Recovery and then renewal: the innovation imperative for health and care

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'At the end of the first wave [of Covid-19], staff received an email from senior leaders to thank them profusely for all they had done and to emphasise it was now back to business. We were flabbergasted.'

A&E consultant

Since the turn of the year, staff have been battling a second wave of Covid-19, even bigger than the first. This second wave has threatened to break systems and staff across the UK with its force.

Staff were already exhausted and, in many cases, deeply wounded by their experiences over the past year. They have had to dig down to the limit of their reserves. The system relies on them doing yet more to care for the vast numbers of people hospitalised and also to cope with death as an everyday event. When they have used up their reserves and yet are required to do more, they can break. They get sick, they experience mental health problems, and many already report they are planning to quit.

'Before the pandemic, the NHS was already in the middle of a workforce crisis with the highest-ever stress levels, numbers of staff vacancies and turnover'

When the pandemic eases what will happen to the care workers, ambulance staff, GPs, community nurses, acute and mental health staff, including porters and managers who have been on the front line of the crisis? There will be a huge number of people waiting for treatment but the context will be reduced staff numbers through sickness, exhaustion and the ‘moral injury’ of not being able to provide the care they wanted to. What can be done to help staff hollowed out by witnessing so much suffering, fear and high levels of death?

Now and in the future we must remember that back in January 2020, before the pandemic, the NHS was already in the middle of a workforce crisis with the highest-ever stress levels, numbers of staff vacancies and turnover of nurses, health visitors, care home staff, midwives and doctors. The system was cracking… and then the pandemic struck.

There can be no return to where the health and care system was in 2020 and certainly not to ‘business as usual’. There is an urgent need to prioritise compassionate support for those on the front line before we can hope to address the huge backlog of non-Covid work. As Don Berwick , an international visiting fellow at The King’s Fund, wrote when reflecting on choice for the ‘new normal’, ‘Without a physically and psychologically safe and healthy workforce, excellent health care is not possible.’

'What can be done to help staff hollowed out by witnessing so much suffering, fear and high levels of death?'

The first imperative will be giving staff the space and time to rest and recover. They will need breathing space. And that will take months rather than days or weeks. Leaders across our health and care systems must start planning now to create the space to help staff heal and replenish their reserves. It will require creative thinking, courage and persistence to put in place enlightened practices to retain and sustain a healthy, caring and compassionate workforce. The support needs of leaders are also important in this planning, as they have also had to contend with the relentless pressures of recent months.

The second imperative then will be to seek to transform the way health and social care are delivered because demand for services will be unrelenting, given both the backlog and the wider mental and physical health problems that have developed over these past months. The health and care system has witnessed innovation in the delivery of services at a scale and pace during the pandemic that would have been beyond imagination just a year ago.

So how can we replicate, support and sustain the conditions that enabled innovation during the pandemic? Fundamentally, this will need to include meeting the ABC of core needs of staff (see Figure).

The ABC framework of nurses' and midwives' core needs

For autonomy and control (A) this will mean removing unnecessary hierarchies and regulation that prevent innovation. The voice of staff must be heard loudly in determining and driving transformation of services at every level. But first there needs to be a collective drive to transform their working lives by improving basic work conditions. This includes spaces and time to rest on long shifts, access to nutritious food on night shifts, control over rotas, and teams working to create supportive cultures with values of learning, compassion and support rather than values of control, fear and blame. The aim must be for staff to experience joy at work and a sense of fulfilling engagement every day, rather than exhaustion and burnout, to ensure their health and the health of the services they provide. When teams feel safe and engaged at work, they innovate at scale and pace.

Employers must meet the needs of staff for belonging and support (B) by ensuring everyone is part of a ‘home’ team where they experience strong, caring collegial support. These teams must be given time and space to meet for reflection and learning. For the sceptics, to be clear, this is not some soft cushions and scented candles intervention. Such teamworking practice leads to impressive improvements in services and productivity via the innovations effective teams repeatedly generate. And such teamwork is powerfully protective of staff health and wellbeing and thereby care quality.

Multidisciplinary teams where diversity is valued are fountains of innovation. Nurturing supportive and inclusive cultures that prioritise high-quality, continually improving and compassionate care for patients and staff can seed innovation and transcend fixation on externally imposed targets by ensuring organisations achieve high standards of care and productivity.

And organisations must meet the need for competence or contribution (C), particularly after the tragic moral injury that has scarred health and care staff over the past year. That means tackling the blight of chronic excessive workloads on staff stress, intention to quit and patient safety. This must be named and confronted head on. This fundamentally is the role of line managers and leaders but requires the active engagement of people and teams every day at every level. That focus and commitment will be a powerful force for innovation as staff get rid of unnecessary activities, deploy new technologies, develop new roles, and improve team and inter-team co-operation.

