Tired of being exhausted: seven key actions for leaders in the NHS workforce crisis

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‘I’m exhausted from being exhausted...’ is the harrowing expression of weary, depleted staff across the NHS and in social care.  

We know the impact of the Covid-19 pandemic on staff in health and social care, but even before the pandemic, these sectors were facing the biggest staffing crisis since the introduction of the welfare state in 1948. High levels of vacancies, sickness absence, staff turnover and stress were typical with damaging consequences for staff health, which puts patient and service-user safety and quality of care at risk, and undermines organisational performance.  

This workforce crisis presents an enduring and enormous leadership challenge in health and care, made even more difficult by the huge demands of dealing with a pandemic. This is the context for the review of health and social care leadership being undertaken by Sir Gordon Messenger and Dame Linda Pollard. 

What can be done to help address this crisis? We propose seven key actions for leaders.  

Make compassionate leadership the foundation of their leadership

The challenge for leaders and managers across health and social care is monumental. While most leaders are committed to the maxim that ‘our people are our most important asset’ and there are many good and outstanding examples of teams and organisations in health and social care where staff wellbeing is a priority, this is often not the experience of staff in practice.  

A new approach to leadership is needed based on the core value of compassion.

A new approach to leadership is needed based on the core value of compassion. Compassionate leadership is not a soft option, it requires huge courage, resilience and belief, and sustaining cultures of high-quality compassionate care requires compassionate leadership at every level – local, regional and national – and in interactions between all parts of the system – from local teams to national leaders. 

Commit to equity, equality, diversity and inclusion

All leaders can practise compassionate and inclusive leadership, positively and overtly valuing equity, equality, diversity and inclusion both for their own sake and for the impact on care quality. Staff wellbeing must also be part of every leader’s training, ongoing development and objectives.  

All leaders should: 

  • be familiar with the evidence showing that combining compassionate and inclusive leadership with diversity is associated with team and organisational effectiveness and innovation in health and social care (such as West and Markiewicz 2016; Downey et al 2014; Lyubovnikova and West 2013) and with the research evidence on the impact of racism and discrimination on health, life chances and mortality (such as Byrne et al 2020; Williams and Mohammed 2013
  • actively offer to mentor and coach staff from systematically disadvantaged groups 
  • regularly assess their own performance as inclusive leaders ensuring every person they lead feels included by their leadership   
  • offer stretching project and career opportunities to staff from systematically disadvantaged groups, while offering sufficient support to enable them to succeed.   

Address the core needs of staff

Central to addressing the workforce crisis is a leadership focus on better meeting the core workplace needs of health and social care staff – their needs for autonomy and control, belonging, and contribution and effectiveness (the ABC of needs) (West et al 2020; West and Coia 2019).  

Inquiries into the mental health and wellbeing of doctors, nurses and midwives across the UK suggest there are eight key workplace factors that will have an impact on the wellbeing, flourishing and work engagement of health and social care staff, aligned across these three core needs (see Figure below).

The ABC framework of core staff needs

Source: West et al 2020

Prioritise collective leadership

Health and social care are provided by highly skilled and motivated people, yet still there are too many places where people describe how they are ‘managed’ through overly directive, command-and-control leadership. However, it is collective leadership, where emphasis and effort is placed on developing relationships and trust between people, that provides the optimum basis for compassionate cultures. Collective leadership also describes how the whole health and social care system and its communities can forge networks of organisations that work better together to deliver high-quality care. 

It is collective leadership, where emphasis and effort is placed on developing relationships and trust between people, that provides the optimum basis for compassionate cultures.

To encourage collective leadership, leaders can: 

  • engage everyone on the team in how they contribute to shared responsibility for high-quality, continually improving and compassionate care, offering timely feedback where this is not evident to facilitate team development  
  • continue to practise shared rather than dominating leadership in teams, inviting others to actively contribute to the daily leadership of the team  
  • encourage interdependent leadership, with leaders developing relationships with others across boundaries and prioritising overall patient/service-user care rather than only their area of responsibility 
  • genuinely involve patients, carers, communities and community groups in the design and ownership of health and social care services  
  • ensure consistent approaches to leadership across organisations characterised by authenticity, openness, curiosity, kindness, appreciation, and, above all, compassion.  

Align the national approach to regulation and oversight

More supportive and aligned national regulation and oversight is essential. The cultures of national bodies and the behaviours of those who work for them profoundly affect the cultures and workloads of health and care organisations. They too must embody institutional compassion, listening to those in the services they regulate and performance manage, seeking to understand the challenges they face, empathising with them (given all we say above, this is fundamental), and then seeking to help and support them. Supporting them means helping to remove obstacles to their work (such as excessive bureaucracy, data-reporting burden, excessive performance management) and helping to ensure they have the resources they need to do their jobs effectively (such as adequate numbers of staff, the right equipment, and appropriate training and development).

