Title: Care Under Pressure: a realist review of interventions to tackle doctors’ mental ill-health and its impacts on the clinical workforce and patient care
Funder: Department of Health and Social Care

Abstract: Introduction: The NHS needs healthy, motivated doctors to provide high quality patient care but being a doctor is a challenging job. In recent years, increasing workload due to societal demand for healthcare services, combined with increasing external scrutiny, has been associated with a high prevalence of mental ill-health amongst doctors. In November 2015, the Head of Thought Leadership at the King’s Fund said stress levels among NHS staff are “astonishingly high”. Our focus on doctors working in the NHS reflects the pressing recruitment and retention issues in this profession (e.g. doctors-in-training, general practice, emergency medicine), the significant potential for sick doctors to cause harm to patients and the financial implications of doctors’ mental ill-health and loss from the profession. Changing the work environment to prevent the development of mental ill-health would be preferable to a focus on alleviating the ‘symptoms’, such as presenteeism, absenteeism and workforce retention. However, prevention strategies may be challenging and take time to implement. A multi-pronged approach of prevention, support and treatment is likely to be needed for the foreseeable future. Aim: To understand how, why and in what contexts mental health services and support interventions can be designed in order to minimise the negative impacts of providing care on doctors’ mental ill-health. Methods: We will conduct an evidence synthesis (realist review) of interventions to tackle doctors’ mental ill-health and its impacts on the clinical workforce and patient care, drawing on diverse literature sources. Throughout the process, we will engage iteratively with diverse stakeholder perspectives (e.g. doctors who have experienced mental ill-health, representatives of patients and public, other healthcare professionals, policy makers, charities) in order to produce actionable theory. This will lead to recommendations that support the tailoring, implementation, monitoring and evaluation of contextually-sensitive strategies to tackle mental ill-health and its impacts, using the principles described in a framework called the Evidence Integration Triangle. The project will summarise how, why, who and in what circumstances mental ill-health is more likely to develop; and what can remediate the situation. We anticipate that such knowledge will enable policy makers, health services decision makers, and local team leaders to modify working environments and inform the design of appropriate existing/future support for doctors suffering mental ill-health. Outputs: The project will produce a range of outputs, tailored to intended audience, including: academic publications, conference presentations and reports; more innovative outputs such comics, animations and/or information graphics; Plain English summaries and opinion pieces; and measures/indicators that can be used in existing healthcare systems to monitor and evaluate the impact of changes made as a result of our research.

Lay abstract: The National Health Service (NHS) needs healthy, motivated doctors to provide high quality care for patients. Unfortunately, being a doctor is a challenging job in a pressurised work environment, so doctors are more likely to suffer from mental ill-health than other working adults. A recent survey of doctors who were members of the Medical Protection organisation suggested that 85% had experienced mental health issues, including stress (75%), anxiety (49%), depression (32%) and suicidal feelings (13%). In November 2015, the Head of Thought Leadership at the King’s Fund said stress levels among NHS staff are “astonishingly high”. When they become ill, doctors often continue to work because they don’t want to let colleagues and patients down and/or worry about the impact on their career. Many doctors also feel the benefits of their job do not make up for the workload and risk to their health. Doctors often retire early and/or work part-time or abroad. Data suggest 61% of GPs aged 50 and older intend to quit direct patient care in the next five years and around half of junior doctors two years into practice are choosing not to progress directly on to their next stage of training. This has led to shortages of doctors in some areas. Our study uses a literature review method called ‘realist review’ to gain insights on how to reduce doctor’s mental ill-health. A realist review uses the published literature to understand and explain a given problem (in our case doctors’ mental ill-health). It can answer questions such as: How? Why? For whom? To what extent? In what circumstances? Although other literature reviews exist, they do not take sufficient account of the complexity of the problem, are not focussed on the NHS and/or are out of date. Therefore our research aims to: 1) Understand when and why doctors develop mental ill-health, and which strategies to reduce doctor’s mental ill-health are effective and in what circumstances. 2) Make practical recommendations about strategies to reduce doctors’ mental ill-health and retain them within the NHS. To do this, we have brought together a team of experts who have already collaborated successfully on other projects, and created a Stakeholder Group who can help us interpret the findings and make recommendations. The research team will search the literature and make sense of it, using a range of strategies including drawing on our knowledge of the NHS. At regular intervals in the process we will share our progress with the Stakeholder Group, which will include patient and public representatives and doctors who have suffered mental ill-health. The Stakeholder Group meetings will usually start with a progress report from the research team, followed by discussion and feedback where people can share their unique viewpoints and help us to design solutions that will work for the NHS. As well as the reports and publications that are typically produced by research projects like ours, we will also use more innovative approaches such as cartoons, animations and plain English summaries to help our work reach a wider audience.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH