Dr Vasumathy Sivarajasingam Assesses the Reasons Behind High Rates of Burnout in the Primary Care Workforce, and Looks at Measures to Reduce its Impact
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Burnout is defined by the World Health Organization (WHO) in the 11th Revision of the International classification of diseases (ICD-11) as a syndrome ‘resulting from chronic workplace stress that has not been successfully managed’.1,2 In the ICD-11, burnout is classified as an occupational phenomenon rather than a medical condition or mental disorder.1,2 The condition is characterised as having three dimensions:1,2
- feelings of energy depletion or exhaustion
- increased mental distance from, or feelings of negativism or cynicism related to, one’s job
- a sense of reduced professional efficacy and lack of accomplishment.
Burnout leads to a state of emotional, mental, and physical exhaustion in which an individual can no longer meet the demands placed upon them.3 The syndrome has a spectrum of symptoms including tearfulness, depersonalisation, feelings of hopelessness, depression, and anxiety.3
History of the Concept
The term ‘burnout’ was conceived in the 1970s by the American psychologist Herbert Freudenberger, who used it to describe the consequences of severe work-related stress among those working in the ‘helping’ professions.4 Since then, it has become apparent that burnout can affect anyone experiencing stress and overwork.4
In 1981, the first and most commonly used instrument, the Maslach Burnout Inventory, was developed for self-assessment of the risk of burnout.5,6 The tool assesses three aspects of the syndrome—emotional exhaustion, depersonalisation, and reduced personal accomplishment.5,6
Burnout in the Health Service
Although burnout can occur in all contexts, it is particularly prevalent among healthcare professionals (HCPs), who chose their professions to care for and support people in society and may sacrifice their wellbeing to do so.4 The medical profession is intellectually demanding and involves complex decision making, especially when dealing with challenging patients, and there is an emotional element to almost everything undertaken. In addition, HCPs often have to perform their roles with inadequate personal and organisational resources, such as skills, training, equipment, technologies, and staff,7 further increasing the risk of burnout.
This article examines the causes, symptoms, and consequences of burnout among HCPs, and provides strategies to combat the condition.
The Scale of the Problem
In March 2020, around 1.3 million people were employed by the NHS,8 and in July 2021, the number of people working in adult social care was 1.54 million.9 Combined, these account for approximately 8% of the working age population.10 The health and wellbeing of the nation depends on this workforce’s commitment; it is essential that they are able to carry out their duties safely and effectively.
Across all health systems, approximately 50% of doctors meet the criteria for burnout at any one time, with rates rising as high as 70% in younger doctors.3 This is consistent with the global picture: data gathered over the past 20 years consistently show that about one-third of doctors worldwide are experiencing burnout at any one time, regardless of their specialty,3 threatening the long-term health of the profession.11 In 2018, the General Medical Council (GMC) reported that nearly one in four UK doctors in training, and one in five trainers, feel burnt out to a very high degree as a result of their work.12
Burnout is particularly prevalent among HCPs working in primary care.11 Before the COVID-19 pandemic, the incidence of burnout and poor mental wellbeing was found to be higher among GPs than other HCPs and the general population.11,13 In a survey conducted in 2015, GPs reported that they were experiencing the highest stress levels since 1998.14 More recently, a study of a 2018 survey published in 2020 identified that one-third of the UK doctors surveyed—mostly those working in emergency medicine and general practice—were exhibiting signs of burnout.15 This situation has been compounded by the COVID-19 pandemic.16
Burnout is also a serious problem in staff working in adult social care.17 However, The King’s Fund has highlighted that data comparable to the NHS Staff Survey are not available for adult social care workers.18
Causes of Burnout
The factors that contribute to burnout are manifold, and include work-related causes (for example, lack of control over work, an overly demanding job, or a high-pressure work environment), lifestyle causes (such as, poor sleep, poor work–life balance, or a lack of supportive relationships), and sociopolitical causes (including society’s expectations of doctors, insufficient funding and pressure resulting from Government targets).3 Personality factors (for example, perfectionism, pessimism, or a need to be in control) also play an important, but perhaps overlooked, role in causing burnout.3,19 Evidence suggests that an independent relationship exists between burnout and individual factors in clinicians, such as sex and age, as well as with work-related factors such as hours and administrative burden.11
Occupational factors that contribute to burnout include a challenging work environment (for example, a chronic excessive workload, increased paperwork, long hours, poor work–life integration, and high patient demand), and insufficient control (for example, lack of skills, efficiency, and autonomy) and/or resources (such as lack of peer and managerial support, or inadequate physical resources) at work.13 Historically, excessive paperwork has been a chief stressor for GPs; in a 2015 survey of UK GPs, paperwork was cited as the fourth biggest stressor.13,14