'There is an urgent need to prioritise compassionate support for those on the front line before we can hope to address the huge backlog of non-Covid work'

All leaders including those in national organisations with an oversight role must help this transformation by actively modelling compassionate leadership. This will not happen overnight or easily. It will require important shifts in how leaders deeply listen to those they lead, understanding the challenges they face, empathising and helping them. This means removing the obstacles that prevent staff from having autonomy and control and providing the resources they need – the right staffing levels, the right equipment, effective IT systems, personal protective equipment (PPE), and training to enable them to do their jobs effectively and confidently. This will help to strengthen climates of psychological safety in teams and release innovation.

The determined, successful and sustained implementation of enlightened people-support processes underpinned by national policies is vital to support these culture changes. This will take time and will need national leaders and politicians to remain committed for the tough decisions and investment of time and money that will be required.

As a country we must address the causes of much ill health, including inequality, poverty and discrimination, if our health and care services are not to buckle and break. As Michael Marmot and colleagues recently concluded, ‘It is essential to have a better resourced, flourishing public health system. Without this it will be impossible for England to build back fairer.’ Covid-19 has tested our local and national systems to their limits so we cannot pretend a ‘return to normal’ is even possible let alone desirable.

'The aim must be for staff to experience joy at work and a sense of fulfilling engagement every day, rather than exhaustion and burnout, to ensure their health and the health of the services they provide'

There are great examples such as the Nuka system in Alaska and the Wigan Deal in north-west England where communities and agencies have come together as equal partners to transform services. When our communities genuinely co-own and co-design care, we will see transformational change and radical innovation. The model of the benevolent state doling out care to compliant or increasingly demanding supplicants is no longer relevant.

Leaders must have the courage to plan now to make our health and care services a crucible for innovation by releasing the energy, skill and motivation of their workforce as we emerge from the worst of the pandemic. But first they must provide the space and support for them to heal.

Comments

Aden Hailu

Position
Support worker,
Comment date
29 January 2021

As a care assistant and support worker during a pandemic a national health crises, we are tiered of being told we are valued but not valued enough to get paid more, not valued enough to be permanently employed. Resting and having space is not affordable in our circumstances. How are we going to rest when we are on zero hour contract. It’s a choice of being able to buy food and pay rent vs resting and having a break. We rest and we will be back on benefits. Resting is not an option our option is to work until we have a breakdown then live on benefits for the rest of our lives. If what we are doing is so valuable to society how come the fact that we are on such harsh contracts, where we have to work up to 50 hours just to be out of the benefit system. That tells us we are not valued but we are exhausted. Even free parking for care workers is to expensive for the government so we are forced to take public transport exposing ourselves to the virus and that is even only for the few that can actually afford a car.

Katrina james

Position
Ward manager,
Organisation
Portsmouth Queen Alexandra university hospital
Comment date
30 January 2021

I agree with all the above information. But it will need investment and protected time .PTDS is the impact of COVID-19 and we need to be on top of this to ensure we can support are teams

Michael Rock

Position
Junior Surgeon,
Organisation
NHS Wales
Comment date
01 February 2021

This is a critically important and insightful article. Is this being listened to by the people that make decisions? See also the massive "Stress and the Surgeon" argument raging in the Royal College of Surgeons Bulletin about whether the current generation are "tough" enough:

Roche C Bull R Coll Surg Engl 2021 Volume: 103 Issue: 1, January 2021, pp. 9-9

and

Piper H. Bull R Coll Surg Engl 2020; 102: 349–350.10.1308/rcsbull.2020.199

The training crisis is real and it's going to be a huge problem. A whole generation of trainees are at risk of failing to progress.

Helen Taylor

Position
Clinical Psychologist,
Organisation
Independent, after 13 years NHS
Comment date
01 February 2021

This is really important. It's too late for me. I left the NHS before the Pandemic hit for exactly the reasons you set out here. I think transforming services should take be informed by and take into account the experiences of the people who have already gone, we have a hard won wisdom to be shared and for some of us, if we sensed the environment was safe enough, might even consider returning. Leaving the NHS was not my first choice but it was the only choice I could make between my own well being and loyalty to an organisation I used to love. I still love it, but it hasn't loved me back for some time.

paul muller FRCS

Position
consultant surgeon rertired,
Organisation
NHS
Comment date
04 February 2021

I have read through all of the above paragraphs it has taken me about 25 minuits most of it was writen by persons who have never worked on the front line of the NHS. Before the pandemic you rightly state that there was a massive shortage of nurses and doctors in the NHS. This is caused by the massive increase of so called managers who tell the Doctors and the Nurses when and how to do thier jobs. This causes demoralistion in the highly trained work force and so they no longerr wish to be in the NHS and leave.
The final destruction of our NHS is the Corona 19 Pandemic. We now have the highest number of deaths in the world in our small island. I fear for the future.

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