Are we supporting or sacrificing NHS staff?

For our fifth quarterly monitoring report in a row, staff morale tops the list of NHS foundation trust finance directors’ concerns, and understandably so. With financial pressures at unmanageable levels, increasing demands and great uncertainty, staff are exposed to the violence of a perfect and continuous storm.

As long ago as 1997, research showed that 26.8 per cent of NHS staff were suffering damaging levels of stress, compared with 17.8 per cent of the general population. Evidence suggests that little has changed in the intervening 18 years, and health professionals (nurses in particular) have consistently reported the highest rates of work-related stress, depression or anxiety for the past three years. In the last NHS Staff Survey, 39 per cent of NHS staff reported that during the past 12 months they had felt unwell as a result of work-related stress. 65 per cent of staff reported that they had attended work in the previous three months despite not feeling well enough (physically or mentally) to perform their duties. However, only 43 per cent said that their organisation took positive action on health and wellbeing.

We are creating conditions in which the health, wellbeing and quality of life of those who have committed their working lives to the NHS are being profoundly damaged. And stress can kill people.

How should NHS leaders respond? One way is to implement health and wellbeing strategies to help staff take more responsibility for their health (for example, by promoting the ‘five ways to mental wellbeing’). And there are lots of very good health and wellbeing strategies across the NHS. But, to some extent, this is treating the symptoms, not cause – preparing staff to be more resilient in order to send them back into the trenches. And there is a danger that leaders could use a health and wellbeing strategy as a sticking plaster, instead of addressing the underlying and pervasive structural and cultural causes of low staff morale.

We know that stress is a result of a toxic cocktail of high work demands coupled with low levels of control and support. We must address all three elements.

First is the need to reduce work demands. A recent study showed that long shifts are associated with poor patient care and higher levels of errors and it is key to address the culture of long working hours that often characterises NHS organisations.

At a national or regional level, reducing work demands requires there to be sufficient resources in local systems of care to run services effectively and credible workforce strategies which provide a pipeline of staff qualified to work in the areas of care where demand is rising. And it requires we reduce demands by developing credible strategies for preventive health care. This starts in the early years of our lives and needs collaboration between all sectors of health, and education and housing too. At a service level, reducing work demands also involves challenging activities that do not add value to delivering high-quality care for patients.

Second, control. NHS staff are more highly motivated, skilled and experienced than staff in virtually any other industry. Command and control cultures in such a context are unnecessary; the number of levels of hierarchy in NHS organisations is far too high; and we must give frontline staff the autonomy and control to provide care (within safe boundaries) in the way they know is most effective. In effect, we must create shared leadership in teams and cultures of collective leadership.

Third, staff must have support to do their jobs effectively. This includes developing effective team- and inter-teamworking in health care because effective teamworking (where teams have clear objectives, work closely together and meet regularly to review their performance) is associated with better-quality care, staff wellbeing and innovation in improving patient care.

The role of leaders is to create the conditions that enable staff to do what it is they chose to commit their working lives to – offering high-quality, continually improving and compassionate care. And there needs to be the necessary resources, staff and time for the work to be conducted effectively.

Leaders must model compassion in their dealings with staff: paying attention, appraising the situation, having an empathic response and taking intelligent action to support them. Our surveys of culture in the NHS suggest that leaders are not always seen as being compassionate towards staff. Indeed, a shocking 24 per cent of NHS staff report being bullied by colleagues and managers compared with around 16 per cent in some of the worst-offending industries outside health care. This in turn affects how compassionate staff are in relations with patients and service users.

There are good examples across the NHS of organisations that are safeguarding the health, wellbeing and morale of staff. For example, at our forthcoming conference on encouraging staff wellbeing in health and care, we’ll be hearing about the work Northumbria Healthcare NHS Foundation Trust are doing in this area. It may not be easy, particularly in a period of rising demand and diminishing resource, but it is possible for organisations to create environments in which staff are supported rather than damaged. A service focused on delivering high-quality compassionate care must not be damaging to those who deliver that care in the process.

This blog was co-authored by Donna Willis, Programme Director, Collective Leadership.

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#545036 Susan Rayment
retired teacher
Mother of a Junior Doctor

Please make this article very widely available. Junior doctors already work incredibly long hours which leads to exhaustion and low morale. Being asked to do even more for less money only adds to stress.

#545042 Liza Walter-Nelson
director, chartered psychologist
Phare Practice

Health and well-being programmes need to tackle the issues at a primary, secondary and tertiary level so that there is alignment between people, processes and culture. Programs also need to include a range of approaches as one size does not fit all (I.e. An EAP is not the answer to all well-being concerns, it's just one tool). If you give staff the opportunity to define the health and well-being approach in their org is more likely to work and orgs world be surprised at how creative staff can be in order to make the best use of resources.

#545056 Donna Willis
Programme Director, Collective Leadership
The King's Fund

Liza - thanks for writing a comment. I think you make a great point by suggesting staff should be involved with defining the approach. It is, after all, their health and their wellbeing. We meet and are regularly inspired by highly creative NHS and social care staff and harnessing this is vital.

#545057 Donna Willis
Programme Director, Collective Leadership
The King's Fund

Thanks for your comment Susan. There are a number of studies demonstrating a relationship between long hours and staff perceptions of not having given the best care they are capable of. Looking after our staff is essential for good care.

#545076 Prof.Minesh Khashu
Consultant & Prof.of Perinatal Health

A big cultural and paradigm shift is required but in the current climate of adhockery it is unlikely that we shall see a robust and sustained effort for a meaningful change.

