If the NHS wants to become a ‘well-being service’, and not a ‘sickness service’, what better place to start than its own staff?
The recent announcement by NHS England to invest £5 million in its staff is warmly welcomed. Part of the plan is to pilot a series of health promotion activities in ten acute trusts covering 55,000 staff. These activities include health checks, physiotherapy and talking therapies for those that require it, healthier food options and physical activity opportunities. The hope is to reduce staff sickness absence rates (which costs an estimated £3.3million annually per NHS organisation), increase staff retention and reduce the use of temporary staff; thus improving patient care.
This all sounds good, but will it really make a difference for patients?
Evidence so far shows that better staff health and wellbeing is associated with improved patient outcomes. The Keogh review of 14 hospital trusts with high patient mortality rates found all these trusts also had higher levels of staff sickness, compared to national average. The Francis inquiry into Mid Staffordshire also exposed the consequences for patients and staff of not addressing this issue of staff morale and sickness. In a time of great public sector financial constraint, rising healthcare demand and NHS staff shortages, this couldn’t be more paramount.
So is the NHS staff sickness absence really that bad?
According to the Office of National Statistics, the NHS staff sickness absence is 27 per cent higher than any other public sector organisation average and 46 per cent higher than the average for all other sectors . From the QualityWatch indicators we can see that rates of sickness absence fell gradually between April 2009 and March 2014 (solid line, see chart below), but over the last year they have risen again, peaking at 4.8 per cent (or 1.5 days a month) in December 2014. NHS England is right to encourage initiatives to address absence, as investing in staff health and wellbeing has the potential for significant gains. One has to ask if this possible change in the trend is a reflection of low staff morale, stress and burnout.
Are the rates of absence uniform across the NHS?
No, there is fluctuation between the type of organisation and the type of job role. Ambulance and mental health trust staff have consistently over the last five years had the highest rates of sickness absence, taking an average 22 days off a year (primary care data is not included).
There is also a relationship between skill level and sickness- see chart below. The lower the pay band of the employee, the higher the rate of sickness absence, with those in band one and two having an average of 22 days off a year compared with band nine employees taking an average of 4.3 day. This difference might be explained by a sense of less job control which is known to be associated with higher rates of non-communicable disease.
Why are NHS staff sickness rates so high?
Jobs in health care, whilst rewarding, are known to be more physically, emotionally and psychologically demanding than other jobs. In the 2014 NHS staff survey, 39 per cent of respondents reported being unwell in the last year from work related stress; with 14 per cent reporting having experienced physical violence and 28 per cent being bullied or abused by patients, their relatives or members of the public. These figures are highest among paramedics and mental health workers, which are reflected in their high absence rates.
So is enough being done to support NHS staff to cope with the high levels of emotional and physical stress? It appears not. In the same survey, only 41 per cent of staff felt that their Hospital Trust valued their work and 29 per cent believed that senior managers acted on staff feedback.
What can the NHS do to improve NHS staff health and wellbeing?
The health promotion activities announced by NHS England will address some of the lifestyle issues exacerbating the staff sickness absence. With half of the NHS workforce either obese or overweight, the NHS as an employer has a lot to gain by supporting behaviour change and challenging catering companies to offer healthy food options. However these interventions alone will not address the causes of work related stress identified in the NHS staff survey.
This national initiative across ten trusts is welcomed, but this needs to be implemented alongside a wider culture change across the NHS. Although more Trusts (65 per cent in 2014 compared to 41 per cent in 2011) now have a plan for workforce health and wellbeing, a third do not; and a plan alone will not deliver change. NHS organisations need to prioritise staff health and wellbeing in the long term. Staff health and wellbeing needs to be championed by senior management. More managers need support to identify stress and ‘burn out’ early, as less than half of NHS managers say they have ever received training, and managers need to have the available resources to act. Most importantly, staff need to feel that they can influence their work experience, engage with their organisation and feel that their feedback is valued. The government has set a poor example of this with the recent punitive implementation of the junior doctor's contract , which will only result in further disengagement by the clinical workforce.
Will the current initiative work?
The current initiative announced by NHS England is evidence based, has some resource behind it and is well intentioned. But in addition to promoting behaviour change interventions, it needs to advocate for a more supportive team and management culture. Examples should be taken from NHS organisations with low reported levels of staff work stress and higher staff engagement scores.
In an environment where four out of five hospital trusts are likely to be in deficit by the end of the financial year and targets such as the four hour wait in A&E are at their worst level; it is hard to imagine NHS organisations prioritising staff engagement and developing a more supportive team culture. However, the support of the clinical workforce is key to achieving the transformational change required currently in the NHS. Investing in staff health and wellbeing is more important than ever.
Bhatia T (2015) 'What will be the real cost of poor NHS staff wellbeing?'. Nuffield Trust comment, 5 October 2015. https://www.nuffieldtrust.org.uk/news-item/what-will-be-the-real-cost-of-poor-nhs-staff-wellbeing