceptance. There is also a perceived dichotomy
technical study programmes - now called T Levels, between its negative impact and the potential for
that are equivalent to, but different from A Levels support and engagement. However, the NHS needs
and from general vocational programmes such to recognise that the workforce entering higher
as BTEC. The first three T Levels will be available education today has not known a world without the
from September 2020, in digital, construction, and internet and social media and should recognise that
education and childcare, with the remainder from it is an important part of the lives of the current and
2023, and all will have a substantial mandatory future workforce.
work placement.
2.6 Numeracy and literacy
This creates an opportunity for the NHS to become
more proactively and systematically involved A consideration that is emerging for pupils
with schools and colleges and to open up the considering health careers is their education in, and
enormous range of opportunities that the NHS attainment of, literacy and numeracy skills. Figures
offers for students undecided about their future show that in the adult population nine million
career intentions. The Government’s new Careers people in England struggle with basic quantitative
Strategy specifically calls for employers to: “Provide reasoning or have difficulty with simple written
encounters that inspire people and give them the information.18
opportunity to learn about what work is like and
what it takes to be successful in the workforce,” There are illuminating reports regarding the
and the NHS is well-placed to be a prime mover in numeracy of some newly qualified health service
doing so. staff. NHS staff surveys reveal that more than half
of the health and social care workforce experience
2.5 Risk factors for mental ill health workplace stress, some even consider resigning
from their work, due to their difficulties coping with
There are many risk factors which appear to be the expected level of numeracy. The lack of learning
associated with mental ill health in adolescence. of these core skills at school has a direct impact
The WHO and Calouste Gulbenkian Foundation upon people’s subsequent self-confidence at work,
(2014) have identified these as including factors their ability to work safely and efficiently in their
such as parenting, household (including income, roles, and on career progression. Poor numeracy
housing and employment), community and deters people from applying to, and accessing,
neighbourhood safety, availability of education some careers in healthcare, and is associated with
and health services, and national factors such as high levels of rejection at interview for a number
poverty reduction, inequality and discrimination.17 of healthcare jobs. These factors all affect personal
mental wellbeing.19 Recommendations have been
The lasting effects of adverse childhood experiences made through ‘Skills for Health’ reports that the
affect the current and future NHS workforce health sector should connect with those creating
not only through the interactions they have with short and long-term national policy and undertake
patients who may have suffered these events, but action to improve skills in basic English and maths.20
also a proportion of staff who may have themselves
been directly affected in childhood. While the It is essential that all learners and staff have the
psychological scars and suffering of childhood numeracy and literacy skills required to both learn
may enable healthcare professionals to be more and to deliver safe care. There is much good work
empathic with their patients, they may also increase in this field including that by National Numeracy
the risk of compassion fatigue and burnout. and other education institutions to support NHS
staff and learners to have the necessary functional
The relationship between social media and skills to do the job asked of them.
20. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commission2.7 Planning for a future career in healthcare not best suited. Equally there are some schools
that have never had a pupil attend medical school.
2.7.1 Access to careers advice The impact on the social capital of that community
cannot be overlooked. HEE can already observe a
A career in the NHS encompasses huge trend of future healthcare professionals who seek to
variety and numerous possibilities. There are live and learn locally and when qualified to deploy
approximately 350 different health roles in the those skills into the communities they are proud to
NHS including management, leadership, finance call home.
and administration, professional services and
many more. Knowing what these are and the The careers landscape - and types of opportunities
types of pupils that may be best suited for each - within the NHS is constantly evolving. By 2027
of these roles can be confusing for school career it is estimated that approximately 45,000 nursing
professionals let alone their pupils. Often with a associates will be in post in the NHS - 17,000 of
lack of dedicated careers staff, schools rely on the whom are expected to up-skill to become registered
sometimes-patchy careers knowledge of teachers.21 nurses. The defining of a meaningful career path is
The NHS locally, regionally and nationally should thought to have triggered a rise in the number of
be doing much more with schools and colleges people applying to become healthcare assistants
to better explain the routes of entry that will where a career escalator to becoming a registered
ultimately lead to jobs and careers in the NHS. In nurse is now more apparent. Applications and
the Commission’s online engagement, (see section recruitment to medical associate professions,
1.6) only 5% of undergraduate respondents had such as surgical care practitioners and physician
accessed careers advice through their school or associates, are similarly likely to increase across
college service, and only 7% had accessed the NHS the NHS if we invest more in career profiling at all
Health Careers website.22 The majority (62%) had phases of transition. The increasing demand for
undertaken internet-based searches themselves to more flexible careers is set to influence how NHS
find the guidance they required, with 20% sourcing career paths develop, with the prospect of more
advice from family members and friends already clinical professionals choosing a portfolio career in
working in the NHS. Similar responses were given future.
in relation to accessing work placements prior to
commencement of training in NHS careers, with It is important that school pupils and college
only 7% accessing placements through school students get accurate careers guidance, both to
or college, and 15% sourcing work experience inform important life decisions, and to reduce the
opportunities through family and friends already risk of later career disillusionment and career goal
working within the NHS. discrepancy, which may be a risk for later mental
ill health. Potential NHS career applicants need to
The Commission feels there needs to be awareness be made aware of the benefits and the challenges
and honesty about the personal attributes that are of working in the NHS. Personalised advice in
required not only for entry to clinical professional secondary schools and colleges is essential and can
roles but also to sustain and thrive throughout be supported by resources available online such as
future careers, and that some, despite academic Health Careers and Step into the NHS.23
prowess, are simply not suited to careers in
healthcare or to the career of their choosing. Some Several NHS trusts have evolved work-based
have the grades but not the necessary attitudes and education teams delivering a range of interactive
some have the required values and behaviours but career session to pupils and students in years nine,
have not yet demonstrated academic capability. We ten and 11, colleges and sixth form. These sessions
need to ensure that careers guidance encourages delivered in NHS hospitals - often on weekends
an honest conversation about careers and routes - provide taster tours, bespoke tours and specific
into those careers which may not always be from A tours for those considering specific careers (for
levels to higher education, and that some, however example nursing or medicine). East Lancashire
much they seek a career in healthcare, may remain Hospitals NHS Trust is an exemplar, working across
21. Health Education England - NHS Staff and Learners’ Mental Wellbeing Commissionagencies including the Department for Work and in the workforce,” and the NHS is well-placed
Pensions, the Prince’s Trust, Step Into Health and to be a prime mover in doing so. NHS work
local schools and colleges. experience must be for all pupils - not just those
with ‘connections’, this is also key to widening
In December 2017 the Government published its participation in health careers.
careers strategy 24 to build a world class careers
system. A key aim is that all young people in There is increasing evidence of learners wishing to
secondary school receive a stable, structured live, learn and develop careers locally which the NHS
programme of advice and guidance delivered by should embrace. This is good for patients, good for
individuals with the right skills and experience. We communities and good for the NHS staff who serve
believe that every school, college and academy those communities.
providing secondary education should improve
their careers provision using the Gatsby Charitable 2.7.3 Applying for places
Foundation’s Benchmarks which define an excellent
careers programme. Good careers guidance Many young people applying to study in further
should motivate young people and protect their and higher educational environments may find
mental wellbeing by giving them a clearer idea of the process stressful due to the competitive
the routes to jobs and careers that they will find nature of the application process, the often high
engaging and rewarding. academic demands, and the perceived ‘high stakes’.
While these factors are not limited to healthcare
One benchmark is that every pupil should have careers, the entry requirements for undergraduate
the opportunity for a personal guidance interview. programmes leading to NHS employment can be
But to what extent are pupils considering careers some of the most demanding. ‘A streamers’ (high-
in the NHS currently getting appropriate advice achievers) who are used to being top of the class
and benefiting from revamped careers guidance? may find it difficult to adjust to a new scenario
Currently schools are struggling to meet the Gatsby in which they are excelled by their peers. For the
Benchmarks. One in five schools are not achieving first time these students may perceive themselves
any benchmarks and on average schools are only to be ‘failing’ - a point highlighted in this report’s
meeting 1.87 (out of eight) of the benchmarks. foreword.
The current NHS careers offer is not sufficient for
the needs of today’s school pupils. Schools and If we consider pupils applying to medical school as
their pupils need proactive engagement with ready a case study the dedication required to pursue a
access to work experience and experience of work career in the NHS becomes apparent. UK applicants
in the NHS. to medical school must almost universally achieve
academic excellence from GCSE level upwards.
2.7.2 Work experience Standard entry requirements to study medicine at
university are three ‘A’ grades at A level. Dentistry
NHS ‘place-based’ systems and employers (for similarly requires three ‘A’ grades. Applicants will
example, sustainability and transformation be expected to have succeeded in some subjects
partnerships (STPs), integrated care systems for which they may not have a natural aptitude.
(ICSs), clinical commissioning groups, primary Medicine is one of only a few undergraduate
care networks, GP federations/super-practices courses, along with law and mathematics that
and provider trusts) working with schools, colleges, mandates an aptitude test as part of the application
further and higher education institutions need to process. All of this can be a source of anxiety and
co-ordinate support to deliver local NHS careers distress.
advice sessions. This must include, as
recommended by the Government’s careers Additionally, medical school applicants are expected
strategy: “…encounters that inspire people and to be polymaths with a broad range of skills and
give them the opportunity to learn about what hobbies and often voluntary activity, but the
work is like and what it takes to be successful pressure of work at university can gradually squeeze
22. Health Education England - NHS Staff and Learners’ Mental Wellbeing CommissionYou can also read
