By Mohraeel Obeid, Dr Nicky Eddison, and Dr Ros Leslie

Mental health and well-being are concepts which have become increasingly familiar in recent years, especially following the COVID-19 pandemic. Leading to the World Health Organisation (WHO) focusing on ‘strengthening our response’ by ‘increasing the effectiveness of leadership and governance…to improve mental health both nationally and internationally’1. WHO defines mental health as a ‘state of mental well-being that enables people to cope with the stresses of life, realise their abilities, learn well and work well, and contribute to their community’2. The definition implies that compromised mental health would negatively impact our ‘normal’ day-to-day living and our self-development. From a healthcare perspective, the statistics released by the Mental Health Services Monthly Statistics publication3 indicate the size of the mental health challenge in the UK. 1.61 million individuals had utilised mental health services by the end of June 2022. The National Health Service (NHS) employs 1.4 million staff. Reports suggest that approximately £1,794 to £2,174 is spent on each NHS employee annually for poor mental health4.

NHS Implementations
Whilst WHO has been implementing the ‘Comprehensive mental health action plan 2013–2030’5, the NHS has also responded by offering a plethora of support for its staff, setting up mental health and well-being hubs across England6. Additionally, the NHS has taken accountability for its staff by providing support in the form of extensive health and well-being programmes produced by the NHS People Plan7 and the NHS People Promise8, alongside how-to guides. Examples of the programmes provided include Well-being Guardians9, Well-being Conversations10, and the introduction of the Civility and Respect initiative11. Support has also been provided digitally in the form of apps such as Unmind12 and WorkLife Central13. It is interesting to note, that the NHS People Promise states “Well-being is our business and our priority – and if we are unwell, we are supported to get the help we need”8. Which feels like a reactive stance on mental health and well-being, something that needs to be addressed when someone becomes “unwell”. Whilst there is a range of support on offer to support the health and well-being of NHS staff, there is very little evidence of the success of these interventions when implemented at scale.
Despite the implementation of so many support services for NHS staff, mental health and well-being is still a concerning challenge. Results from the NHS Staff Survey in 202114, which included 648,594 respondents from 280 NHS organisations, evidenced these challenges in more than one category including ‘Workload and resources’, ‘Organisational action’, and ‘Burnout’. Only 23.5% of staff reported that they never or rarely have unrealistic time pressures. Only 57% of staff reported that their organisation takes positive action on health and well-being. Regarding burnout, 46.5% of staff reported feeling worn out at the end of their working day/shift, with 38% feeling emotionally exhausted and 31.4% reporting a lack of energy with family and friend engagement during leisure. A lack of social engagement can be detrimental to mental health, with data indicating a negative correlation between social engagement levels and poor mental health15.

Back to basics
According to Maslow’s hierarchy of needs16 introduced in 1943, humans require five basic needs forming the five levels of Maslow’s pyramid: (1)Physiological, (2)Safety, (3)Love, (4)Esteem, and (5)Self-actualisation. Based on this hierarchical pyramid, the lowest level of need that needs to be fulfilled before being able to advance higher up the pyramid are the physiological needs which involves having access to necessities such as food, drink, and rest.

Figure 1: Maslow’s hierarchy of needs16
Should the NHS be considering the importance of Maslow’s hierarchy to the mental health and well-being of NHS staff? The NHS people promise states, “We have clean safe spaces to rest and reflect, and access to hot food and drinks, including fresh water. These are the basics, but they really matter and can’t be underestimated”8. However, a recent survey completed by 8,573 NHS staff, explored access to breaks and food, and its effect on the ability of NHS staff to deliver patient care17. The results reveal that 53% of NHS staff who completed the survey report they are unable to take regular breaks and a further 31% reported that they had ‘nowhere’ to go to unwind during rest breaks. 78% reported a ‘lack of or poor-quality food’ that was readily available on-site, with 56% rating the food available as ‘unsatisfactory’. Comments from the NHS staff who responded to this survey include:

A personal perspective (Mohraeel Obeid)
Some of the issues raised by NHS staff resonate with me and my experience as a physiotherapy student on a previous clinical placement. My mental health and well-being were often challenged and neglected. Some of the challenges I faced included not having appropriate areas to eat my lunch. Due to limited office spaces and the need to maintain social distancing in line with COVID-19 regulations. Multiple teams sitting in an office having lunch together was no longer an option, and other hospital spaces had to be utilised, including corridors. Other options included utilising outdoor spaces in freezing temperatures. The disparities between the facilities offered to medical students were evident. Medical students were provided with a large, comfortable, designated area to take their lunch breaks. Students from other healthcare professions were not accommodated in the same way.
Being a Christian Coptic Orthodox, fasting lent for me involves breaking fast later in the day and then only eating a vegan diet which not only clashed with team lunch times, but I quickly realised that there were no suitable food options available to me. Whilst clinical educators tried to accommodate my fasting commitments, it quickly felt like an extra burden as I would often miss patient handovers or clash with patient treatment sessions, which often meant I had to wait until I got home to eat my lunch. Working daily from 8 am to 4 pm on an empty stomach with a restricted diet and a demanding post-COVID environment does not facilitate learning and does not meet the basic needs of Maslow’s hierarchy. A common consolation was the voice in my head reminding me it is only a four-week placement. But is it really the end? The realisation that this will be my life once I graduate was an ominous thought and made me contemplate my career choice and whether I could cope with such a draining daily routine. This left me feeling trapped and disheartened.

