The NHS is struggling with the increasing realisation that the allocated money for the next few years will not be enough to pay for the demands being placed upon it. We have also heard that there is unlikely to be any more money, despite the significant inflationary shock that may follow the recent currency devaluation. Yet less attention has been given to a potentially greater problem: the inter-related problems of workforce shortages and poor morale.
The junior doctors’ dispute shone a light on the issue, but there has been growing concern and signs that a sense of detachment and demoralisation is creeping its way through the workforce. This threatens to undermine the huge change programme required to deliver the savings that are needed and the Five Year Forward View. How can we expect staff to champion far-reaching changes to transform care if they are demotivated and disaffected?
In the latest survey of NHS staff, only 42 per cent were satisfied with the extent to which their work was valued by their organisation, while 57 per cent said they were unable to meet the conflicting demands made on them. The Nuffield Trust’s most recent survey of 100 health leaders found almost 60 per cent thought that morale had deteriorated at their organisation, with workload cited as the main factor, closely followed by the financial position of the organisation and the NHS more generally.
So what can we do about it? At this year’s political party conferences, the Nuffield Trust and the Royal College of Surgeons brought together leading politicians, trade unions, doctors, nurses, allied health professionals and employers for roundtable discussions about those extra-contractual issues that, if addressed, might boost morale and make NHS staff feel valued at work.
Two broad types of solution were identified: those within the power of NHS staff to change and those outside of their immediate control that require action from those in more senior positions in the health system.
Actions within local control
In recognising that NHS activity is unlikely to become less intense over the coming years, we cannot just wait for a top-down solution to improve morale. So what can individuals working on the frontline do to champion positive behaviour and improve morale?
#HelloMyNameIs has been a great success for patients, partly through its simplicity, in raising awareness about problems with clinician–patient communication. Some attendees felt that a similar campaign was needed for workforce colleagues. Busy hospital staff under pressure sometimes don’t take the time to properly introduce themselves or say hello to a fellow member of staff. Being polite at work does not cost more money.
Doctors at our events felt there was a particular need for consultants to show more leadership by being positive about careers in medicine, and mentoring and supporting those in training. Senior clinicians also have a role to play in stamping out poor workplace culture, including undermining behaviour and bullying.
While there has been an emphasis on improving care at nights and the weekends, there has been less importance placed on providing better out-of-hours support for staff at work at these times. Weekend availability of canteens or crèches is very variable. If we expect staff to work at weekends, it was argued, then it is only fair to provide access to these services as well.
Attention to the detail of how staff are treated is important. For example, some hospitals have been poor at providing sufficient notice of rotas. Better advanced planning in the age of technology and the Doodle poll does not cost anything and would make a huge difference.
For the medics, recruitment into training programmes does not feel personal and therefore the opportunity to make initial and lasting mentoring relationships is often missed. Induction, especially for junior doctors but also for midwives and nurses, can be repetitive and poorly organised. Yet when done well it can be very important for helping orientation and communicating an organisation’s values. NHS trusts should therefore be thinking more carefully about the structure of these sessions and whether they are making the most of inducting new members of staff appropriately.
Schwartz rounds are seen as very beneficial to morale, helping teams to have a sense of community and to discuss their concerns.
Action for national leaders
The pressures of the wider system, and the focus on finance and performance management in particular, play their part in impacting morale – not least through rising workloads and declining staff numbers. It’s hard to see how the current performance pressures are conducive to encouraging a caring culture in our health service. Ultimately these wider issues still need addressing.
Providers with good staff morale tend to be those who invest in personal development and training. In this context it is concerning that professional development budgets in the NHS have been cut. This is particularly relevant as the NHS is looking to develop more non-medical roles to support the current workforce. Equally, more support needs to be given to developing clinical management opportunities and skills.
Low morale, as well as bullying, affects trust chief executives as much as frontline staff. Those at the top play a vital part in establishing the culture of their own organisations. If they are being pressured and harshly performance-managed by system leaders, this poor culture risks trickling down, infecting the wider system. With the turnover of chief executives’ resembling the short tenures of Premier League football managers, more needs to be done to provide support for our organisations’ leaders.
Due to the nature of system-wide decisions in the NHS, staff can sometimes feel the locus of control is far removed from them. Sustainability and Transformation Plans are a recent example. If more is not done to engage clinicians and patients in significant changes to the health service, there is a risk of further demotivating staff.
There were a number of other issues identified that need further reflection. Doctors working in acute specialties such as surgery often support a nostalgic return to a ‘firm structure’ of apprenticeship-style working. While team working is common, the lack of regular senior mentoring opportunities is what is missing from the current structures. Other specialties have questioned whether 'the firm' is a realistic model for the modern NHS and argued that it does not apply as well to general practice, or to nursing and other health professions. Nonetheless, the mentoring opportunities, or lack of them, apply across the profession.
Consideration also needs to be given to the experiences of different groups of staff. Black and minority ethnic staff report much worse concerns, for example. The NHS Staff Survey and the General Medical Council’s trainee doctors survey need to be more widely studied by the NHS to monitor areas for improvement in morale. There is also a vast workplace psychology literature that needs to be better explored, with further options presented.
One way or another, it is absolutely clear that workforce morale requires much greater priority. Let’s try some simple things now – they may make a difference.
Edwards N and Marx C (2016) 'The morale maze'. Nuffield Trust comment, 27 October 2016. https://www.nuffieldtrust.org.uk/news-item/the-morale-maze