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The best place to work?

Jocelyn Cornwell 13 June 2019

The Interim NHS People Plan, published last week, is a first instalment of the ‘comprehensive plan’ for the NHS workforce promised in the Long Term Plan. 

Perhaps necessarily, it is short on detail at this stage, and much of it is geared towards defining activities to feed into the longer term plan. We await further individual plans for several sections of the workforce, including AHPs, psychological workers, dental workers and healthcare scientists. The interim plan identifies nursing as a priority area which, with tens of thousands of vacancies in need of filling, certainly needs urgent attention. 

An area where the plan goes into some depth is culture. This is vital to resolving the workforce crisis. In an article last year on workforce, written as part of a project designed to influence the long term plan, we argued for the importance of thinking about the lived experience of people working within the health service. Recruitment is obviously a big challenge for nursing and other health professions, but as the plan notes, the other issue is retention – a problem echoed across many groups of staff. Without proper thought to what good culture looks like, retention will not improve and the problem of workforce numbers is unlikely to be resolvable.

Recognising the health workforce as individuals

For a long time there has been a tendency to see the health workforce as a somewhat amorphous mass of people, with little attention paid to the individuals who comprise it, and their relationships with colleagues and managers. The mood music in the Interim People Plan indicates that this thinking may be evolving and it is welcome. 

The interim plan says: “There is compelling evidence that the more engaged our people, the more effective and productive they are, and most importantly, the higher the quality of care they deliver to our patients. Our patients know that to be true – they tell us clearly that they want the staff who look after them to be well cared for themselves.”

The plan’s headline ambition, therefore, is for the NHS to be ‘the best place to work’. This is commendably ambitious, but the degree of performance management implicit in such an aspiration brings to mind the kind of target-driven leadership style that has caused so many of the problems within the culture of the NHS. The evidence of the NHS staff survey and our own research on staff engagement is that people tend to have more trust in their immediate managers than in senior leaders, who seem remote. It might win more trust among staff if the top team set the more realistic goal of simply ensuring the NHS is always a good place to work.

What does good look like?

Our definition of good workplace culture is drawn from experience and the evidence underpinning our work. We see the impact, for example, of good staff engagement, provision of opportunities for reflection, and a leadership culture that recognises workers as individuals with their own lives and priorities, who need to be treated respectfully if they are to be retained. We also know that staff welcome the opportunity to look afresh at how services are delivered, and that work on quality improvement, led by staff working in partnership with patients, can provide these.

Impacts like these come from more than a generalised sense of staff ‘wellness’. Policies for yoga at work, healthy food in vending machines, or cycle to work schemes are all useful, but they are peripheral to the culture of an organisation, not central to it. What is needed are changes in the workplace and to the conditions in which people work with patients. These include flatter hierarchies, more mutual understanding and respect within and between teams, senior staff being open and receptive, and zero tolerance of bullying.

Policies for yoga at work, healthy food in vending machines, or cycle to work schemes are all useful, but they are peripheral to the culture of an organisation, not central to it. What is needed are changes in the workplace and to the conditions in which people work with patients.

All of which brings us to ‘compassionate leadership’, or the value of leaders in establishing compassionate cultures within the NHS. It is another area highlighted in the interim plan. While this is again a welcome theme, we must remember that organisational culture cannot only be driven by senior leaders. 

While boards and senior managers set strategic direction, most people working within health organisations relate far more to their teams than to the organisation as a whole. Actual leadership happens at all levels within an organisation. 

It is the nitty-gritty of these lower-down processes that make a bigger difference to staff, and this is where we believe senior leaders should focus attention. Compassionate leaders might ensure training in people management is available, to support everyday leadership and help develop environments in which people are respectful towards each other and patients. They might ensure that regular team meetings take place to facilitate this, and that rosters are sufficiently flexible to allow people time to support their families at times of crisis. These are the small but profound things that can make the biggest difference. 

More detail needed

Much more detail is needed about how workforce changes will be developed, and particularly how they will be funded. The plan acknowledges that much of its implementation will depend on the Spending Review. Immigration policy is another variable that could undermine the whole process, so needs to be cleared up as a priority. 

At the Point of Care Foundation we will continue to work to support NHS staff and leaders to help improve organisational culture at all levels.