Rosalind Raine

Background: Moral injuries (MIs) may result from individuals being exposed to potentially morally injurious events (PMIEs). PMIEs have been a feature of work within much of the National Health Service (NHS) for many years, and the understanding of MI is now more commonplace, having been highlighted during the COVID-19 pandemic; however, understanding of how such events affect workers over the long term is lacking. Objective: To understand the development of healthcare workers’ (HCWs) experiences of PMIEs over a period of 3 years. Design and participants: We carried out follow-up semistructured qualitative interviews with 15 NHS staff who were previously interviewed on the same topic in 2021. All interviews were recorded, transcribed and analysed using reflexive thematic analysis following an inductive approach. Results: Three main themes and six subthemes were identified: (1) internal context and subjective experiences, (1.i) control in a rigid system, (1.ii) psychosocial dynamics, (2) external context and the moral cost of culture, (2.i) organisational culture, (2.ii) sources of MI, (3) responses to PMIEs, (3.i) maladaptive responses, (3.ii) adaptive responses. Key issues identified included perceptions of insufficient control over their work and work environment, low psychological safety and perceived misunderstanding of the value of their work from patients and colleagues, leading to a challenging organisational culture. We found that in the 3 years between the interviews many staff reported developing ‘secondary’ feelings of betrayal as a result of perceived ongoing governmental neglect of recognition for HCWs’ sacrifices during the pandemic and a lack of acknowledgement of governmental mistakes made in the acute period. Conclusion: Findings show an interplay between individual and organisational factors that HCWs faced while working in the NHS, underlining the need for wide-ranging intervention strategies. Since the HCWs’ original interviews in 2021, a secondary betrayal has developed, emphasising the need for interventions that can restore trust in the system.

Objective: To provide descriptive analysis of observational data on breast screening uptake and coverage in North East London with a focus on health inequalities. Setting: Areas in North East London with amongst the lowest breast screening uptake, coverage and breast cancer survival in England. Methods: We investigated screening uptake and coverage for 163 general practices (GPs) served by the NHS Central & East London Breast Screening Service retrieved from Public Health England's Fingertips resource. The 10 highest and 10 lowest GPs by uptake and by coverage were identified. We summarised pre-treatment T-stage (tumour size) over time and by age group. Results: Overall, uptake and coverage were lowest in City & Hackney, Newham and Tower Hamlets, with uptake of 7–26%, 13–26% and 24–28% respectively. GPs with the highest uptake and coverage rates tended to be in Waltham Forest (uptake 56–65%). The maximum uptake observed in 2022 was 72%, above the national uptake target of 70%, for one practice. For women receiving a breast cancer diagnosis, the proportion of larger-sized tumours seemed to increase during the 2020–2021 Covid-19 pandemic period (implying later diagnoses), eventually returning to pre-pandemic levels. Smaller tumours were identified at the screening ages 50–70 (<20% T3/T4, implying earlier diagnoses) compared to younger (∼25% T3/T4) and older (∼30% T3/T4) women. Conclusions: Breast screening uptake varied between areas and GPs. City & Hackney, Tower Hamlets and Newham were identified as areas with low screening uptake and coverage.

Background: The COVID-19 pandemic raised concerns about the mental health of an already burdened healthcare workforce. This study examined mental health trajectories among healthcare workers (HCWs) across the pandemic and identified personal and employment factors associated with different symptom patterns. Methods: Longitudinal data were drawn from the NHS CHECK cohort, including clinical and non-clinical staff from 18 NHS Trusts in England (April 2020–April 2023). Growth curve and growth mixture models identified latent classes of HCWs characterized by distinct trajectories of probable common mental disorders. Secondary outcomes included anxiety, depression, alcohol misuse, and post-traumatic stress symptoms. Logistic regression examined associations between baseline personal and employment characteristics and class membership. Results: The analytical sample included 22,764 participants. For each outcome, growth mixture models identified two latent classes. Approximately 31% of HCWs experienced persistently high symptoms of probable common mental disorders, while 69% experienced persistently low symptoms. Similar patterns were observed for secondary outcomes, with small subgroups demonstrating worsening symptoms followed by improvement. Logistic regression analyses showed that being female, younger, single, working as a nurse, or having a pre-existing mental health diagnosis increased the odds of belonging to a high symptom class. Perceived support from colleagues and managers was protective. Conclusions: While many HCWs reported consistently low mental health symptom levels, almost a third belonged to a latent class characterized by persistently high symptoms across all time points. These findings underscore the need for mental health support for vulnerable HCW groups, embedded within routine NHS practice rather than limited to crisis periods.

