The need for increased productivity has become a prevailing narrative underpinning much of the NHS 10-year plan. With latest analysis from the Kings Fund highlighting that productivity remains lower than pre pandemic, challenged finances across the NHS and growing demand for services, it is unsurprising that increased productivity is seen as a necessary step to achieving the ambitions set out in the 10-Year Plan.
The foundation to improving productivity is an engaged workforce, as the latest Gallup survey of over 3.3 million employees confirms. Asking already overworked and overwhelmed clinicians to work harder, faster and longer without any additional resources is unlikely to yield increased productivity, but rather creates the opposite impact. Such a narrow focus risks undermining, disengaging and undervaluing a medical workforce already experiencing historically high levels of burnout.
The latest NHS Staff survey has found that half of doctors feel unable to make improvements happen; as a measure of engagement this is of real concern. Self-determination theory teaches us that intrinsic motivation requires agency and autonomy, an ability to drive quality improvement. A disengaged workforce lacks such motivation and accepts the status quo as inevitable.
This serves no one. The consequences of both a physical and psychological withdrawal of the workforce are well-known, leading to reduced work effort and cognitive function, a decline in empathy and communication along with early retirement. This list goes on and the impact on for NHS providers is clear: unsafe and low-quality care at a higher cost, with lower efficiency. Who wants that?
So, can we think about how we support and engage clinicians in a manner that can lead to increased productivity? What if we took the approach of supporting and engaging clinicians first to enable them to thrive and flourish instead of pushing then to be more productive and risk burnout?
We believe that such an ‘upstream’ focus on increasing the number of engaged doctors will ultimately deliver sustainably higher levels of productivity than a narrow, short term, ‘downstream’ focus on productivity data.
We propose a different approach that recognises the power of an engaged workforce. Rather than a transactional model of engagement seen as an action (engagement is something done to a workforce by seeking their views), we think of being engaged as a state of being. To be engaged is the opposite of to be burned out. Considering the three domains of burnout, we can therefore describe the opposite states, of being engaged:
- The emotional exhaustion of burnout is replaced by a state of high energy, vitality, enthusiasm and motivation
- Disconnection, cynicism and dissociation are replaced by a state of absorption and connection with meaning and values
- A low sense of efficacy is replaced by a sense of accomplishment and higher purpose
Insights can be gained when considering and mitigating, wherever possible, the 6 main drivers of burnout according to Christina Maslach:
Workload/resource mismatch.
We need to make it easier to do the right thing, focusing resources on removing unnecessary irritations and inefficiency. Examples include reducing the burden of unnecessary and repetitive mandatory training, improving the efficiency of digital systems, and the use of Artificial Intelligence for task automation and Natural Language Processing. And crucially, understanding the pivotal role administrative staff play in allowing doctors to focus on their clinical work, rather than seeing them as easy targets for cost reduction. Given that up to half of doctor’s time is spend on administrative tasks, a focus on both automation and retaining critical administrative staff is crucial in mitigating the workload/resource mismatch.
Control
Empowering clinicians whenever possible, avoiding the pernicious impact of responsibility without control. Examples include more flexible scheduling, annualised job plans, real clinical engagement in digital implementation and optimisation, with input actually shaping its design rather than tokenistic engagement, with decisions already made. And protected time in job plans to focus on service redesign, quality improvement and system working.
Reward
Truly recognising the extraordinary work of clinicians, consistently, specifically and authentically. Above and beyond financial reward, a consistent and specific, regular and authentic acknowledgement of the amazing things doctors achieve. And recognition by investing in personal and professional growth, removing bureaucratic obstacles to taking study leave.
Community
Building a sense of togetherness, finding and prioritizing space and time for clinicians to meet, share ideas and build connection, esprit de corps. The development of a peer to peer support programme for doctors facing challenging times is a good example of building a sense that we are all in this together.
Fairness
A constant commitment to compassionate leadership, psychological safety and job plans that value contributions above and beyond Direct Clinical Care, as these contributions may be fundamental to allowing clinicians to thrive. Evidence suggests that spending just 20% of our working week on the work we derive greatest meaning from is sufficient to reduce burnout. Meaningful work enhances intrinsic motivation and professional fulfilment. Doctor’s most meaningful work may be non-clinical, for example education, teaching, research, regional/national work. And yet, increasingly, job plans prioritise direct clinical care over all else.
Values
Ensuring that organisational values are the lived experience of clinicians, rather than just words painted on the walls. Are our organisational values decorative or are they truly operationalised into meaningful behaviours and actions? This clarity enables leaders to consistently role model Trust values and an openness to challenge when Board decisions are not aligned with them. And a dialogue that values and recognises the need for quality and safety as much as volume of activity. This requires high functioning senior leadership teams, where the polarity between quality and volume can be explored, understood and managed.
In addition to the above, we advocate for the development of a senior doctor role looking at leadership development / senior doctor wellbeing and engagement with a focus on clinical leadership development; capable leaders foster engaged clinicians which we have written about elsewhere. And measuring the proportion of engaged doctors in our organisations using validated tools such as the Stanford Professional Fulfilment index and tracking over time, assessing the effectiveness of the above interventions in real time and adjusting accordingly.
The kind, brave leadership that this would offer, enables us to take a detour upstream to support and engage clinicians, allowing us all to provide the safe, high quality, kind, compassionate care we aspire to. Together we can help form a new path that values and measures engagement first, safe in the knowledge that productivity will follow and so much more.
Authors
Anna Baverstock
Anna is a consultant community paediatrician looking after children and young people with complex neuro-disability and their families. She also has a leadership role as associate medical director looking at medical leadership and wellbeing. A member of civility saves lives group, a senior consultant at Doctors training and a passionate advocate of kindness in healthcare.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: Senior consultant at doctors training, speaker with civility saves lives
Paul Molyneux
Paul is a consultant neurologist and former Medical Director. He has held clinical leadership roles for over 20 years and is currently Associate Medical Director for Senior Doctor wellbeing at East Suffolk and North Essex NHS Foundation Trust. He has a deep interest in the organisational drivers of burnout and developing strategies that allow doctors to thrive in their working lives, as well as being a qualified coach.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: Consultant at doctors training