#545091 Umesh Prabhu
Medical Director
Wrightington Wigan and Leigh FT

Well written Blog Mike then knowing your passion for staff well-being I am not at all surprised. NHS needs leaders who are kind, caring, compassionate but also with courage. Courage to say 'enough is enough' when it is right that too when senior leaders, managers and clinicians behaviour puts patient safety and staff well-being at risk.

In Wrightington, Wigan and Leigh Trust we have adopted following Mantras which has made us a very successful organisation. Of course, I am not claiming we are perfect but we have reduced harm to patients by 85% since 2008 and staff feedback has improved from being bottom 20% to top second in the country.

Here are our 5 Mantras;

1. Patients at the heart of everything we do
2. Happy staff - happy patients
3. Duty of candour not simply with patients and their families but also with staff
4. Robust governance and accountability for all including leaders and managers for their values and behaviours.
5. Staff and patient engagement in everything we do.

Since we defined our values, culture and appointed values based leaders; we have 50% of our medical leaders who are BMEs and 20% who are women. They were all appointed for their values and not for ethnicity or gender!

Unless NHS gets values, culture, leadership, governance and staff and patient engagement right; patients, staff and NHS will continue to suffer.

NHS needs leaders who are kind, caring, compassionate but also with courage and they are value based leaders who are role models for staff and inspire and motivate staff to do their best for their patients.

#545096 John Miller
nhs consultant and observer

Fantastic insights by colleagues above. However the NHS system over past 20 years has meant most medics seek a quiet life where one does not demonstrate moral courage or attempt to live up to one`s professional ethics. The BMA had to even publish a pamphlet for military doctors to remind them of their obligations under the Geneva Convention in 2009! Bizarre but understandable given the corruption of the military medical command by politicised agency control in previous 10 years.
I would suggest all civilian colleagues need a similar copy too when working for the State in the NHS.
Perhaps if you wait it out the excess unthinking managerialism pendulum will swing towards patient centredness again. However that would require trust of the profession at a political level and clearly that does not exist anymore.
Thanks for article. I don't feel so alone.

#545100 John Bamford
Patient Safety Campaigner
Private Individual

Very good arrticle. As always the challenge is actually doing something.

#545122 Matthew Mezey
Engagement Specialist
Only speaking in a personal capacity...

Hi Michael and Donna,

Thanks for your inspiring and insightful blog post!

Here are some suggestions for changes that could help with the transformation you’re talking about – help remedy ‘low levels of control’ etc - and not get caught up in the usual morass of ‘sticking plaster’ solutions and superficial espoused strategies. (I try to keep in mind the crucial point made my Helen Bevan and other NHS change agents: we need to move from one-off ‘change strategies’ towards creating ongoing ‘change platforms’ that distribute power and enable bottom-up action!).

My suggestions:

**Make Everyday Meetings Engaging and Creative**
The recent 452-page report ‘Evaluating the evidence on employee engagement and its potential benefits to NHS staff: a narrative synthesis of the literature’ unfortunately didn’t cover the topic of the quality of meetings inside the NHS. Surely a crucial determinant of engagement? How often are meetings actually engaging? Creative?
We could encourage the use of quick assessments like this Inclusion and Engagement Quotient survey: - so that leaders (and others) can become more aware of whether they are running meetings in a creative and involving manner or not. To make our meetings more energising and involving we can make use of engaging approaches, large and small, such as ‘Liberating Structures’: These tools have been used in healthcare:; interested people can join a users’ group, such as the one in London.

**Using New Self-organised Structures Would Make the Current Pseudo-empowerment Efforts Redundant**
Truly distributed power – rather than occasional token empowerment from above – will only come via novel organisational structures; rather different to what we’re used to. For example the successful Buurtzorg model of community social care in the Netherlands. It has 10,000 nurses, no managers – and almost no bureaucracy! (Only 50 admin staff). It is a wonderfully rewarding workplace for its nurses – and effective for its clients. The RCN is backing the model: and there is the possibility of Buurtzorg-inspired pilots in Scotland and at Guy’s and St.Thomas’ Hospital.

It’s estimated that half of Dutch hospital care could be done more effectively and cheaply using Buurtzorg ‘s hierarchy-free model.

You can read Frederic Laloux’s inspiring book of case studies of ‘Next Stage’ (non-hierarchical) organisations here:

**Deliberately recruit Inspiring/collaborative Leaders to the NHS**
It’s possible to use a quick psychometric to distinguish between command-and-control leaders who tend to use unilateral power and more collaborative leaders (who naturally take a more mutual approach). This assessment could be used to help guide final choices in choosing new leaders. (Such approaches have made an impressive difference when used by Borough /County Council Chief Executives). See for example page 70-71 of this leadership report:

Though if one is serious about recruiting mutual-orientated leaders, we need to create workplaces that support such styles – not squeeze such leaders out.

**Help the Friends and Family Tests to Lead to Ongoing Improvements in the NHS – Not Just to Amass Ever More Quantitative Data**
- Add a question to specifically ask NHS staff what improvement the workplace most needs on the newer NHS staff version of the Friends and Family Test surveys.

- Do a one-off survey of the public/patient Friends and Family Test improvement processes around the country to uncover whether the key elements needed for a full improvement process are in place or not. (Many surveys currently don’t even include the key element of asking for improvement ideas!).
I spoke in favour of this at the recent NHS Citizen’s Jury in Stoke!.

Hope something in here may be of interest!

Matthew Mezey

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