Skip to content

This content is more than five years old


The NHS crisis of caring for staff: what do we need to do?


It is astonishing that politicians have watched the NHS staff crisis develop to this point without taking action. The reality is more than 100,000 NHS staff vacancies – that’s 1 in 11 of all NHS posts.

There are very high levels of staff turnover with large numbers of nursing, midwifery and medical staff leaving every month (in secondary care, community services and general practice in particular). And there are chronically high levels of sickness absence and presenteeism. Add to this the struggle most NHS organisations now have in recruiting staff and the picture becomes clear. This is a crisis that threatens the ability of the service to deliver safe, high-quality care for the people in our communities. In any other industry, increasing staff turnover, absenteeism and difficulty recruiting would be seen as red flags, warning of fundamental toxicity in organisational cultures.

The latest NHS staff survey data reinforces this understanding. For years we have recorded high levels of stress that damage staff health, causing a range of issues including cardiovascular disease, diabetes, addictions, cancers, sleep disorders and depression. Fifty per cent more NHS staff now report debilitating levels of work stress compared to the general working population, and year after year, around 40 per cent report being unwell as a result of work stress during the previous year. This affects the delivery of care – undermining safety and quality of care and, in the acute sector, associated with higher levels of patient mortality – and contributes to higher levels of bullying, harassment and discrimination.

After 15 years of surveying NHS staff in England, we still see very high levels of bullying and discrimination and little evidence of improvements in staff experience over recent years. Staff engagement appears to be holding up (rather than increasing dramatically) because of the intrinsic motivation and commitment of staff. But the latest survey results show only minor changes in a context where staff experience unacceptable work conditions day in day out. I talk to staff who tell me they often can't find time to use the toilet on a shift; or get a drink of water; or doctors who say they have nowhere to sleep or rest on night shifts. The experience of many staff is a toxic cocktail of unmanageable demand and little control.

We have to significantly improve the workplace environments for NHS staff in all trusts. But how?

Humans have three core needs and it is particularly important these are met in the workplace. They are the needs for belonging, competence and autonomy. When these needs are met in the workplace, people are more intrinsically motivated and have better health and wellbeing.

The need for competence reflects our need to be able to have a positive effect on the work environments we find ourselves in, as well as to get valued outcomes (to deliver high-quality care, for example). The need for belonging refers to the desire or need to feel and be connected to others – to care and to be cared for. Autonomy refers to having free will, choice and control in order to be consistent with our sense of our self (as a health care professional, for example). It is not about being independent of others. Psychological health requires satisfaction of all three needs; one or two are not enough.

The challenge is translating these elements into appropriate interventions in the many different contexts in which NHS staff operate. For belonging, it is about constantly nurturing cultures and climates that reinforce the sense of relatedness: having a clear, enacted and shared vision focused on the delivery of high-quality and compassionate care; aligning all efforts around that vision; creating commitment among staff by leading and managing them in a way that ensures trust, motivation and positivity and building effective team and inter-team working throughout the system. It is especially about ensuring inclusive and compassionate leadership at every level.

The need for competence is met first and foremost when workloads do not exceed the ability of staff to deliver high-quality, safe and compassionate care. It is also ensuring that staff have enabling and supportive supervisory support, focused on removing the obstacles in the workplace, rather than creating directive, controlling the culture of 'holding to account'. And it is ensuring we continue to help people grow, develop and learn so that their skills and competence are constantly improving throughout their careers.

The need that is least met in the NHS is the need for autonomy or control (it is a quintessentially command and control culture). The challenge then is to ensure everyone feels they have voice and influence (including community groups, patients and carers) in the genuine co-design of services and management of the organisation. This means moving away from excessive hierarchy and encouraging collective leadership. And it requires ensuring that staff feel their organisations are just and fair places to work where procedures are transparent and fair (with regards to promotion, rewards and challenging assignments, for example) especially in relation to discrimination on the grounds of race, gender, disability, sexuality and so on. Simple hygiene factors also make a huge difference to the experience of control – having somewhere to get a drink or some food on a night shift, a locker to put clothes in (that locks) and being able to travel to work relatively easily (and park if required).

In short, the workforce implementation plan is more likely to succeed by focusing on the underlying and basic needs of staff and aspiring to make the NHS the very best place to work.