Background: Long COVID (LC) occurs when COVID-19 symptoms continue for 12 + weeks after the onset of infection. LC may have several impacts, including sickness absence. This study explored number of days off work due to COVID-19 infection among healthcare workers (HCWs) and predictors of long-term sickness absence (i.e., 4 + consecutive weeks off work). Methods: Data were from the NHS CHECK survey and included 4,721 HCWs (19.6% of the cohort) who reported COVID-19-related symptoms and sickness absence at two follow-up periods, approximately 12 and 32 months post-baseline (baseline collected between April 2020 and January 2021). We conducted descriptive analysis to explore COVID-19-related sickness absence at both timepoints and to examine differences depending on whether HCWs self-reported symptoms consistent with LC or an LC diagnosis. We used multi-level logistic regression modelling to explore baseline predictors for reporting long-term sickness absence at follow-up among HCWs who reported LC symptoms. Results: At 12 months, 89.5% of HCWs attributed sickness absence to a COVID-19 infection, while 84.6% reported the same at 32 months. Median self-reported days off work at both timepoints were higher among HCWs who self-reported LC symptoms (12mo = 14 days (IQR = 10–30), 32mo = 7 days (IQR = 4–14)) compared with HCWs who did not (12mo = 9.5 days (IQR = 3.5–14), 32mo = 5 days (IQR = 2–7)). A similar finding was observed for HCWs who reported a formal diagnosis of LC compared with those who did not. There was a noticeable reduction in COVID-19-related sickness absence between our 12 and 32 month follow-up surveys across all groups. Among HCWs who self-reported LC symptoms, predictors for reporting long-term sickness absence at both timepoints included having a pre-existing respiratory illness and being aged 41–50 years. Conclusions: We found that reporting LC symptoms or having an LC diagnosis were associated with greater sickness absence among HCWs. The cause of the reduction in reported sickness absence between the timepoints is unclear, though it is most likely due to natural recovery from COVID-19, greater support available to staff with LC or the withdrawal of a special COVID-19 sickness absence payment in 2022. The need to support workers with LC to return and remain in work is still present.

The COVID-19 pandemic accelerated the adoption of remote consultations across health care, requiring rapid adjustments in service delivery. Consequently, there is an urgent need to understand the impact of remote consultations on health pathways. This viewpoint paper explores key challenges in data sources in England that hinder research on the impact of remote consultations on health outcomes. Based on our experience conducting research on this topic, we present variations in observational study findings and their validity, considering differences in population characteristics and data sources. We provide recommendations to enhance data quality for future research, including improvements in data recording platforms and strengthened structures for linking primary and secondary care electronic health records.

Objective The COVID-19 pandemic prompted a significant increase in the use of remote consultations—by telephone or video—in both primary and secondary healthcare. The reported advantages of remote consulting for both patients and clinicians include greater efficiency, flexibility and convenience. However, disadvantages, such as the uncertainty created by a loss of face-to-face contact, have also been highlighted. The aim of this study was to explore, explain and interpret patients’ and clinicians’ perceptions and experiences of remote consultations and assist decision-making about their future use. Design A qualitative study based on semistructured online interviews. Setting Primary mental healthcare or secondary care cardiology services, London, UK, February–March 2022. Participants Primary care mental health patients (n=5), primary care clinicians (general practitioners) (n=15), secondary care cardiology patients (n=9) and secondary care cardiology clinicians (n=5). Results The results demonstrate that a range of factors have influenced the experiences of both clinicians and patients and indicate shifts in the norms of professional practice and clinician–patient relationships. Conclusions Patients and clinicians demonstrated pragmatic acceptance of remote consultations and, looking forward, a preference for a balanced ‘hybrid model’ of remote and face-to-face appointments. The study also highlights a need to consolidate and build on the informal learning and adaptation to remote consulting that has already taken place.

Objectives This study aims to determine key workforce variables (demographic, health and occupational) that predicted National Health Service (NHS) staff’s absence due to illness and expressed intention to leave their current profession. Design, setting and participants Staff from 18 NHS Trusts were surveyed between April 2020 and January 2021, and again approximately 12 months later. Outcome measures Logistic and linear regression were used to explore relationships between baseline exposures and four 12-month outcomes: absence due to COVID-19, absence due to non-COVID-19 illness, actively seeking employment outside current profession and regularly thinking about leaving current profession. Results 22 555 participants (out of a possible 152 286 employees; 15%) completed the baseline questionnaire. 10 831 participants completed the short follow-up questionnaire at 12 months and 5868 also completed the long questionnaire; these participants were included in the analyses of sickness absence and intention to leave, respectively. 20% of participants took 5+ days of work absence for non-COVID-19 sickness in the 12 months between baseline and 12-month questionnaire; 14% took 5+ days of COVID-19-related sickness absence. At 12 months, 20% agreed or strongly agreed they were actively seeking employment outside their current profession; 24% thought about leaving their profession at least several times per week. Sickness absence (COVID-19 and non-COVID-19 related) and intention to leave the profession (actively seeking another role and thinking about leaving) were all more common among NHS staff who were younger, in a COVID-19 risk group, had a probable mental health disorder, and who did not feel supported by colleagues and managers. Conclusions Several factors affected both workforce retention and sickness absence. Of particular interest are the impact of colleague and manager support because they are modifiable. The NHS workforce is likely to benefit from training managers to speak with and support staff, especially those experiencing mental health difficulties. Further, staff should be given sufficient opportunities to form and foster social connections. Selection bias may have affected the presented results.

Objectives: During the COVID-19 pandemic, NHS staff support services aimed to support healthcare workers’ (HCWs) wellbeing, alongside informal support from colleagues and managers. However, bullying, harassment, and discrimination against HCWs from ethnic minority and migrant groups, along with low wellbeing support uptake, suggest disparities in workplace support. This study aimed to address the following research questions: 1) How does support programme use vary by ethnicity and migration status? 2) How does the perception of support from managers and colleagues vary by ethnicity and migration status? Methods: This study analysed NHS CHECK survey data which examined the mental health and occupational outcomes (including support use) of HCWs during the COVID-19 pandemic across 18 Trusts in England. Data from 9,769 participants who completed the baseline survey (launched April 2020) and the six-month follow-up was analysed using descriptive statistics and binary logistic regression. Results: HCWs from White Other (AOR 0.79; CI 0.64-0.99) and Asian ethnic groups (AOR 0.65; CI 0.57-0.74) were less likely to feel supported by their colleagues than White British HCWs. Similarly, those born outside of the UK and EU were less likely to feel supported by their colleagues than UK-born HCWs (AOR 0.70; CI 0.52-0.94). No variations in support programme use or support from managers were found across ethnicity or migration status. Conclusions: The study suggests equitable formal support but identified critical disparities in perceived collegial support for HCWs during the COVID-19 pandemic. Improving workplace wellbeing should address the underlying social and structural factors that influence peer support and belonging. What is already known on this topic – Healthcare workers (HCWs) in the UK from ethnic minority and migrant groups are more likely than White British HCWs to experience abuse and discrimination from other staff. Therefore, they may be less likely to use workplace support, and feel less supported by their colleagues or manager. However, this has not been examined. What this study adds – The study indicates that formal support mechanisms for HCWs during the COVID-19 pandemic were generally equitable. However, it highlights significant disparities in perceived collegial support, with HCWs from some ethnic minority groups and HCWs born outside of the UK reporting lower levels of peer support compared to White British HCWs. How this study might affect research, practice or policy – These findings suggest that while structured support systems may be in place, the day-to-day experiences of workplace camaraderie and informal support vary considerably, underscoring the need for targeted interventions to foster a more inclusive and supportive work environment.

Objectives The objectives of this study were to examine post COVID-19 syndrome (PCS) among healthcare workers (HCWs) in England and explore risk factors for the condition. Methods Data were collected by National Health Service (NHS) CHECK, a longitudinal study exploring HCWs’ mental and physical well-being during and after the COVID-19 pandemic. NHS CHECK collected data at four timepoints: the baseline survey between April 2020 and January 2021, and then three follow-up surveys at approximately 6, 12 and 32 months post baseline. PCS data were collected at 12 and 32 months, while risk factor data were from baseline. HCWs were asked what COVID-19 symptoms they experienced and for how long and were classified as having PCS if they had any symptom for ≥12 weeks. Multilevel regressions were used to examine risk factors for PCS. Results This study included 5248 HCWs. While 33.6% (n=1730) reported prolonged COVID-19 symptoms consistent with PCS, only 7.4% (n=385) reported a formal diagnosis of PCS. Fatigue, difficult concentrating, insomnia and anxiety or depression were the most common PCS symptoms. Baseline risk factors for reporting PCS included screening for common mental disorders, direct contact with COVID-19 patients, pre-existing respiratory illnesses, female sex and older age. Conclusions While a third of HCWs reported prolonged COVID-19 symptoms consistent with PCS, a smaller percentage reported a formal diagnosis of the condition. We replicate findings that direct contact with COVID-19 patients, older age, female sex, pre-existing respiratory illness and symptoms of common mental disorders are associated with increased risk of PCS.

Introduction: With the growing use of remote appointments within the National Health Service, there is a need to understand potential barriers of access to care for some patients. In this observational study we examined missed appointments rates, comparing remote and face-to-face appointments among different patient groups. Methods: We analysed adult outpatient appointments at Imperial College Healthcare NHS Trust in Northwest London in 2021. Rates of missed appointments per patient were compared between remote vs. face-to-face appointments using negative binomial regression models. Models were stratified by appointment type (first or a follow-up). Results: There were 874,659 outpatient appointments for 189,882 patients, 29.5% of whom missed at least one appointment. Missed rates were 12.5% for remote first appointments and 9.2% for face-to-face first appointment. Remote and face-to-face follow-up appointments were missed at similar rates (10.4% and 10.7%, respectively). For remote and face-to-face appointments, younger patients, residents of more deprived areas, and patients of Black, Mixed, and ‘other’ ethnicities missed more appointments. Male patients missed more face-to-face appointments, particularly at younger ages, but gender differences were minimal for remote appointments. Patients with long-term conditions (LTCs) missed more first appointments, whether face-to-face or remote. In follow-up appointments, patients with LTCs missed more face-to-face appointments but fewer remote appointments. Discussion: Remote face-to-face appointments were missed more often than face-to-face first appointments, follow-ups appointments had similar attendance rates for both modalities. Sociodemographic differences in outpatient appointment attendance were largely similar between face-to-face and remote appointments, indicating no widening of inequalities in attendance due to appointment modality.