Rapid responses are electronic comments to the editor. They enable our users
to debate issues raised in articles published on bmj.com. A rapid response
is first posted online. If you need the URL (web address) of an individual
response, simply click on the response headline and copy the URL from the
browser window. A proportion of responses will, after editing, be published
online and in the print journal as letters, which are indexed in PubMed.
Rapid responses are not indexed in PubMed and they are not journal articles.
The BMJ reserves the right to remove responses which are being
wilfully misrepresented as published articles or when it is brought to our
attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not
including references and author details. We will no longer post responses
that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor,
Dr Salisbury’s concerns around the imposition of QOF activities focusing on staff wellbeing can and should be generalized across the entire medical field. Recent surveys have shown that 78% of junior doctors have felt unwell as a result of workplace stress, and 39% have reported experiencing burnout, with issues of pay, understaffing, inability to take breaks, and a lack of access to rest facilities all being cited as prominent factors [1]. Recognition of the problem has grown in recent years, and many employers and deaneries have taken it upon themselves to provide wellbeing programs of one kind or another. However, whilst research into the effect of these programs is rather sparse, there are many anecdotal reports of how they are received in practice: Twitter abounds with stories of trainees being told to reframe their struggles with unsustainable workloads as a matter of personal resilience rather than organizational dysfunction, whilst others speak of the irony of mandatory wellbeing sessions which run through any possible lunchbreak. The unfortunate reality, it seems, is that wellbeing is already being weaponized – and, perhaps, cannot help but be weaponized.
Whilst generally benign in intention, workplace wellbeing programs are often ineffective or counterproductive in practice. Employee uptake is often low, especially when time and work pressures are prominent or when the needs of the employees are misaligned to what is provided; likewise, when trust in the organization and its motivations becomes eroded, employee resistance is greater – and under these conditions there is a significant risk that overinvesting in wellbeing programs may further erode organizational confidence [2].
Even when these factors are taken into account their impact is often questionable: the relationship between the type and number of interventions deployed and their effectiveness is inconsistent [3], the evidence for mental health promotion in the workplace is weak [4] , and one recent study found no evidence that workplace health and wellbeing programs help to prevent psychological distress, or provide a buffer against the effect of psychosocial hazards in the workplace [5].
Systemic problems require systemic solutions; if difficulties emerge as a result of systemic factors it is rarely appropriate to locate the solution to these difficulties in the individual. Where wellbeing initiatives focus on changing the individual rather than the organization, this can mask systemic problems and hinder change in the longer term [6]. Nor is it effective – as Cotton and Hart found twenty years ago, across many sectors of employment organizational context has a greater impact on morale and stress than individual coping strategies [7]. To their credit, NICE’s 2022 guidance on metal health in the workplace recognizes this and advises against using individual-level approaches as a replacement for organizational strategies [8] – though given the way in which much of the rest of the guidance reifies the location of the difficulties and their solutions in the individual, this is a point which could be easily overlooked.
The inclusion of the wellbeing QOF thus begs a question: for whose benefit? Uncharitably, it could be seen as little more than a public relations exercise on behalf of NHS England; a common criticism of QOF is that it prioritizes a focus on what can be easily measured over what actually matters, and the wellbeing framework could be said to particularly suffer from this. Ultimately, no amount of mindfulness is able to change the material realities of working in the NHS. In many cases the time, effort, and money invested in wellbeing initiatives would be better spent in any number of better places – with pay restoration perhaps being chief among them.
References
1. Hicks R. 4 Out of 5 Junior Doctors Say Their Health Wellbeing Has Worsened in Past Year. Medscape UK 2023 Feb 06. https://www.medscape.co.uk/viewarticle/4-out-5-junior-doctors-say-their-...
2. Spence GB. Workplace wellbeing programs: If you build it they may NOT come...because it’s not what they really need! International Journal of Wellbeing 2015, 5(2), 109-124. https://doi.org/10.5502/ijw.v5i2.7
3. Ryan JC, Williams G, Wiggins BW, et al. Exploring the active ingredients of workplace physical and psychological wellbeing programs: a systematic review. Translational Behavioral Medicine 2021, 11(5), 1127-1141. https://doi.org/10.1093/tbm/ibab003
4. Carmichael F, Fenton S-J, Pinilla Roncancio M, Sadhra S, Sing M. Workplace wellbeing programmes and their impact on employees and their employing organisations: A scoping review of the evidence base. University of Birmingham, 2016. http://epapers.bham.ac.uk/2103/1/bbs_dp_2016_04_carmichael.pdf
5. Daniels K, Fida R, Stepanek M, Gendronneau C. Do Multicomponent Workplace Health and Wellbeing Programs Predict Changes in Health and Wellbeing? International Journal of Environmental Research and Public Health 2021, 18(17) 8964. https://doi.org/10.3390/ijerph18178964
6. Kinman G, Teoh K. What could make a difference to the mental health of UK doctors? A review of the research evidence. Society of Occupational Medicine, 2018. https://www.som.org.uk/sites/som.org.uk/files/What_could_make_a_differen...
7. Cotton C, Hart PM. Occupational wellbeing and performance: a review of organisational health research. Australian Psychologist 2003, 38(2) 118-127. https://doi.org/10.1080/00050060310001707117
8. NICE. Mental wellbeing at work (NG212). 2022 Mar 02. https://www.nice.org.uk/guidance/ng212
Dear Editor,
Succinctly put. What is happening in our society when this kind of thing is rolled out? Just when the system should be paying more and making the job easier to attract GPs into the current mess to try and make it less of a mess, derisory pay offers are made and more nonsense arrives. It’s bizarre and must represent toxic configuration and dysfunctional organisational culture at the top.
