A study from the Royal College of Emergency Medicine and University of Bath, led by clinical psychologist Dr Jo Daniels in collaboration with colleagues at UWE Bristol and the University of Bristol, argues that hospitals need better leadership to help change cultures and support people’s basic needs.

In addition to reflections from current frontline doctors, nurses and advanced clinical practitioners, the research features exclusive interviews with former doctors who left the profession to become comedians. Adam Kay, Harry Hill and Phil Hammond all offer reflections on why they left, and how they hope the NHS can be better managed in the future to avoid others from doing likewise.

In February last year, a report by the Institute for Policy Research at the University of Bath concluded that as many as one in seven healthcare workers were actively trying to leave the NHS. According to the Royal College of Nursing, almost 27,000 people left the register in the past year, with more than half leaving earlier than planned citing burnout, workload, and concerns over care quality.

The new study, funded by UKRI and published in the Emergency Medicine Journal, investigated perceived barriers to implementing better working practices and conditions for emergency medicine clinicians in the UK.

Building on previous work from the team looking at the toll of Covid on healthcare workers, the study highlights multiple issues associated with poor retention. These include a culture of blame and negativity in hospitals, untenable working environments, compromised leadership, and a perceived general lack of support leading to burnout and low morale.

Basic needs unmet

Across the board, participants reported feeling undervalued owing to their basic demands going unmet. These ranged from ‘sharing toilets with patients’, to poorly functioning IT systems, or the absence of rest spaces and staff rooms. A lack of private space within hospitals meant many also found it hard to decompress.

In an accompanying video to the research, comedian and former doctor Adam Kay describes a toxic culture where it was a ‘a badge of honour to work as hard as possible’, where staff felt blamed, disempowered to seek support as they should be ‘unbreakable’, and where expectations set were unrealistic.

Several participants highlighted a lack of formal training for consultants in charge of busy wards, while the need for more ‘visible, compassionate leadership’ was also cited. Reflections from people interviewed suggested leadership training should be embedded as part of medical training.

Phil Hammond suggested: “We need to say to doctors, one really interesting career pathway for you is to get involved in NHS management and clinical leadership. And not in a way that says ‘we have gone over to the dark side.’”

And when considering how staff continue to work in such difficult conditions for so many years, Harry Hill emphasised the ‘force for good’ that has traditionally motivated NHS staff. Yet he suggested, after repeated reorganisations and a lack of support, this was wearing thin. “When I was a doctor, doctors . . . were held in some esteem by society,” he said. “That’s gone to a large extent.”

Leadership training

Dr Daniels observed: “A common thread that emerged across our interviews was the critical importance of leadership in hospitals. Those in leadership positions are powerful agents of change and have pivotal influence over team functioning, staff wellbeing and patient outcomes. However, lines of accountability and communication with executive management need to be clarified, opened up and improved.

“A new focus on leadership training and ongoing support for those in leadership roles will be critical to this. Given its central importance and the scope for leadership improving wellbeing at work, we have a prime opportunity now to address the problems that force staff to leave the workforce. Harnessing the potential in our leaders is where our focus should now lie.”

Dr Adrian Boyle, president of the Royal College of Emergency Medicine, said the research findings reinforce that the NHS must get better at caring for its workforce. “This research will now be shared with policymakers and will form part of the College’s advocacy work to help inform and bring about the cultural shift that is so needed in our A&Es,” he added.

The research team plan to work with healthcare professional bodies to help improve training and policies.

Dr Daniels explained: “We have outlined specific steps that can be taken by NHS trusts, but we need to start with recognition of how important this role is, and how vital it is that those in leadership positions are supported to lead. Without strong leadership, we can expect poor outcomes for all.”

The recommendations in the paper and the associated Royal College of Emergency Medicine ‘PiPP Key Recommendations’ publication form the basis of a new parliamentary briefing, ‘Acute Insight Series: The impact of staff burnout and how to improve retention which call the government to action’.

The study, ‘Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: A qualitative study’, is published in the Emergency Medicine Journal.