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

Anna Morgan

Position
Director of Nursing,
Organisation
Norfolk Community
Comment date
03 March 2019

The absolute fundamentals essential to our workforce are set out here. Success relies on leaders really making this happen, this requires leaders to want to know how it is for staff at frontline and support teams to make the changes needed. This takes time and energy and real compassion for others. Hopefully this article will be the start of a focus on the basics that often get overlooked.

Cecilia Braithwaite

Position
Neonatal nurse,
Organisation
NCUH NHS Trust
Comment date
03 March 2019

I have just completed 40 years unbroken service in the NHS ,while I appreciate it is funded by the public purse and therefore it would be inappropriate to receive any monetary reward a word of recognition might not go amiss ! If you want to recruit and retain staff in the NHS start improving their working conditions .Protected meal breaks ,free parking gratitude ,but above all adequate safe staffing , is it any wonder that people go off with stress when they put under constant pressure ?

Matthew Mezey

Position
Q Community Manager,
Organisation
Health Foundation
Comment date
04 March 2019

My little suggestion is to start small and let things spread quickly - by encouraging all NHS staff (and KF staff too!) to use some of the 'Liberating Structures' tools, that can help us all to run meeting in a more engaging, more creative way. These meetings are more enjoyable, safer, less hierarchical - and more effective too. They get really good results.

Little wonder I've seen new user groups pop up involving NHS stuff in Belfast and in Glasgow, in the last few months.

I blogged about why NHS improvers like using Liberating Structures here, following a taster workshop: https://q.health.org.uk/blog-post/how-to-power-your-improvement-work-wi…

We get so caught up in the big strategies, top-down mandates et al , yet look at how a bottom-up movement - Learning from Excellence - can spread to 200 different NHS organisations in a short time. By recognising and learning from positive behaviours in healthcare, rather than focusing on the negative, the failings etc. And letting everyone do it in their own way too...

Simon Diggins

Position
Business Development Manager,
Organisation
SLaM
Comment date
04 March 2019

This is a very powerful piece, made more so because too much discussion of the NHS is insufficiently critical.

My suggestion, stemming from my previous service in the military, is not only to encourage 'inclusive leadership' but to change from the current 'command and control' culture - what the Germans call 'befehl' or 'orders-giving' - to a 'mission-command' ('aufstrag') approach. Leaders set: policies and goals; identify resources; establish the minimum of constraints, co-ordination measures, or boundaries, and then allow subordinates to get on with it. This requires: effective information, that is widely shared; goals that are understood from the 'board to the ward'; initiative encouraged; and lastly, most important of all, mutual trust. Not all subordinates are as effective or capable as others and so a leader has to judge how much latitude to give but, by establishing a 'mission command' culture (through education and best practice), eventually the 'command culture' will change for the better. Some will not cope, along the way, but we can surely afford to lose the 'process, protocol and procedures', princes and princesses in order to serve our patients and the public purse better.

NMCWatch

Comment date
06 March 2019

Politicians need to stand up and recognise the toxic nature of workplace bullying and the impact of Nmc proceedings on retention. Many of our group have retained their PIN throughout investigation but decided to leave the profession none the less because of how they have been treated. Years of experience lost

Kate Pollock

Position
Independent Mental Health Advocate,
Organisation
Mind
Comment date
12 March 2019

An excellent article. It is refreshing to read about "basic human needs" and how the NHS (and all organizations) need to attend to these as a means to create functional, vibrant, competent and effective services. Another thought that continues to crop up for me is the importance of fostering accountability rather than blame. Blame, scapegoating, and non-pre-empted discipline undermines accountability, progress, learning, and innovation. What we see is an increase in secrecy and disengagement. These are dangerous to health and social care. Blame does not make anyone or anything better. Accountability is not about removing the "bad apple" its about people feeling able and safe to own up to making mistakes. We are all human and WILL make mistakes. We all need to be able to grow from mistakes and failure. Thank you for your thoughtful piece.

Frazzled Physio

Position
Community Physiotherapist,
Organisation
NHS ( Scotland)
Comment date
13 March 2019

I qualified in 1984 and have worked in many locations. I loved my job but now every day on the calendar is one step closer to retirement. That is sad! I'm not sure that the NHS has ever 100% cared for it's carers/ staff but I definitely think more is expected now and with fewer resources. Fourteen years ago I had an assistant and three days to do my job. Now I have no assistant and one and a half days to do the same job; with a couple of added specialities thrown in. We are stretched to breaking point and expected to take on other developments, learning as we go. So long as the waiting lists are ok and everything is recorded and data collected ( and no one is complaining), what you are doing is irrelevant, as no one has time to mentor or monitor. To have a successful organisation, autonomy, belonging and competence are vital. At each level, people need to know and believe that what they are doing is making a difference and is recognised and valued. We waited two years for our grubby toilets to be painted whilst across the corridor, offices were refit twice in one year for new management teams! There is too much knee jerk reaction from the top down. e.g. Blanket sickness policies rather than tackling those few who really are playing the system. Trust the line managers to do their job. Give line managers time to do their job. Really listen to those at the coal face rather than send out meaningless lip service surveys that go nowhere. We are here because we want to help our patients. Let us do that by allowing us to make the decisions to make our system more efficient. Autonomy. Recognise the value of your staff and remind them of their worth and how important each cog is in the wheel. Belonging. If staff feel that they are doing meaningless tasks or providing a mediocre service, they will either leave, become demotivated or stressed. There are some amazing people working in the health service. The NHS is amazing. Let's work to protect it by looking after those who provide it.

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.

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" !

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!

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