The key issue in expanding NHS capacity is staff, and the need for a long-term workforce strategy. Without significant investment, and a willingness to change the way staff are treated and managed, the chronic shortages are only likely to grow – putting patient safety and quality of care at risk.
This was highlighted in a heavy-hitting speech last month in the Lords by Lord Stevens of Birmingham, aka Simon Stevens, no longer constrained by his seven years in charge of NHS England.
Stevens was keen to lay the responsibility firmly for delays and failure at the door of the government and the Treasury, who he argued had time and again blocked the development of any serious workforce plan by failing to guarantee the necessary funding, and prevented discussion of any plans that might cost more. Tracing this right back to his own first year in post, he said:
“It was back in 2014 that the NHS Five Year Forward View talked about the service changes that were required, but it was not permitted to talk about future capital investment, social care or workforce training, since they were being kept separate.”
Two years later “in summer 2016, the Department of Health and Social Care was going to produce this detailed quantified workforce plan instead.” But that didn’t happen:
“instead, in December 2017– three years after the Five Year Forward View – Health Education England launched a consultation document which said: “Your responses will be used to inform the full strategy to be published in July 2018 to coincide with the NHS’s 70th birthday.”
“Twenty-eighteen came and went, and answers saw we none. Then in June 2019, we got another, in this case interim people plan, with lots of excellent content but unfortunately no actual numbers and no new pound notes.”
A full, costed five-year Plan was promised “later this year” but nothing was heard until in July 2020 “we had a one-year people plan which, at that point, was covering just the next eight months,” and promising “Further action … to be set out later in the year … “once funding arrangements have been confirmed by the Government.”
But instead, “in July 2021, last summer, the Department of Health and Social Care again commissioned Health Education England to start from scratch.”
Whether or not the Lords amend the Health and Care Bill to include a requirement for regular updates and planning of workforce, and whether ministers accept it in the Commons remains to be seen: but there is no evidence in recent statements that ministers have grasped the need for more than empty promises.
On 25 January Sajid Javid told MPs he had “recently” commissioned an NHS workforce strategy: but in the same meeting of the Health and Social Care Committee, its chair Jeremy Hunt reminded Javid that Health Education England, the body charged with deciding how many doctors and health professionals are trained, still does not know how much money they will have from April, as it goes in to a merger with NHS England.
The government’s Red Book last October declared that the Spending Review settlement “will keep building a bigger, better trained NHS workforce,” and reaffirmed “the government’s existing commitments for 50,000 more nurses.”
On January 24 Lord Kamall tried to reassure the Lords debate that the government was “on target” to recruit the promised 50,000 nurses.
The facts are very different. No funding has been allocated to pay the £1.5bn per year minimum cost of an additional 50,000 staff. The 50,000 target also included an ambitious number of overseas recruits – and retention of 19,000 existing staff – while anecdotal evidence suggests demoralised and burned-out staff are leaving and overseas recruitment has stalled.
Workforce statistics (September 2021) show nurse numbers up overall by just 11% since July 2010, and midwife numbers by 13%, but health visitor numbers down by 19%. Mental health nurse numbers are also down by 2,350 (5.6%) and falling, despite the promise by Theresa May’s government in 2017 that 21,000 new posts would enable mental health trusts to treat an extra million patients a year.
In the last quarter of 2021 a record 27,000 clinical staff voluntarily resigned from the NHS.
The most recent figures, to September 2021, show 99,460 (7.3%) unfilled posts across England’s NHS of which almost 40,000 are nursing posts, with vacancy rates ranging from 7.8% (South West) to 13.1% in London (with higher rates for mental health staff, ranging from 8% in the North West to 14% in London).
They also show only 8,440 nursing and midwifery vacancies were being advertised in September 2021, almost 23% down from 10,944 in September 2020.
The ridiculous decision of Tory MPs to vote down Jeremy Hunt’s proposal for two-yearly reviews of staffing levels and workforce plans serves only to underline the yawning gap where there should be a workforce strategy.
This is compounded by the lack of realism in ministers’ attempts to hold down NHS pay.
A substantial across the board fully-funded pay increase for all NHS staff – over and above the 3% 2021 ‘increase’ that has already been swallowed by inflation and increased national insurance payments – is also needed to show hard-pressed and demoralised staff, who are beginning to leave, that they are valued. It would help retain them, recruit new staff – and make it more attractive for qualified staff who have left already to come back and work for the NHS.
Last October Andy Cowper in Health Policy Insight urged an immediate resumption of the work that had been done to get retired clinicians to return to practice, which had been halted “once the first wave of infections in 2020 was not believed to have demonstrably overwhelmed the NHS. That decision was a big and foolish error, and it should be fixed.”
