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‘The workforce’: People and relationships

Jocelyn Cornwell 13 August 2018

This article was written as part of ‘Priorities for the plan. The long-term NHS plan and beyond: Views from leaders in charities and voice organisations’ which was published in July. The Point of Care Foundation was invited to contribute a chapter on ‘Workforce’.

Topics and programmes


What is the problem?

There are not enough of the right people with the right training and experience to meet the needs of patients. This is the immediate problem staring the NHS in the face. The critical lack of bodies on the ground has focused senior decision-makers’ attention on ‘the workforce’. But to solve the problems, we need to stop talking about ‘the workforce’, and start talking about people and relationships. And we need to focus on the deep-seated systemic issues within the health system that underlie workforce problems.

In primary care and in community settings, the shortage of qualified personnel is desperate. Over half of GP practices report at least one vacancy, and between 2009–14, district nursing posts halved. In hospitals, consultant numbers have risen, but there are rota gaps in all specialities because the number of newly qualified doctors choosing to go straight into NHS posts is falling – from 72 per cent in 2011 to 50 per cent in 2016. In nursing, 36,000 posts are vacant and leavers are not being replaced quickly enough. The number of student nurses has fallen since the Government removed bursaries, and the number of new joiners from Europe has fallen from 9,389 in 2015/16 to 805 in 2017/18.

It is impossible to overstate the impact of these shortages on the staff who remain in post or have recently joined the service, and who have to help or work around temporary staff, plug gaps and spread themselves more thinly. They come under increasing pressure, which in turn causes stress and make the work less satisfying. Surprisingly perhaps, sickness absence has declined in the last few years – while it is very highly managed, presenteeism (people reporting to work when they do not feel well) has reached an all-time high of 65 per cent. The everyday experience of too many employees is one of feeling that although their work with patients is worth doing, the organisational environment makes the work difficult or impossible.

Some of the people under the most intense pressure are the middle managers – the department and directorate managers, many of whom are clinicians in management roles who sit below the level of executives, with numerous, often first time managers reporting to them. These are the people who have to reconcile conflicting and sometimes incompatible demands. They are operationally responsible for everything that happens to staff and patients, but have very little power over resources and decisions.

Recent annual NHS staff surveys show that staff engagement and relationships between staff and their immediate managers are satisfactory and improving, but they also tell us that NHS organisations discriminate against black and minority ethnic staff and tolerate levels of bullying and harassment by managers and co-workers that would not be tolerated by good employers. In 2017, 38 per cent of staff reported feeling unwell due to work related stress.

What needs to happen?

At national level, senior policy makers need to stop talking about ‘the workforce’ as if it is some kind of abstract and renewable natural resource, and start talking about people – with lives of their own, who have choice and who need to be attracted, rewarded and supported as they do the difficult work of caring for patients within a difficult and uncertain environment. Employers need to make practical provision to promote the physical and mental health of employees, provide opportunities (such as the Schwartz Rounds) for them to reflect together on their work with patients, and reduce the administration and bureaucracy that weighs people down and gets in the way of delivering good care.

At local level, NHS employers must make sure the people who work for them feel supported, listened to and valued by their managers and colleagues. Staff must be able to seek help when they need it, without being labelled as ‘weak’, and be able to develop their career and themselves.

Finally, staff wellbeing and experience needs to be incorporated into the narrative about change and transformation. We cannot change services in the ways described elsewhere within this collection, without investing in helping the people who provide the services to change. This will require investment in training, coaching and on-going support. To give just one example: doctors today have had no formal training in patients’ experience of illness, patients’ experience of services, how to share decisions about treatment with patients or how to help patients manage symptoms. If we want staff to have compassionate, more equal relationships with patients, and to provide leadership and work effectively in multi-disciplinary teams, then we need to offer new and different types of training and supervision at scale.

What priority action needs to be taken ‘now’?

NHS England is the lead organisation responsible for providing safe, high quality services and should not delegate responsibility for ‘the workforce’ to other bodies. It needs to set the pace and create a bold and inspiring ambition for the NHS to become the place where people of all ages in the UK want to work, and it needs to lead practical actions that will achieve it.

Nationally, more can be done to recognise the intense pressures on people who work for the NHS and how hard they are working to maintain standards for patients. The NHS is brilliantly positioned to exploit its position as Britain’s most loved institution and actively and openly celebrate the fact that, in an era when work for many is soulless and unsatisfying, the work of caring for people and helping them to live healthier and fulfilling lives has meaning and purpose.

Local NHS organisations should cultivate a reputation for listening to and caring about their staff. For trusts that have yet to make staff engagement a board level priority, the recommendation is to make it one. All trusts should have board level strategies for staff engagement that are supported by an operational plan, a two-way communications plan co-created with staff, a governance plan, and a plan for investment in organisational development and training. Within these, trusts need to recognise and respond to the needs of middle managers – the people with most influence over how other employees feel at work – including through investment in multi-disciplinary leadership training and on-going developmental support.

There is much to do, but we must start by remembering that staff and services are synonymous. Without engaged and motivated staff it is simply impossible to provide high quality treatment and care, let alone accelerate improvements.