Naming the issue: chronic excessive workload in the NHS

The Health and Social Care Committee’s report on workforce burnout and resilience in the NHS and social care is unequivocal. Chronic excessive workload is damaging staff health, patient care and staff’s long-term ability to provide high-quality and compassionate care for people in their communities. In a context of inadequate resources including unsatisfactory levels of staffing, equipment, training and supportive leadership, workload is the number one factor predicting ever-increasing levels of staff stress.

The Committee rightly points to high levels of turnover created by a vicious circle of staff shortages and excessive workload that is the most cited reason for staff leaving health and social care organisations. The high levels of stress this causes are linked to medical and nursing errors, patient dissatisfaction and poor care quality. For staff, sustained stress is associated with cardiovascular disease, addictions, cancers, diabetes, depression and early mortality. It is a bitter irony that many of those working to care for the health and wellbeing of people in their communities are having their own health damaged in the process.

Chronic excessive workload has become like the pattern on the wallpaper we no longer see. Some leaders avoid naming it because they feel powerless to find lasting solutions. It is not a problem that will be solved easily or quickly. But it will never be solved if we do not have the courage to name it and address it. Workload should be discussed as core business in team meetings, departmental meetings, executive team meetings, Board meetings, appraisal meetings and national policy meetings. The Committee has started that process. Everyone must now take responsibility for maintaining momentum.

'It is a bitter irony that many of those working to care for the health and wellbeing of people in their communities are having their own health damaged in the process.'

It is essential to explore all the means available to eradicate chronic excessive workloads by using the knowledge, skills and experience of staff to continue to develop new solutions. First, as the Committee demands, there is a need for national (and local) workforce strategies based on long-term assessments of staffing and skill needs and system demands over the coming decades. This requires adequate funding to provide the staff needed to deliver the services for communities need. This is not the case now, nor has it been for some years, so delivering this funding will require some difficult choices and trade-offs.

Second, national organisations must ensure their own cultures and behaviours are not part of the problem. When arm’s-length bodies are reporting stress levels above the (very high) average for the sector, they are also part of the problem. Regulators also exacerbate this by placing unnecessary burdens on provider organisations, especially in making the category error of assuming that improvement means adding processes rather than taking them away, or when they inadvertently contribute to fear and blame cultures with excessive demands on the system.

Third, and perhaps most importantly, leaders can help to create environments in which staff feel psychologically safe and supported to help design, test and implement necessary changes as part of continuous improvement.

Some organisations are addressing these issues. East London NHS Foundation Trust staff have named the issues of excessive bureaucracy and unnecessary rules, a cacophony of meetings, and having to seek managerial permission for every initiative. Northumbria Healthcare NHS Foundation Trust has made staff and patient experience a core focus for the chief executive and executive team via a chief experience officer on the executive team.

In other organisations, the use of new technologies has contributed to improvements in care and patient experience while helping reduce unnecessary workload. We also know that demands are intensified by extended hierarchies. Every reporting level adds an estimated 10 per cent more bureaucracy and some of the most effective organisations in the world operate with no more than three or four reporting levels. In contrast, in most NHS trusts, the number of reporting levels is well into double figures. There are shining exceptions such as the Langley Green Hospital at Sussex Partnership NHS Foundation Trust with its leader–leader model where patients (named as ‘service leaders’) play a key role in service improvements.

There is a pathology in the health and care system that assumes the only way to manage more demand is to spin the hamster wheels ever faster. In fact, we must stop. Time and space for reflection, learning, creativity and innovation are essential. Leaders, teams, organisations and sectors must work together to develop and nurture cultures where time and space for pre-briefs, debriefs, after action reviews, learning spaces, compassion circles, Schwartz Rounds© and reflection become the norm. Teams that take such regular time to reflect are on average between 35 per cent and 40 per cent more productive and are far more innovative than teams that simply keep spinning the wheel. And it is in the space created that ideas for new and improved ways of avoiding chronic excessive workload will be developed.

'There is a pathology in the health and care system that assumes the only way to manage more demand is to spin the hamster wheels ever faster. In fact, we must stop.'

The simple reality is that when staff feel they have voice and control and can influence key decisions in their workplaces; when they feel valued, respected and cared for in their teams and organisations; and when they have manageable workloads that enable them to deliver the compassionate and high-quality care they aspire to; then they find joy and meaning in work. And then quality of care, patient/user satisfaction, staff retention, financial performance and care outcomes are all far better.

Excessive chronic workload is the key barrier standing in the way of this vision. Now and for the future it must be named and courageously and effectively addressed. Otherwise, in the words of the Health and Social Care Committee, staff burnout will continue to be ‘an extraordinarily dangerous risk to the future functioning of both [health and social care] services’.