The NHS crisis of caring for staff: what do we need to do?

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It is astonishing that politicians have watched the NHS staff crisis develop to this point without taking action. The reality is more than 100,000 NHS staff vacancies – that’s 1 in 11 of all NHS posts. There are very high levels of staff turnover with large numbers of nursing, midwifery and medical staff leaving every month (in secondary care, community services and general practice in particular). And there are chronically high levels of sickness absence and presenteeism. Add to this the struggle most NHS organisations now have in recruiting staff and the picture becomes clear. This is a crisis that threatens the ability of the service to deliver safe, high-quality care for the people in our communities. In any other industry, increasing staff turnover, absenteeism and difficulty recruiting would be seen as red flags, warning of fundamental toxicity in organisational cultures.

The latest NHS staff survey data reinforces this understanding. For years we have recorded high levels of stress that damage staff health, causing a range of issues including cardiovascular disease, diabetes, addictions, cancers, sleep disorders and depression. Fifty per cent more NHS staff now report debilitating levels of work stress compared to the general working population, and year after year, around 40 per cent report being unwell as a result of work stress during the previous year. This affects the delivery of care – undermining safety and quality of care and, in the acute sector, associated with higher levels of patient mortality – and contributes to higher levels of bullying, harassment and discrimination. 

After 15 years of surveying NHS staff in England, we still see very high levels of bullying and discrimination and little evidence of improvements in staff experience over recent years. Staff engagement appears to be holding up (rather than increasing dramatically) because of the intrinsic motivation and commitment of staff. But the latest survey results show only minor changes in a context where staff experience unacceptable work conditions day in day out. I talk to staff who tell me they often can't find time to use the toilet on a shift; or get a drink of water; or doctors who say they have nowhere to sleep or rest on night shifts. The experience of many staff is a toxic cocktail of unmanageable demand and little control. 

We have to significantly improve the workplace environments for NHS staff in all trusts. But how?

Humans have three core needs and it is particularly important these are met in the workplace. They are the needs for belonging, competence and autonomy. When these needs are met in the workplace, people are more intrinsically motivated and have better health and wellbeing.  

The need for competence reflects our need to be able to have a positive effect on the work environments we find ourselves in, as well as to get valued outcomes (to deliver high-quality care, for example). The need for belonging refers to the desire or need to feel and be connected to others – to care and to be cared for. Autonomy refers to having free will, choice and control in order to be consistent with our sense of our self (as a health care professional, for example). It is not about being independent of others. Psychological health requires satisfaction of all three needs; one or two are not enough.

The challenge is translating these elements into appropriate interventions in the many different contexts in which NHS staff operate. For belonging, it is about constantly nurturing cultures and climates that reinforce the sense of relatedness: having a clear, enacted and shared vision focused on the delivery of high-quality and compassionate care; aligning all efforts around that vision; creating commitment among staff by leading and managing them in a way that ensures trust, motivation and positivity and building effective team and inter-team working throughout the system. It is especially about ensuring inclusive and compassionate leadership at every level.

The need for competence is met first and foremost when workloads do not exceed the ability of staff to deliver high-quality, safe and compassionate care. It is also ensuring that staff have enabling and supportive supervisory support, focused on removing the obstacles in the workplace, rather than creating directive, controlling the culture of 'holding to account'. And it is ensuring we continue to help people grow, develop and learn so that their skills and competence are constantly improving throughout their careers. 

The need that is least met in the NHS is the need for autonomy or control (it is a quintessentially command and control culture). The challenge then is to ensure everyone feels they have voice and influence (including community groups, patients and carers) in the genuine co-design of services and management of the organisation. This means moving away from excessive hierarchy and encouraging collective leadership. And it requires ensuring that staff feel their organisations are just and fair places to work where procedures are transparent and fair (with regards to promotion, rewards and challenging assignments, for example) especially in relation to discrimination on the grounds of race, gender, disability, sexuality and so on. Simple hygiene factors also make a huge difference to the experience of control – having somewhere to get a drink or some food on a night shift, a locker to put clothes in (that locks) and being able to travel to work relatively easily (and park if required).

In short, the workforce implementation plan is more likely to succeed by focusing on the underlying and basic needs of staff and aspiring to make the NHS the very best place to work.

Comments

Toby Weston

Comment date
19 February 2020

I couldn’t agree more with Michael Rock’s comment. Staff are voting with their feet. We have allowed systems to be changed without considering the unintended consequences. Doctors who are not thriving due to systems imposed on them are themselves blamed for not thriving. They can’t move. They can’t become a fellow. They have no option so they leave. The working culture is be grateful and don’t make a fuss…. Get rid of national selection. Make CESR and CCT truly equal. Get rid of box ticking ARCP by consultants who don’t know a thing about you. Let doctors transfer deanery. It’s not rocket surgery

Stephen Woodman

Position
Journalist,
Organisation
Freelance
Comment date
19 February 2020

Deanery transfer rules are way too strict and need changing. It promotes bullying because the trainer can’t get rid of the trainee and the trainee can’t really move away from a bad work situation. So many problems with it and so many doctors impacted and now we’re seeing the results. Combined with inflexible national selection and strict person specification rules, it’s a perfect storm. Basic autonomy is taken away and the attitude is take it or leave it. Well, the numbers suggest a lot of doctors are choosing to leave it

Michael Rock

Position
Junior surgeon,
Organisation
NHS
Comment date
07 February 2020

For doctors (I know we are only one subset of the workers in the NHS) there are lots of quick wins which could improve autonomy and belonging overnight. For example:

1) Make clinical fellows able to become consultants just like doctors in a training programme - immediately removing a two tier system that promotes bullying and overnight belonging and autonomy would go up.

2) Remove the Soviet-style "treat you as a number" national selection pathways and prison-like deanery transfer rules - overnight allowing doctors autonomy over their lives.

Morale would go up straight away with just the flick of a pen from someone with the authority to make these changes!

Réka B

Position
Service manager -NHS,
Organisation
Guy's Hospital
Comment date
18 November 2019

They say when you have suicidal thoughts the best is to open up to someone but what happens when you do and being mocked and humiliated for it? What happens when you already work for the NHS and those who let you down are NHS professionals? Does it really worth telling people what you're going through?
I had a paracetamol overdose at work but instead of receiving support from managers, I was mocked and humiliated. They referred to my overdose as "alleged" and failed to report the incident on the the Trust's database, claiming later it was for my benefit. I received no compession or sympathy, even though I had zero day of sick leave prior to this event and for months they harvested off my unpaid overtime. The sad part, NHS organisations should lead on mental health support but many fail and it's not necessarily due to funding but lack of care.

Ann Marie Harrison

Position
Psychologist,
Organisation
Occupational Health NHS
Comment date
05 October 2019

I am a Psychologist who has worked with a leading Occupational Health service for a large UK Mental Health Trust (coming to an end shortly). I have probably dealt with over 300 hundred referrals from this trust including Admin, Nurses, psychologists, psychiatrists, support workers and the list goes on. sticking my neck out, I have many concerns about this and would appreciate a private conversation with someone who cares about staff.

Dave

Position
Senior Mental Health Practitioner,
Organisation
NHS
Comment date
22 June 2019

I'm not sure use of the word 'subordinates' is helpful. Seems a good demonstration of the attitude coming down from the top.

Isla

Position
Student,
Organisation
Private School
Comment date
30 May 2019

I totally agree. The NHS does need more money to be able to buy more products and have a better healthcare experience.
The staff that work at the NHS need support too, I have seen how they work so hard and all they receive out of it is grumpy, angry and ungrateful people.
Keep up the good work!

Marta Butrym

Position
Pathway Administrator,
Organisation
Miss
Comment date
13 April 2019

Great reading thank you. Can I just plead to all of you discussing the subject do not forget about the admin staff! Do not exclude admin, we are as much running the NHS as you and the cleaners do, and we are as much in need of the care as you are. Low banding positions are there battling day in and day out. Unappreciated, unmotivated, certainly not treated with compassion, taking the abuse from patients and clinicians, right in the middle of raging frustration, disengaged and pushed to the limits and failed most of the time by incompetence of our bosses. We need good leaders too, to be able to help us, to coach us to give you and the patients the excellence of the service that we all deserve!

Dr Malcolm Rigler

Position
Retired NHS GP,
Organisation
Partners in Health ( Midland) Ltd.
Comment date
28 March 2019

Wild Horses would not have been able to drag me away from my GP Practice in late 1999. I had set up the practice in the early 1980s and was totally committed to what the practice had become after near 19years. But what forced me to leave was the management decisions of the Community Health Trust leaders who completely lacked the ability to notice that I was unwell and needed skilled diagnostic help for my multiple joint pains not "a disciplinary hearing and re-training" . Just like so many NHS patients who are from the "laity" so to speak doctors too can suffer from "missed diagnosis " and "damaging management decisions" . Providing great occupational health care for doctors and all NHS Health Professionals to my mind needs to be part of the agenda for retaining skilled and committed doctors and all health professionals. In my own case obtaining the right diagnosis and treatment meant that I was able to continue in full time work as a GP Locum for a further 17 years . My episode of illness so many years ago has taught me that NHS Managers need much more training and education in being able to spot
doctors and health professionals who need a diagnosis , treatment and care not "a disciplinary hearing" !

Lisa

Position
Staff nurse,
Organisation
Uhcw
Comment date
17 March 2019

Too many band 7s and 8s giving orders and working us to the bone. Treat us like colleagues and not numbers. The NHS is run by band 5's and 6's , catering staff,cleaners etc. Get the managers out if their offices and come and do a shift with us rather than devising unreasonable guidelines for us to constantly follow.

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