Another key cause of burnout among medical professionals is the professional dissonance or psychological discomfort experienced while working in a system that does not align with their professional values, resulting in low professional fulfilment.11 In addition, workplace stress can originate from an environment in which healthcare staff feel personally unsupported or discriminated against.13,18 The King’s Fund has highlighted that discrimination against Black, Asian, and minority ethnic staff in the NHS is a contributory factor to burnout.18
In summary, ever-increasing responsibilities with decreasing autonomy over work in a challenging and unsupportive work environment account for the high prevalence of burnout among healthcare professionals working in primary care.11,13,18
Signs and Symptoms of Burnout
Self-screening for Burnout
Clinicians are expected to identify the signs and symptoms of burnout in their patients but, in my experience, they are not always aware of their own stress levels. It is easy to ignore the signs of burnout and persevere with routine work; indeed, some HCPs may dismiss their symptoms as they consider them stigmatising. Box 1 provides some early warning signs to help clinicians recognise that they may be approaching burnout.20
|Box 1: Seven Key Early Warning Signs of Burnout20|
Adapted from Stevens R. The vital signs in primary care—a guide for GPs seeking help and advice. London: Royal Medical Benevolent Fund, 2016. Available at: rmbf.org/wp-content/uploads/2017/01/rmbf-the-vital-signs-in-primary-care.pdf
Adapted by Stephens from Cox J, King J, Hutchinson A, McAvoy P. Understanding doctors’ performance. Abingdon, Oxon: Radcliffe Medical Press Ltd, 2005.
© 2005 from Understanding doctors’ performance by Cox J, King J, Hutchinson A, McAvoy P. Reproduced by permission of Taylor and Francis Group, LLC, a division of Informa plc.
In addition, the British Medical Association has produced a confidential online questionnaire enabling clinicians to self-screen for symptoms of burnout (bit.ly/3KP0CDN).21
The Effects of Burnout on Physical and Mental Health
Burnout has a wide range of physical and psychological effects on the individual.1–6 Common symptoms of stress are shown in Box 2.22
|Box 2: Symptoms of Stress22|
Changes in behaviour:
NHS website. Stress. www.nhs.uk/mental-health/feelings-symptoms-behaviours/feelings-and-symptoms/stress/
Contains public sector information licensed under the Open Government Licence v3.0.
Left untended, these symptoms can lead to burnout, which has long-term physical and mental health consequences such as substance misuse and addiction, depression and anxiety, and even suicide.3 They may also have a knock-on effect on the wellbeing of co-workers, family members, and close friends of an individual suffering from burnout .3
The Impact of Burnout on the NHS
The GMC report Caring for doctors, caring for patients states that ‘staff wellbeing significantly improves productivity, care quality, patient safety, patient satisfaction, financial performance and the sustainability of our health services’.12 Conversely, burnout among clinicians is a major public health issue, with harmful consequences for patients and the healthcare system.13,23
Effects on Patient Safety and Performance
GPs recognise that poor wellbeing and burnout can have a negative impact on their ability to deliver safe patient care, resulting in poorer patient safety outcomes, such as an increased risk of adverse events and near misses13,24—up to 2% of GP consultations result in patient safety incidents, and 12% of patients are subject to prescription errors.25–27
In addition to the negative relationship between healthcare worker burnout and quality of patient care,13,24 studies have confirmed a strong association between burnout and medicolegal risk. Burnout correlates with an increased risk of medical errors, poor patient outcomes, and patient dissatisfaction and complaints, affecting the overall performance of healthcare organisations.12,13,24,28
The Primary Care Workforce: Causes and Consequences of Burnout
There is a concerning workforce shortage in primary care—large numbers of HCPs are leaving or considering leaving the medical profession, in many cases because of burnout.3,13 A survey conducted by The Commonwealth Fund in 2015 found that nearly 30% of GPs in the UK intended to leave the profession within 5 years, and many others were unsure whether they would remain working in general practice in the long term.3,29 In addition, in 2019, the number of GPs taking early retirement had tripled compared with a decade earlier.30 As a result of the difficulty of retaining existing staff and recruiting new healthcare workers, many GP practices are now closing or merging.31
Workforce shortages have added to the pressure faced by GPs,31 and are compounded by the growing complexity of delivering primary care in line with increasingly stringent guidelines and policies to a demanding, ageing population who often have multiple comorbidities and polypharmacy.32 Furthermore, the COVID-19 pandemic has increased workforce pressures considerably, raising concerns about staff wellbeing, stress, and burnout.16 Time and money must be invested in tackling burnout in primary care, both to provide the high quality of care that patients deserve, and to stop the spread of the condition through the health service.