Similar student experiences have been reported whereby students experience poorer healthy food choices, fewer chances to exercise, and being away from their usual support system4. It is recommended that a well-being check-in involving a personal well-being tutor should be provided to every student in addition to the standard educator and supervisor. The aim is to provide support for all aspects of the student’s well-being, independent of their studies4.
The importance of understanding student experiences and monitoring any support systems that are put in place has been advocated for by Health Education England through the National Education and Training Survey (NETS)18. The survey is open to all undergraduate and postgraduate students, trainees, doctors, and dentists in training, undertaking a practice placement or training post in all healthcare services across England. The next survey is due to launch on 18th October 2022 and will remain open until 30th November 2022. NETS aims to gather feedback about student practice placements and training posts. Gathering information on what went well and student opinions on required improvements.
The results from the November 2021 NETS18, indicate that of the 165 allied health profession’ students who responded, 47.9% reported that the culture of the learning environment was deterring them from recommending their placement to others. 41.2% reported a negative impact on their health and well-being as a direct result of their placement. Regionally, across all healthcare professions in the Midlands, similar results were reported. 51.3% of the 938 student respondents, reported the culture of the learning environment was a deterrent, ranking in the top four reasons for students being unlikely to recommend their placement. 38.4% reported a negative impact on their health and well-being. Participating in the NETS 2022 will help to identify aspects contributing to a successful student experience and highlight where improvements are required. Every survey response helps in shaping the experiences of both current and future students and trainees.

Conclusion
Whilst there has been a significant investment by the NHS to support the mental health and well-being of its workforce, we appear to have failed to ensure, first and foremost, that we have met the basic needs of our staff and students. That being, access to suitable food, not only throughout the day but 24 hours per day for the many staff and students who work unsociable hours. Ensuring staff and students have time to drink and remain hydrated and ensuring they have adequate breaks in a comfortable environment. If the mental health and wellbeing initiatives introduced by the NHS are to succeed, we need to consider the human hierarchy of needs, ensuring first and foremost that the basic physiological requirements are met.

References

1. World Health Organisation. Mental health?: strengthening our response. Fact sheet N.220. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response. Published 2014. Accessed September 26, 2022.
2. World Health Organization. Promoting Mental Health: Concepts, Emerging Evidence, Practice: Summary Report. Geneva, World Health Organization. Retrieved.; 2004. http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf. Accessed June 13, 2022.
3. NHS Digital. Mental Health Services Monthly Statistics Performance. 01 Jun 2021 to 31 Jul 2022. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-services-monthly-statistics/performance-june-provisional-july-2022#. Published 2020. Accessed September 26, 2022.
4. Health Education England. NHS Staff and Learners ’ Mental Wellbeing Commission. Heal Educ Engl. 2019;(February):1-96. https://www.hee.nhs.uk/sites/default/files/documents/NHS %28HEE%29 – Mental Wellbeing Commission Report.pdf.
5. World Health Organization. Comprehensive Mental Health Action Plan 2013–2030. Geneva.; 2021.
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7. NHS England. We Are the NHS?: People Plan 2020/21.; 2020. https://www.england.nhs.uk/wp-content/uploads/2020/07/We-Are-The-NHS-Action-For-All-Of-Us-FINAL-March-21.pdf.
8. NHS England. NHS England. The Promise. https://www.england.nhs.uk/ournhspeople/online-version/lfaop/our-nhs-people-promise/the-promise/. Published 2020. Accessed September 26, 2022.
9. The National Health Service. Wellbeing Guardians: Guidance for Introducing the Role in Healthcare Organisations.; 2021.
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11. The National Health Service. NHS England. Civility and respect. https://www.england.nhs.uk/supporting-our-nhs-people/health-and-wellbeing-programmes/civility-and-respect/. Accessed September 26, 2022.
12. The National Health Service. NHS England. Unmind. England NHS. https://www.england.nhs.uk/supporting-our-nhs-people/support-now/wellbeing-apps/unmind/. Accessed September 26, 2022.
13. The National Health Service. NHS England. WorkLife Central. https://www.england.nhs.uk/supporting-our-nhs-people/support-now/wellbeing-apps/worklife-central/. Accessed September 26, 2022.
14. The National Health Service. Working to improve NHS staff experiences. NHS Staff Survey. 2021. https://www.nhsstaffsurveys.com/results/. Accessed September 26, 2022.
15. Luo, Ding, Bauman, Negin, Phongsavan. Social engagement pattern, health behaviors and subjective well-being of older adults: An international perspective using WHO-SAGE survey data. BMC Public Health. 2020;20(1):1-10.
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17. UNISON. ‘No breaks, no food’ culture leaving NHS staff hungry and affecting care, says UNISON. https://www.unison.org.uk/news/press-release/2022/06/no-breaks-no-food-culture-leaving-nhs-staff-hungry-and-affecting-care-says-unison/. Accessed September 26, 2022.
18. Health Education England. The National Education and Training Survey (NETS). https://www.hee.nhs.uk/our-work/quality/national-education-training-survey. Published 2021. Accessed September 29, 2022.