Expect yet more retirements and lateral moves into niche areas. The latter protect doctors from the impossible onslaught of demand.
The days of the effective committed GP doing the crucial core role that patients need and expect must be numbered.
Why would you anyone do thus; huge clinical risk, declining pay and falling numbers.
Re: Helen Salisbury: Wellbeing shouldn’t be weaponised
Dear Editor,
Dr Salisbury’s concerns around the imposition of QOF activities focusing on staff wellbeing can and should be generalized across the entire medical field. Recent surveys have shown that 78% of junior doctors have felt unwell as a result of workplace stress, and 39% have reported experiencing burnout, with issues of pay, understaffing, inability to take breaks, and a lack of access to rest facilities all being cited as prominent factors [1]. Recognition of the problem has grown in recent years, and many employers and deaneries have taken it upon themselves to provide wellbeing programs of one kind or another. However, whilst research into the effect of these programs is rather sparse, there are many anecdotal reports of how they are received in practice: Twitter abounds with stories of trainees being told to reframe their struggles with unsustainable workloads as a matter of personal resilience rather than organizational dysfunction, whilst others speak of the irony of mandatory wellbeing sessions which run through any possible lunchbreak. The unfortunate reality, it seems, is that wellbeing is already being weaponized – and, perhaps, cannot help but be weaponized.
Whilst generally benign in intention, workplace wellbeing programs are often ineffective or counterproductive in practice. Employee uptake is often low, especially when time and work pressures are prominent or when the needs of the employees are misaligned to what is provided; likewise, when trust in the organization and its motivations becomes eroded, employee resistance is greater – and under these conditions there is a significant risk that overinvesting in wellbeing programs may further erode organizational confidence [2].
Even when these factors are taken into account their impact is often questionable: the relationship between the type and number of interventions deployed and their effectiveness is inconsistent [3], the evidence for mental health promotion in the workplace is weak [4] , and one recent study found no evidence that workplace health and wellbeing programs help to prevent psychological distress, or provide a buffer against the effect of psychosocial hazards in the workplace [5].
Systemic problems require systemic solutions; if difficulties emerge as a result of systemic factors it is rarely appropriate to locate the solution to these difficulties in the individual. Where wellbeing initiatives focus on changing the individual rather than the organization, this can mask systemic problems and hinder change in the longer term [6]. Nor is it effective – as Cotton and Hart found twenty years ago, across many sectors of employment organizational context has a greater impact on morale and stress than individual coping strategies [7]. To their credit, NICE’s 2022 guidance on metal health in the workplace recognizes this and advises against using individual-level approaches as a replacement for organizational strategies [8] – though given the way in which much of the rest of the guidance reifies the location of the difficulties and their solutions in the individual, this is a point which could be easily overlooked.
The inclusion of the wellbeing QOF thus begs a question: for whose benefit? Uncharitably, it could be seen as little more than a public relations exercise on behalf of NHS England; a common criticism of QOF is that it prioritizes a focus on what can be easily measured over what actually matters, and the wellbeing framework could be said to particularly suffer from this. Ultimately, no amount of mindfulness is able to change the material realities of working in the NHS. In many cases the time, effort, and money invested in wellbeing initiatives would be better spent in any number of better places – with pay restoration perhaps being chief among them.
References
1. Hicks R. 4 Out of 5 Junior Doctors Say Their Health Wellbeing Has Worsened in Past Year. Medscape UK 2023 Feb 06. https://www.medscape.co.uk/viewarticle/4-out-5-junior-doctors-say-their-...
2. Spence GB. Workplace wellbeing programs: If you build it they may NOT come...because it’s not what they really need! International Journal of Wellbeing 2015, 5(2), 109-124. https://doi.org/10.5502/ijw.v5i2.7
3. Ryan JC, Williams G, Wiggins BW, et al. Exploring the active ingredients of workplace physical and psychological wellbeing programs: a systematic review. Translational Behavioral Medicine 2021, 11(5), 1127-1141. https://doi.org/10.1093/tbm/ibab003
4. Carmichael F, Fenton S-J, Pinilla Roncancio M, Sadhra S, Sing M. Workplace wellbeing programmes and their impact on employees and their employing organisations: A scoping review of the evidence base. University of Birmingham, 2016. http://epapers.bham.ac.uk/2103/1/bbs_dp_2016_04_carmichael.pdf
5. Daniels K, Fida R, Stepanek M, Gendronneau C. Do Multicomponent Workplace Health and Wellbeing Programs Predict Changes in Health and Wellbeing? International Journal of Environmental Research and Public Health 2021, 18(17) 8964. https://doi.org/10.3390/ijerph18178964
6. Kinman G, Teoh K. What could make a difference to the mental health of UK doctors? A review of the research evidence. Society of Occupational Medicine, 2018. https://www.som.org.uk/sites/som.org.uk/files/What_could_make_a_differen...
7. Cotton C, Hart PM. Occupational wellbeing and performance: a review of organisational health research. Australian Psychologist 2003, 38(2) 118-127. https://doi.org/10.1080/00050060310001707117
8. NICE. Mental wellbeing at work (NG212). 2022 Mar 02. https://www.nice.org.uk/guidance/ng212
Competing interests: No competing interests