Fixing the broken wheels on the CoW: how can NHS organisations improve staff experience?

A few years ago, I was sat in a room with about 100 acute physicians. And the mood was tense. Their hospital estate was so knackered that at one point the medical director said: ‘I know about the broken toilets on the surgical floor. I have been told about “the bucket”. We are trying our best to solve this.’

The mood only turned for the better when a new plan was unveiled to reduce login times for the many computer systems clinicians use each day. The ripples of excitement spreading across the room made it feel like he had just announced an extra public holiday.

The world can feel pretty macro right now. We have national negotiations on staff pay and industrial action, national plans to grow the NHS workforce and transform NHS services over the next decade, and we have lived through seismic national events like Covid-19, Brexit and general elections. But what happened in that room five years ago showed there are still plenty of problems that blight the daily lives of NHS staff that can be fixed without national action without waiting for the collective view of a provider collaborative, and without the approval of a regional team or integrated care board. The recent GMC report on workplace experiences is a powerful reminder that there are things employers could be doing now to improve staff wellbeing, alongside these longer-term and broader solutions national workforce planners are pursuing.

...there are still plenty of problems that blight the daily lives of NHS staff that can be fixed without national action without waiting for the collective view of a provider collaborative, and without the approval of a regional team or integrated care board.

What do these problems look and feel like? To be honest, they feel closely related to ‘activities of daily living’ – the basic tasks that people need to do every day to keep themselves safe, healthy, clean and well (Table 1). These issues have also come through time and time again in our previous research into the core needs of health and care staff.

Table 1

And the problems also include those snags and niggles that annoy staff and get in the way of delivering good and efficient care. For example, some NHS organisations have invested millions of pounds in electronic patient record systems that can – in theory – capture information at the patients’ bedsides. But staff in these same organisations sometimes record patients’ vital signs on scraps of paper and then walk over to a machine to transcribe them because the wheels on the supposedly mobile ‘computer on wheels (CoW)’ are broken.

Some organisations have invested in ambient dictation software so clinicians spend less time writing up notes. While staff in other organisations bear more resemblance to scribes or detectives in 70s police dramas doing paperwork – with surveyed hospital consultants spending 4.7 hours a week on average on documentation each week out of their normal working hours. And while clinicians in some organisations struggle with logging in to multiple slowly-loading systems (as one clinician said: ‘when it takes longer to wait for systems to load than to walk to the patient it defeats the purpose of remote monitoring’), other organisations have slashed log-in times using single-sign-on technology.

Of course, tackling these problems is easier said than done. Offering NHS staff free car parking on-site sounds like a no-brainer, unless you are an organisation in the middle of a conurbation with 1,000 parking spaces for nearly 20,000 staff. And keeping canteens open out-of-hours might not help on-call staff get hot meals if they work on a labour ward at the end of one of the longest corridors in Europe.

But even if these things are easier said than done, they are also not impossible.

But ultimately, NHS staff are employed by local organisations and some of the responsibility also lies with them.

National bodies and the government have some role to play in all this, including providing dedicated funding and guidance for improving staff health and wellbeing, and creating an environment where staff feel like they can ‘get rid of stupid stuff’. But ultimately, NHS staff are employed by local organisations and some of the responsibility also lies with them. It is employers who will worry most about 52% of midwives feeling dehydrated because they don’t have time to get a drink; about the quarter of staff who use their cars or store cupboards as a quiet space to unwind before returning to their shift; and about the higher rates of chronic illnesses like diabetes in shift workers.  

The types of improvements to the physical working experience of staff in Table 1 and the snags and niggles outlined above share some common characteristics. They are:

• relatively small in scale – while they might take time to negotiate and deliver, they are not going to account for substantial additional spending, for example, developing a points-based system to prioritise access to free staff car-parking, rather than building a new car park in the middle of a city

• not novel or contentious – putting in smart fridges that are accessible to staff who work far away from mess halls or providing an on-site nursery or creche are unlikely to need the same HM Treasury approvals that novel financing arrangements like staff salary advance schemes might

• can be delivered by one organisation largely acting alone – good practice could be shared with other organisations, but you don’t need other organisations to put in sleep pods, fix broken wheels on mobile computers or improve the management of staff rotas and scheduling.

The trend in health policy in England is towards ‘system-by-default.’ But not every problem in the NHS needs a system-response. And there are problems that need to be tackled whether there is a national workforce plan or not, whether the NHS is being flooded of cash or starved of it. It might not always feel like it, but if you lead a local NHS organisation you are cloaked in incredible power. And there are plenty of CoWs to fix.