Address the workforce crisis as a collective leadership responsibility

Leaders at every level in the health and social care system can collectively and courageously help by continuing to bring honest and unequivocal acknowledgement of the key elements of this crisis in order to help to address them: staff shortages, no national workforce plan (for the NHS in England), staff turnover, chronic excessive workload, and very high stress levels. The scale and complexity requires leaders, locally and nationally to work courageously with their peers in partner agencies to co-develop credible plans for workforce that directly answer the questions  ‘How many?’, ‘With what skills, values and behaviours?’ and ‘By when?’. Not just for now but for the next 10 to 20 years. This is particularly challenging in the absence of a funded national workforce plan, but developing and testing local workforce innovations will also be critical in helping address the workforce gaps to maintain service delivery.  

In turn, leaders need policy-makers to face up to the scale of the challenge they are dealing with. The Messenger review has a critical role to play here by squarely addressing the workforce crisis and focusing attention on the biggest challenge facing leadership in health and social care.    

Conclusion

At their best, health and social care organisations epitomise a commitment to compassion, belonging, inclusion, justice, equality, health, happiness and wellbeing. Their health is a mirror of the nation’s health. Well before the pandemic, the image projected was of a system under increasing pressure and selfless staff increasingly exhausted, unwell and distressed.  

The shared vision must be to create an outstanding health and care system that embodies the values we have as a society, focused on enabling the staff who provide care to thrive and deliver the care they are passionately committed to offering. That requires leaders at every level in our society to rise to the monumental challenge and pursue the people-focused, evidence-based strategy we outline here. It is the role of leaders not to manage the inevitable but to courageously face the most difficult challenges and bring their attention and resources to bear on overcoming them. Now is the moment.

Making sense of compassionate leadership

What is compassionate leadership? And why does it matter? Learn more about compassionate leadership and get practical tips on how to apply compassion in your daily work. 

Read the explainer

Comments

john burnham

Position
Retired GP,
Comment date
24 April 2022

This article is well meaning but not dealing properly with the urgent staffing crisis. The NHS is broken. The entire finances of the NHS must be reorganised as private healthcare is organised. All the problems mentioned in this article will be dealt with adequate staffing. The Government and the nation must have the courage, and it will need courage, to oversee this change.

Patricia Oakley

Position
Retired,
Organisation
KCL/PmP
Comment date
15 April 2022

Michael, there is nothing to disagree with in your proposals. I think most would willingly sign up to some decent leadership development, whatever it's called. The issue is how to tackle the problem of those who are not interested in any of this. After 45+years, I reflect on the many cases I have had to deal with that involve dreadful behaviours and attitudes, some of which border on psychopathy. Get to the heart of this to make a workforce strategy work. Easier said than done.

David Sandbach

Position
Retired NHS CEO,
Organisation
NA
Comment date
28 February 2022

Sufficient numbers of staff in the department trump compassion - if a person is knackered they need additional help i.e. more colleagues to work with on a permanent basis and time to catch up on their own sense of doing a good job.

Add on a decent respectful relationship with the organisation and success is certain.

Nitin Shrotri

Position
Consultant Urologist,
Organisation
Independent with NHS involvement
Comment date
25 February 2022

Thank you for such a thoughtful article and some great suggestions. May I add that we ask for rapidity of action, stop asking individuals to run on their hamster wheels, allow over-55s to pace themselves without penalties, not over investigate our patients and encourage joint working between Primary and Secondary care to optimise resource.

Neil Richardson

Position
administrator,
Organisation
retired
Comment date
24 February 2022

Is the article about a big gap between theory and practice, for instance
staff wellbeing a priority according to mission statements, but often
not the experience of staff in practice - with some departments
more troubled than others during recent years? Won't a new source
of income to employ, train and retain staff do more good than attaching
the label Compassion to what managers might (or ought to) be doing
already?

Chris

Position
Cardiothoracic Surgical Trainee,
Organisation
NHS
Comment date
17 February 2022

Great article. The missing word for me: "flexibility". I wrote about this, building on a lot of work that shows inflexibility is consistently cited as a major stressor/barrier for medical doctors and surgeons ('Locked in - Locked out' https://journals.sagepub.com/doi/full/10.1177/1460408621993755). It is related to the autonomy part of the autonomy-belonging-contribution model mentioned here. Current frameworks move us around the system and remove autonomy/control. Multiple national reports (GMC, HEE, BMA etc) have recognised the seriousness of the inflexibility problem.

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