And to tackle the dwindling recruitment of EU and other overseas qualified staff to strengthen NHS and social care teams the government has to scrap all limits on overseas recruitment and the counterproductive migrant surcharge and visa fees which spell out a message that foreigners are no longer welcome. The cost of these measures in lost revenue would be minimal and the potential benefits very substantial.
While the extra spending required to resource a serious workforce plan is substantial, it will, as health spending always does, generate other benefits including the creation of more jobs in construction, in health care, and the supporting industries, which in turn will generate economic growth across the country.
But it’s not all about pay. With pay in some supermarkets and service industries now outstripping NHS rates, a combination of investment in staff, a zero tolerance crackdown on bullying and harassment and all forms of discrimination, and an investment in staff welfare and wellbeing are also necessary to make the NHS an employer of choice.
Andy Cowper has also called for a renewed effort by trusts to look after their staff as well as possible. “If organisations have been foolish enough to take out obvious pandemic improvements like free car parking and provision of good access to food, then put them back immediately.”
The government has offered only complacency and warm words. Last month Lord Kamall claimed that NHS England had an “intensive retention support programme” in place since 2017, offering “emotional, psychological and practical support for NHS and care staff.”
Former Chief Nursing Officer Dame Sarah Mullally boasted that in 2020 £15m funding had pledged to strengthen mental health support for NHS England’s (1 million) staff. But despite a further £37m for 2021-22 to enable the continuation of this offer in the pandemic, staff wellbeing remains a serious concern, and the Nursing Times reports many nurses warning that national support has not been good enough.
Despite being pressed on the point Lord Kamall made no commitment to any additional funding for staff wellbeing.
The practical point about availability of food, especially for hard-pressed staff on 12-hour night shifts, is underlined by recent shocking findings of a survey by the Institute of Health and Social Care Management, which found that less than 10% of 250 responses reported that freshly-made hot food was available 24/7 in their trusts, while 38% reported “no food of any type (hot or cold) was available at all.”
As a result “streams of fast food delivery companies” mean security staff on nights and weekends were being diverted from their normal duties “to act as concierge for deliveries and contacting ward staff who had placed the orders.”
The IHSCM reiterating its support for 24/7 provision of hot food for staff in health and social care, comments: “Whilst the NHS and social care experience severe and consistent workforce recruitment and retention issues it is strange that the issue of hot food availability for staff who may be working long shifts is not taken more seriously.”
Attention to staff wellbeing can help increase staffing levels, improve the quality of patient care, and in so doing improve the morale and job satisfaction of staff, win back the confidence of some patients, and begin to clear waiting lists and rebuild the performance of the NHS after the long dark decade of decline since 2010.
The continued failure to devote serious resources to staff wellbeing especially in such stressful times heads in precisely the opposite direction.
Worst management examples?
The Lowdown recognises that most NHS senior managers have made extraordinary efforts alongside staff before and during the Covid pandemic: but some are clearly detached from the problems faced by staff at the front line – and others are failing to shoulder their responsibility to develop suitable wellbeing support for staff under the greatest stress.
Diane Wake, chief executive of the Dudley Group NHS Foundation Trust, which runs Russells Hall Hospital. She has opted to turn to crowd funding and the hospital’s charity to finance what should be basic wellbeing measures.
The Birmingham Mail reports the charity has been inviting donations through justgiving.com. The suggestions on how the money might be spent show the Trust want charitable funds to do the sort of things a caring NHS management wanting to retain valued staff should itself be doing. The appeal states:
- £5 could cover a hot meal for a frontline staff member who is unable to leave the ward on a twelve-hour shift.
- £15 could fund a wellness pack for one of our extremely stretched staff members, particularly those in financial hardship.
- £50 could help provide emotional support for a nurse at the end of a gruelling shift.
- £10,000 to 20,000 could refurbish a staff room into a wellbeing space where staff can relax, refuel, and recharge as they spend some much-needed time away from clinical areas.
The appeal has so far raised over £210,000 of the £300,000 target. We have no information on whether and how it has been spent.
But the existence of a “fundraising and community development lead” on the staff of the trust, and the call for donations to facilitate what should be the basic work of the NHS as an employer, echoes the desperate Thatcher years in the 1980s in which hospitals were forced to divert management time and effort to “income generation” schemes – and even jumble sales – to keep services going.
What staff need in these new mean, lean times of austerity is a management that recognises their welfare is a management responsibility, rather than hoping a generous public will fork out to fill in the gaps.
If you have evidence of management decisions that are unsupportive to staff send it to us at The Lowdown, with enough information to run a story: we are happy to keep our sources confidential.
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