10 early actions the government can take to improve NHS working conditions

The workforce crisis is at the heart of many of the challenges facing the NHS in England. This briefing outlines early actions the government can take to enable NHS staff and leaders to deliver the highest possible quality of care in the coming months.

Improving staff working conditions will take time and effort across the health and care system and at all levels. This briefing focuses on immediate actions that can be taken by one group, the new government, to start bringing much needed improvements. While this is not a comprehensive list of actions, the recommendations are early measures new ministers can take to improve working conditions and lay the foundations for more comprehensively addressing chronic staff shortages and increasing retention. The ultimate goal is to improve staff wellbeing and productivity, and therefore improve patients’ access to high quality, safe, effective care.

Current context and opportunities

• There has long been an established link between staff experience in the NHS and the quality of care and patient experience, with reports such as the Boorman Review and the Review of Staff Engagement and Empowerment in the NHS, as well as research carried out by the National Nursing Research Unit, exploring this. Delivering high-quality care is only possible if staff get the practical and emotional support they need. There is a huge opportunity to improve the experience of work for NHS staff, and in turn, improve performance and patient outcomes.

• High vacancies continue to have an impact across the NHS. As of May 2024, there were more than 100,000 vacancies across the NHS workforce in England (excluding primary care vacancies such as GPs).

• The 2023 NHS Staff Survey shows the proportion of staff experiencing harassment, bullying and abuse remains high. In the 12 months leading up to the survey 9.9% reported at least one such incident from their manager, 17.7% from other colleagues and 25.1% from patients/service users, relatives or the public.

• Despite the ethnic diversity of the NHS workforce and its long history of relying on international recruitment, staff experience racism. The 2023 NHS Workforce Race Equality Standard report highlights that just 39% of staff from a Black background believed their trust provides equal opportunities for career progression or promotion, with levels below those of other ethnic groups since at least 2015. The percentage of staff experiencing harassment, bullying or abuse from other staff was higher for Black and minority ethnic staff (28%) than for white staff (22%).

• Morale across the NHS workforce is low, with multiple workplace stressors contributing to low morale and burnout; these include excessive workloads, conflicting demands on time and unrealistic time pressures, and bullying, discrimination and harassment. Almost three quarters of respondents to the 2023 NHS Staff Survey said they have unrealistic time pressures at work. Staff experience a demoralising cycle, with high vacancy rates adding to stress and pressures on staff, which then result in rising levels of sickness absence and many staff leaving the profession.

• The most recent NHS Staff Survey found that 29% of staff often think about leaving their job, and less than half said their organisation is committed to helping them balance their work and home life. Since 2011, the number of staff leaving the NHS due to health or work-life balance has more than tripled.

• Many NHS workplace environments are not designed to make best use of staff skills or to protect their health and wellbeing, with staff often unable to access basic facilities such as nutritious meals, adequate space for breaks and rest, and access to toilets when needed.

• Previous research has shown that poor NHS administration combined with bureaucracy and increased administrative tasks place a heavy burden on staff, preventing them from using their time as productively as they would wish and adding to workload, contributing to stress and dissatisfaction.

• Industrial action has been taking place across the NHS in England since 2022, largely in response to concerns regarding pay, working conditions and patient safety, which is being compromised by inadequate staffing levels and staff burnout. Since 2010, pay has fallen in real terms for most NHS staff groups.

• For the first time in two decades, the NHS Long Term Workforce Plan set clear goals for staff recruitment into the NHS but was weaker on measures needed to retain existing staff, failing to address the issues that contribute to high attrition rates across the NHS workforce.

What can the government do?

Working conditions

Workplace environments that protect and encourage the wellbeing of staff should be a given, but are not. Nurses and midwives have previously told us of issues accessing basic facilities while on shift – for example, access to toilets when needed, access to water, and the ability to take proper breaks to access food and hot drinks.

All too often for NHS staff, flexible working means staff being flexible to fit in with their organisation’s needs, with little flexibility in return from the organisation to meet the staff member’s needs. When staff are expected to give discretionary effort but then don’t receive some flexibility in return, it can lead to burnout and, ultimately, more staff vacancies. Successive governments have recognised that flexible working leads to higher levels of job satisfaction, attracts people to an organisation, and enables people to fit work alongside other commitments – but it is still not the norm in the NHS. Failing to modernise its approach to flexible working risks long-term NHS vacancies becoming a permanent fixture, as the number of UK workers expecting flexible working options continues to rise.

It is also common to hear of poor rostering practices – including not giving adequate recovery time after night shifts, unfair management of rotas and requests, and poor design and decision-making processes – all of which can have a significant negative impact on staff mental health.

Staff wellbeing

Indicators of staff wellbeing, including sickness absence rates, reported risk of burnout and self-reported stress, have all been worsening in recent years. Although NHS England’s staff mental health and wellbeing hubs were established in response to the pressures staff were experiencing as a result of the pandemic, they later evolved to address systemic issues, including burnout, suicide risk, workforce wellbeing, and turnover. Those hubs that are still open continue to play an important role in NHS staff staying in, or returning to, work, and have also led to improvements in patient care.

Organisational cultures across the NHS contribute to the burnout, mental distress and exhaustion that staff experience. Staff tend to regularly miss breaks at work due to feelings of guilt and a sense of responsibility to colleagues and patients – a huge danger in the context of chronic excessive workloads.

Levels of discrimination experienced by NHS staff remain persistently high. Previous research from The King’s Fund has exposed the profound and long lasting impact of such racism and discrimination. Similarly, the proportion of staff reporting bullying and harassment is far above what should be expected by services aspiring to create compassionate and inclusive workplace cultures.

It is important to note that there is no conflict between the ‘soft’ skills of compassionate, supportive leadership and the ‘hard’ bottom line of cost-effectiveness and performance measurement. There is clear evidence that compassionate leadership drives better staff and patient experiences, which in turn can drive better outcomes, organisational effectiveness and productivity.

Pay, terms and conditions

Money is not the only lever required to improve NHS staff morale. However, pay is a major dissatisfier for staff and has a significant impact on wellbeing, contributing to a sense of being poorly compensated. This, in turn, corrodes commitment, engagement and the sense of being appropriately valued at work. Improving pay, terms and conditions for NHS staff is a unique lever that only the government has – and should be made full use of.

Support for managers and leaders

Good leadership of services is critical to improving workplace cultures and tackling racism, bullying and harassment among NHS staff. Managers play an essential role in supporting staff and enabling clinical professionals to treat patients but are under increased pressure due to low staffing levels across services. The most recent NHS Staff Survey found that, in some aspects, workplace leadership and culture is deteriorating, with an increase in the percentage of staff experiencing discrimination from other staff (up from 7.68% in 2019 to 9.07% in 2023). Staff wellbeing, psychological safety and belonging need to be valued – and should be required – as a core expectation of what good NHS leadership looks like. While much of the responsibility for this sits within the NHS, and relies on long-term cultural change, national government does have an important role to play.

Conclusion

Workforce challenges across the NHS are on a huge scale, largely entrenched, and varied across sectors and services. The NHS Long Term Workforce Plan was an important step forward in terms of targets for workforce numbers and needs, but had less to say on retention.

Improvements to NHS working conditions will need leadership at the provider, service and team levels, but there is still a role for national government to play. Ministers can set the tone, direct focus, provide support, and take action where national change is needed.

While the recommendations outlined in this briefing will not provide the complete solution to all staff morale issues, they are some early steps the new government can take to boost morale, make the NHS a more attractive place for people to remain working in, and create better conditions for NHS staff to work safely, efficiently and effectively.