Yet, over the past three months health and social care staff have been a constant beacon of hope for us all by transforming the way they work and the way services are delivered, despite the appalling demands and circumstances and demonstrating immense selflessness.
We must grasp the learning that has come from this and let the light come streaming in. We need to address the failure of successive governments to enable an effective adult social care system, which has had such tragic consequences for thousands of families. Now is the time to eliminate the structural and interpersonal inequalities, exclusion and abuse that constitute the reality of racism, both in the NHS and our wider society. The shocking murder of George Floyd in Minneapolis, the continuing violence against Black people and the efforts of the Black Lives Matter movement have all underlined the deep inequalities that Black people face. We need to tackle this injustice in our society, and this urgently requires white colleagues to educate themselves and show up as allies.
The past few months have taught us that staff must have autonomy and control, feel a greater sense of belonging and be supported in order to have a sense of competence, rather than simply being overwhelmed by excessive workload.
Autonomy and control
Throughout the crisis, staff have taken the initiative and taken on greater responsibility. Clinicians and staff right across the system have been leading by initiative and example. They have done the right things quickly, learned and collaborated. They have not been afraid to take responsibility for decisions, but have instead been able to make decisions as professionals, based on patients’ needs, freed from the hierarchical and bureaucratic constraints that have previously severely limited their professional autonomy.
Across the country, NHS and social care organisations have valued their staff, not just by showing appreciation, but by ensuring the basic work conditions were improved. This has included free parking, accommodation in or near the hospital or care home, better access to food and water at all times of the day, and space for staff to take a break when they need it. There has been a recognition that when you are exhausted or distressed at work, it is right there is somewhere (and someone) you can go to take some time to recover.
Support staff have collaborated with clinical staff to quickly enable virtual clinics and appointments, e-consult platforms, the use of digital technologies to work from home and to do virtual care home rounds by video. Staff have been able to work more flexibly, and organisations have made better use of e-rostering in the interests of staff rather than just for efficiency and productivity.
Teams have become more stable entities, so people feel they are part of a ‘home team’. Camaraderie, daily briefings, huddles and regular time to discuss patients has dramatically improved teamwork. Multi-disciplinary teams have had a clear and common sense of purpose, which has built cohesion and a sense of team compassion and support. Protected time for the whole team to huddle, to check-in with each other or have lunch or coffee breaks together has added to this sense of solidarity.
One member of staff explains the benefits of working as one team: ‘We have gone ward-based, one team [for] one ward or two wards – nurses, doctors, physios, dieticians, discharge team. It makes a huge difference in terms of the doctors feeling more integrated into the MDT [multi-disciplinary team] instead of visitors on a ‘safari’ on the ward.’
Improved teamwork is just one outcome of the blurring of hierarchical and professional boundaries. Even organisational identities have been relinquished, for example as staff have transferred from different settings to work in other parts of local health and care services. And cross-boundary working has become the new normal for some staff, with examples of increased collaboration between primary care, secondary care, social care and whole range of volunteer and community groups. Ways of working have been transformed in days and in ways that were unimaginable just three months ago.
Despite the ‘command and control’ structures temporarily required to respond to the crisis, compassionate and collective leadership have been more in evidence and welcomed by staff. Leaders have been listening and asking, ‘what can I do to unblock things?’. Staff say leaders have been doing things with them, not to them, by being supportive, appreciative and sensitive, communicating helpfully, and being proactive in helping. And this style has become more consistent, replacing the top–down leadership style that has so often strangled initiative and good will in the past. Many leaders have been eagerly collaborating across team and organisational boundaries prioritising care overall rather than just their areas of responsibility.
Chronic excessive workload is the key determinant of staff stress, patient dissatisfaction, staff intention to quit and errors that harm patients or staff. The stripping out of unnecessary red tape and hierarchical decision-making has freed up time for staff to focus on doing the right thing. Don Berwick (former health advisor to President Obama, President Emeritus and Senior Fellow, Institute for Healthcare Improvement and International Visiting Fellow at The King’s Fund) says there should be only one rule for staff: ‘do what you know to be the right thing... and if you don’t know, ask’. During this pandemic, we are seeing staff better enabled and trusted to make those decisions based on what is best for patients (what they need and want) now and in the future.
Some of this has been aided by the shift in the constraining power of national bodies. Care Quality Commission inspections have stopped except in the most challenged settings. Several themes have emerged: the national bodies have provided some breathing space from control, inspection and their routine demand on the system. As we start planning for recovery, this provides an opportunity to establish new mutually supportive and adult relationships with national partners and avoid stifling control.
We have also seen changes in the relationships between those receiving care and those delivering it. There have been more mutual, more respectful and more understanding relationships with patients based on shared decisions. Communities have stepped up to help. Thousands of volunteers have been assisting, the public have been developing solutions and taking collective responsibility, seeking to ease pressures on NHS and social care staff.
Hierarchies and boundaries have been softened, blurred and in some cases erased. They must not be redrawn. Teamworking and inter-teamworking must be nurtured much more carefully in the future. All staff should be members of effective (and wherever possible, multidisciplinary) teams that meet regularly and have time to reflect on how to improve services.
Staff must never again be damaged by being subjected to chronic excessive workloads. Leaders must accept excessive workloads on staff as their priority, not treated as a pattern in the wallpaper they no longer pay attention to.
Reflection time for all teams, staff and organisations is vital. During the crisis, the huddles, debriefs, ward rounds and after-action reviews have enabled the astonishing innovation we have seen. All teams must have protected time for meetings, reviews and learning. We know such team time is associated with an average 35–40 per cent higher productivity.
When Aneurin Bevan led the establishment of the NHS he said, ‘we start off with an enormous amount of goodwill behind us and therefore that is an augury for more success in the future.’ The experience of Covid-19 has demonstrated a huge wave of national and local gratitude for key workers regardless of their role or status. As we move forward, we must ensure that the courage and sacrifice of those staff is honoured and matched by national and local action to make to the NHS and social care the best place to work, every day.
Compassionate and collective leadership (individually and institutionally) are core to ensuring staff have the right support. The role of leaders is to truly listen to those they lead, to genuinely strive to understand the challenges they face, to feel with them – to empathise with them, and to take responsibility for helping them deliver the high-quality care they wish to deliver. It takes courage and strength to commit to being a compassionate and collective leader – much more so than choosing the opt-out of command and control. It can also be the light that streams in and our legacy for the future.
Huge benefits is improved communication with ward-based teams and not forgetting that pharmacists are key members too.
I was moved and uplifted by this thoughtful analysis of just how much change and real development have come out of the Covid-19 experience in the NHS. There is much more too, like the emergence of a real commitment to integration of Health and Social care, and the parallel developments of new ways of approach and new management thinking and structures in procurement.
I hope that this learning is embedded, and built on, as we emerge from the pandemic: it will be needed just as much. I also hope that politicians will pick up some of these lessons, which have been driven in the NHS by sheer urgency, plus a feeling that we are up against a real common enemy, and we are in this together.