Investment and evolution: a five-year framework for GP contract reform to implement the NHS long term plan set out NHS England’s aim to recruit more than 20,000 new members of the multidisciplinary primary care team by 2023–2024 through the multimillion-pound Additional Roles Reimbursement Scheme (ARRS).33 The initiative was intended to address workforce issues by increasing the skill mix of the primary care team, potentially freeing up GP time, improving the quality of patient care, and increasing the resilience of general practice for the future. However, rather than solving the workforce shortfall, the scheme has been hampered by it; workforce shortages have hindered primary care network (PCN) development and the delivery of PCN Directed Enhanced Service specifications, and led to 40% of ARRS funding being withheld in 2020.31 A workforce plan for general practice that provides sufficient funding and training to support practices is urgently needed if ARRS roles are to be effectively integrated into primary care.31
Guidelines on Tackling Burnout in Primary Care
To mitigate the risk of burnout, the GMC issued the ABC of doctors’ core needs (see Box 3), which provides recommendations to improve the work lives of doctors and minimise workplace stress.12
|Box 3: ABC of Doctors' Core Needs12|
To ensure wellbeing and motivation at work, and to minimise workplace stress, people have three core needs, and all three must be met.
© West M, Coia D. Caring for doctors, caring for patients—how to transform UK healthcare environments to support doctors and medical students to care for patients. London: General Medical Council, 2019. Available at: www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-patients_pdf-80706341.pdf Adapted and reproduced with permission.
The King’s Fund has published a similar report focusing on nurses and midwives, The courage of compassion: supporting nurses and midwives to deliver high-quality care,34 which sets out a series of suggestions around supporting staff wellbeing (see Figure 1). The success of these hinges on compassionate leadership, which The King’s Fund defines as ‘leaders listening with fascination to those they lead, arriving at a shared (rather than imposed) understanding of the challenges they face, empathising with and caring for them, and then taking action to help or support them’.35 Ensuring that working conditions across all healthcare settings are supporting nurses and midwives in their work will require commitment from all leaders, at every level of the health service, to engage with and address the challenges facing staff.34
Scope for Additional Guidance
To understand burnout and reduce its incidence, it is vital to elicit the diverse viewpoints of the primary care team, and to engage with them in the development and implementation of preventive strategies.11 A recent systematic review and meta-analysis on the prevalence of burnout among GPs emphasised ‘the importance of considering the GP’s work context to better characterise burnout’.36 NHS England and NHS Improvement is currently carrying out research to characterise the factors associated with burnout and identify evidence-based interventions to address them.37
In a testimony on burnout in the health service delivered to the Health and Social Care Committee in 2020, Professor Michael West (Senior Visiting Fellow, The King’s Fund) stressed the need for a comprehensive strategy to tackle the risks of excessive workload: ‘A well-worked-out, thought-through strategy, based on a vision of the kind of health and care we want to be providing in 10 years’ time, is fundamental to our ability to plan for the numbers [of NHS staff] that we will need.’7 A cost-effectiveness evaluation will be essential to identify the most feasible solutions; however, the Boorman Review estimated that improving staff health and wellbeing in primary care will save up to £213,806 annually per trust, and stated that any costs incurred by implementing measures to reduce burnout will be outweighed by benefits such as reduced spending related to sickness absence, staff turnover, use of agency staff, and ill-health retirement.38
The Health and Social Care Committee’s recommendations for the next steps include:
- extension of the NHS Staff Survey to cover the social care sector28
- inclusion of an overall staff wellbeing measure in this survey to better understand staff wellbeing, enabling employers and national bodies to take action based on that understanding28
- introduction of a requirement for integrated care systems to facilitate access to wellbeing support for NHS and social care workers, and be accountable for their accessibility and uptake28
- continuation of work on the Workforce Race Equality Standard alongside the NHS People Plan to ensure equal opportunities for all staff.39
Strategies to Combat Burnout
Burnout does not simply go away on its own—recognition, prevention, and treatment of burnout in ourselves, our team members, and our successors is essential. Burnout can be prevented through a combination of organisational change and education of the individual.3,13,23 Changes made at system or practice level and at an individual level promote a healthier working environment for staff and patients, reducing the risk of burnout and improving patient safety.13
Individuals can minimise their stress levels and recharge by adopting simple measures including taking time off, going on holiday, spending time with family and friends, and taking up hobbies such as participating in a sport or learning a musical instrument.3 Time should be set aside to do something relaxing that is totally unrelated to work. Setting boundaries between work and home life and trying to leave work at work are essential.
In addition, individuals can engage in self-reflection and be vigilant for signs of burnout. Being kind to oneself, practising self-care (for example, eating a healthy diet, undertaking regular exercise, and performing good sleep hygiene), and incorporating stress-reduction strategies (such as deep breathing exercises, yoga, and meditation) into our daily routines may help to avoid burnout.40,41
Understanding our limitations and seeking help early are also key—when things go wrong or when experiencing low mood, people may resort to unhealthy coping strategies. Techniques such as building resilience, practising mindfulness, and participating in cognitive behavioural therapy, mentoring, and coaching may help individuals to respond better to stress, improving wellbeing, performance, and productivity.3
Accepting that burnout is a systemic problem, and tackling it at an organisational level, releases individuals from liability. It also recognises that anyone is susceptible to work-related stress, so those experiencing it should not be stigmatised. At an organisational level, the risk of burnout may be lessened by addressing workplace pressures, ensuring adequate resources (time, people, and funding), and increasing opportunities for team working.3
NICE Guideline 212, Mental wellbeing at work, recommends the creation of a supportive and inclusive work environment to improve mental wellbeing in the workplace, including training and support for managers.42 Similarly, in its 2022 guidance Caring for those who care: guide for the development and implementation of occupational health and safety programmes for health workers, the WHO issues a call to action for member states ‘to take the necessary steps to safeguard and protect health and care workers at all levels, through the equitable distribution of personal protective equipment, therapeutics, vaccines and other health services, effective infection prevention control and occupational safety and health measures within a safe and enabling work environment that is free from racial and all other forms of discrimination’.43
Practical measures that can be put in place at practice level to prevent burnout in the primary care team are proposed in Box 4, and sources of support and resources for tackling the problem are provided in Box 5. These approaches are effective and sustainable, and will benefit organisations as a whole. However, to be successful, they must be viewed as the responsibility of all practice staff, and not just the GP partners or managerial team.
|Box 4: Practical Tips to Prevent Primary Care Team Burnout2,41,42|
|Box 5: Resources and Sources of Support|
Burnout is universal and occurs in all work environments. Given the complexities involved in caring for patients today, combined with pressures such as the workforce shortage and the COVID-19 pandemic, burnout is inevitable among healthcare workers and, as the first point of contact, GPs experience higher rates of burnout than other HCPs.
Healthcare workers are the backbone of any functioning health system; therefore, burnout among HCPs is a major public health issue, with detrimental effects on the entire healthcare system in terms of productivity, quality of care, and patient safety. Thus, recognition, prevention, and treatment of burnout are critical at both individual and organisational levels. Interventions to reduce the risk of burnout that are effective, economical, and acceptable to HCPs must be implemented without delay to prevent the spread of burnout through the health service.
Dr Vasumathy Sivarajasingam
GP Partner, Hillview Surgery, West London