The doctor-patient relationship is another casualty of NHS backlogsBMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p934 (Published 25 April 2023) Cite this as: BMJ 2023;381:p934
UK doctors are increasingly telling us at the Medical Defence Union (MDU) that pressures on the NHS are eroding the doctor-patient relationship that is so essential for good medical care. In the face of long waiting times for appointments, tests, and elective care, patients’ frustrations are often spilling over into their interactions with healthcare professionals. It has become more common, for instance, for a doctor to spend several minutes of a consultation calming down a disappointed patient and apologising for things that are outside a clinician’s control. This situation isn’t good for patients, who then have less time to discuss their health and receive care, or for healthcare professionals, who feel demoralised and dissatisfied on behalf of their patients.
These system pressures are likely to be one factor behind the steep rise in written complaints about the NHS in England.1 Between 2020-21 and 2021-22, complaints about primary care increased by 33 950 (40%) and complaints about hospital and community health services were up by 21 607 (25%). Healthcare staff are trying their best in very challenging circumstances and, understandably, receiving a complaint can have a huge personal impact.
A survey of 843 MDU members found that 85% of GPs and 64% of consultant and hospital doctors felt their relationships with patients had become more strained over the past two or three years.2 A quarter (26%) had experienced a patient complaint or safety incident, with a fifth (21%) experiencing abuse or threats.
Managing patient expectations can help to minimise complaints. This might involve explaining that people won’t receive a call with their blood test results unless they are abnormal, for example, or that you are going to refer them to a specialist but there will be a wait to be seen and what they should do if their condition worsens. These conversations can be difficult but help to maintain trust. They do not, however, tackle the root causes of delays in the health service, or fully alleviate patients’ dissatisfaction and the increasing strain on healthcare staff.
Four in 10 respondents to our survey said they were likely to retire or leave practice in the next five years, while nearly half (48%) had reduced their hours to cope with workplace pressures.2 Testimony from staff on the ground adds to a picture in which workplace stress is forcing some doctors to step back from frontline care for the good of their health.
Former obstetrics and gynaecology registrar Sabrina Cardillo, who now works as a MDU medico-legal fellow, explained: “I might have 20 minutes with a new patient but the first five to 10 minutes can be taken up with them upset and sometimes shouting at me about the wait to be seen. Many doctors are traumatised now because of covid-19 and need support and yet a lot of the conversation about wellbeing and burnout has focused on building resilience. I think we have passed that point.”
Many doctors responding to our survey were turning to coping mechanisms, like mindfulness or breathing exercises, to help with workplace pressures. These strategies might help with symptoms, but it shouldn’t be necessary for people to turn to such techniques to deal with their workload. And they are certainly not a cure for the stress and burnout that doctors are increasingly at risk of. In the GMC's 2022 annual survey of 67 000 UK doctors, two thirds of trainee doctors said they were “always” or “often” worn out at the end of their working day, while 44% said they were regularly exhausted in the morning at the thought of another day of work.3 The GMC warned that their analysis of these findings show that 63% of trainees, and 52% of doctors who work as trainers, are at moderate or high risk of burnout.
Many professional organisations are highlighting these problems and stepping up with support. For example, the Association of Anaesthetists, the Royal College of Anaesthetists, and the Faculty of Intensive Care Medicine are running a Fight Fatigue campaign to tackle the negative effects of shift working and fatigue on the NHS workforce. The Royal Medical Benevolent Fund (RMBF) runs a confidential psychotherapy service for doctors alongside the BMA. The MDU supports these initiatives and offers members legal representation if things go wrong and advice on complaints handling.4 We can also signpost those in need to health and wellbeing resources, including our peer-to-peer support network.5
These efforts all help but it is vital that regulators, such as the General Medical Council (GMC), are compassionate and understand the realities of current practice. A key test will be the soon to be released update to the GMC’s Good Medical Practice guidance.
We need to frame workplace conditions and staff morale as key pillars in patient safety. An interim report by the Healthcare Safety Investigation Branch, published in February 2023, found that NHS staff working in urgent and emergency care were experiencing “‘significant distress”’ at not being able to help patients.6 The report emphasised the “‘strong link”’ between staff wellbeing and patient safety and recommended that staff health and wellbeing be included in the NHS patient safety strategy— a suggestion the MDU would echo. Regulators, NHS employers, and the government need to recognise and tackle the impact of a demoralised workforce on safe patient care.
NHS employers should aim for staff to get sufficient downtime, ensure they have someone to talk to, and provide support if something does go wrong. Ultimately, the government must make good on its pledge to bring down waiting lists and publish a workforce strategy this year that starts to fill the gaps in service provision that are the root cause of many complaints.
Even with these developments, it could take years to rebuild the health service and restore public confidence in the NHS. This recovery will never happen, however, if we don’t prioritise providing support to doctors and other healthcare professionals.
Competing interests: none declared.
Provenance and peer review: not commissioned, not peer reviewed.