show increased reluctance to undertake specialty training, deciding to take career breaks or leave the profession completely (Figure 1.1). This established problem is so significant and widespread that it must be considered to genuinely threaten the future sustainability of modern healthcare. Resilience implies an ability to ‘bounce back’, to regain our well‐being after a distorting experience. The data suggests we are not bouncing back as well as perhaps we once did. This is impacting patient care and providing immeasurable harm to healthcare providers.
‘First, do no harm’
For UK healthcare professions, the past decade is bookended by two events. First, a private citizen’s Freedom of Information request in 2012 led to the publication of an internal review by the General Medical Council (GMC) which revealed that, during the 2005–2013 period, 28 doctors had committed suicide whilst undergoing the GMC’s fitness‐to‐practice (FTP) investigations (Horsfall, 2014). Casey and Choong argued that these deaths were preventable and the GMC has a duty of care towards doctors under investigation (Casey and Choong, 2016) (Box 1.1).
Practitioner suicide and distress is not unique to the UK, nor is it confined to doctors (Hofmann, 2018). Nonetheless, these healthcare professionals likely entered training with the same aspirations and hopes as their peers. In their deaths, they left behind people who loved and needed them. A healthcare culture which seemingly leaves people viewing suicide as their only alternative should concern us all – as John Dunne said, ‘Any man's death diminishes me, because I am involved in Mankind’.
Second, the initial phase in the UK of the Covid‐19 pandemic was characterised by shortages of personal protective equipment (PPE), with the result that staff felt they were being required either to place themselves at risk without adequate protection, or to decline to care for patients and risk disciplinary action. This impression of a lack of concern for healthcare staff reached its apotheosis when a prominent UK politician suggested that shortages of PPE were occurring due to wasteful usage by healthcare staff (see Chapter 6). Subsequently, reports emerged of higher‐risk staff feeling unable to request the PPE to which they were entitled.
Figure 1.1 Change in reason for leaving given by staff (for voluntary resignations), 2011–2012 to 2018–2019 (Index at 2011/2012 = 100).
Source: The Health Foundation (2019). © 2019, The Health Foundation.
On a more mundane level, healthcare staff report day‐to‐day shortages in their work in terms of access to food, rest breaks and adequate on‐call facilities, such that these provisions are not in step with employment law (GMC, 2019). Even a cursory look at Maslow’s triangle (Chapter 3) suggests that meeting a practitioner’s basic psychological and physical needs is required to safeguard and provide support for the high‐level problem‐solving necessary in clinical decision‐making; it is unlikely that depriving people of food, drink and adequate rest improves patient safety. When we consider clinical resilience, it is important that we do not impose on practitioners yet another burden of fearing failure. Rather, it is about enabling clinicians to optimise their cognitive performance, be the best they can be and recover the joy of practice. In this, organisations have a particular responsibility (Chapter 8). With resilience, our recurring theme is kindness. Kind health systems and organisations will more greatly facilitate the potential of their teams and the safety of patients.
Box 1.1 Suicide whilst under GMC's fitness to practise investigation: were those deaths preventable?
In their review of suicides whilst under the GMC’s FTP procedures, Casey and Choong argued that the GMC has a duty of care towards its members and that these suicides were preventable. Coroners were also identified as having a duty to report these suicides as preventable to the GMC. However, Casey and Choong could not identify that these deaths had been reported in line with established legislation. They also commented: ‘The high prevalence of suicide among physicians in general should not obscure the fact that suicide whilst under the GMC's FTP investigations is sufficiently unique and deserves special attention. It is thereby a matter of profound regret that it had to take a random FOI request by an independent party to eventually highlight just how serious and extensive the problem is. That FTP investigation has never, prior to that, been isolated and identified as a distinct risk factor for physician suicide meant that practically nothing has been done to avert such deaths’.
Source: Based on Casey and Choong (2016).
Increasing patient expectations, complaints and litigation
Zuzsanna Jakab (WHO) emphasises that peoples’ expectations of healthcare have changed, and that they wish for greater involvement in their healthcare, including in making decisions about treatment (Jakab, 2011). However, many health inequalities still exist and indicate a need for patient empowerment. Patients may not have the material, educational or political means to access health, now considered a basic human right.
Increasing patient expectations has led to an increasing number of complaints and litigation. In UK Primary Care, patients’ written complaints about care increased by 4058 (4.5%) – from 90579 in 2016–2017 to 94637 (NHS Digital. Data on written complaints in the NHS, 2017–2018). In terms of impact on all parties, this is not sustainable. Where practitioners are unable to cope with understandable negative feelings of shock, burnout and anger following a complaint, there is a risk of post‐traumatic stress disorder (PTSD), leading to their being described as a ‘second victim’ of the event (Chapter 4).
Maintaining resilience is challenging where a practitioner works in an organisation in which they feel undervalued and which appears to favour a culture of punishment rather than one of learning. Bourne found that complaints not only seriously impact doctors’ psychological well‐being but are also associated with defensive practice (Bourne et al., 2016). This has a detrimental effect on patient care. Resolution of complaints and significant event analysis is essential for patient safety and service improvement. However, investigation procedures require transparency and timeliness to actually facilitate patient safety and practitioner resilience. A more resilient approach by practitioners to receiving complaints and their role in learning may then be possible to ensure better patient care.
Why now?
In the twenty‐first century, healthcare workers face multiple local and global challenges to their resilience. In our initial chapters, we explore the emotional impact of working in healthcare (Chapter 2). Healthcare has both challenges and rewards. These are considerable, and we are all familiar with the feeling of seeing a life saved, a goal achieved, perhaps soon followed by the despair of a tragic outcome or setback. Every interaction involves the care of – and communication with – a fellow human with needs and vulnerabilities. The fact that professionals sometimes struggle is predictable and understandable. Often, we begin practicing these skills required for these experiences at a time in our lives when we are still maturing and adapting to the emotional landscape of adulthood. Learning to
