Surgery & Emotion responds to the NHS Long Term Plan

January 2019

Following the release of the NHS Long Term Plan, Engagement Fellow Alison Moulds and Research Fellow Agnes Arnold-Forster reflect on its implications for the healthcare workforce.

Credit: Adrian Wressell, Heart of England NHS FT (Wellcome Collection).
Credit: Adrian Wressell, Heart of England NHS FT (Wellcome Collection).

Last week saw the release of the NHS Long Term Plan, which sets out priorities for the health service for the next 10 years and outlines how the £20.5bn annual budget will be spent. Surgery & Emotion were pleased to see that workforce issues were identified as a key theme, but cautious that more specific actions to tackle these concerns will not be unveiled until later in the year.

In discussing the workforce crisis, the Plan recognises that staff retention is an ‘urgent priority’, and cites lack of development and career progression as the major reasons for staff leaving, which need to be addressed. Crucially, the Plan also acknowledges problems with work-life balance, reflecting on the inflexible and unpredictable working patterns endemic in the health service. The strategy claims that it will ‘shape a modern employment culture for the NHS’, one which entails greater flexibility and staff wellbeing, with enhanced efforts to tackle discrimination, bullying and harassment.

Yet complaints about inflexibility and unpredictability are not new and there’s a long history of recurring interventions and ‘innovations’ designed to ameliorate the culture of the NHS and the wellbeing of its staff. In 1974, John D. Harte wrote in the Royal Society of Health Journal that the NHS was now ‘the largest employer of labour in the country’, with wages and salaries 70% of its total expenditure. ‘It will become a prime duty of management of the reorganized National Health Service to use this resource to the maximum effectiveness and efficiency’, Harte opined.

In 1976, doctor and one-time President of the British Medical Association (BMA), Sir George White Pickering, described working conditions in terms that are familiar to us today: ‘The junior hospital doctors have long been dissatisfied with some of their conditions…Moving from place to place, particularly with small children, has been inconvenient and costly’. One year later, the Royal College of Physicians gave evidence to the Royal Commission on the NHS that also echoed the language and spirit of the new Plan: ‘The success of the National Health Service will always depend above all on the ability, training and morale of the doctors who staff it’.

The terminology used in the Long Term Plan is circumspect and open to interpretation. What, for example, does ‘modern’ mean in the context of the NHS’s ‘employment culture’? What is ‘modern’ about addressing needs and complaints that have been made for decades? The Plan speaks about ‘flexibility’ and ‘wellbeing’ without defining what those words might mean. The Government needs to ensure that any new ‘flexibility’ benefits staff and patients rather than employers or politicians, and it needs to guarantee that ‘wellbeing’ is not achieved through piecemeal ‘solutions’ that place the onus on individuals rather than institutions. The Plan also suggests that staff should feel ‘supported, valued and respected for what they do’ and treat one another with the same values expected in patient care. But it is vague about how exactly this transformation will be achieved.

There are plenty of successful blueprints that the Government could follow and Surgery & Emotion have been delighted to see the number of professional initiatives already at work in this important area. We’ve attended anti-bullying events organised by the Royal College of Surgeons of Edinburgh and the BMA. At our ‘Operating with Feeling’ workshop (held in conjunction with the Royal College of Surgeons of England (RCS)) in June, we heard from surgeons Alice Hartley and Simon Fleming about campaigns to tackle bullying and harassment within surgery.

The Plan also refers to the role played by an ‘expanded’ Practitioner Health Programme (PHP) to help all NHS doctors access specialist mental health support. As part of our work on Surgery & Emotion, we’ve met with Clare Gerada (Medical Director of PHP), and we were delighted to have their Clinical Director Richard Jones speak at our ‘Operating with Feeling’ workshop. Many attendees cited learning about the PHP as an important ‘take-home’ from the day, and we feel the service provides a crucial support system to staff.

We were also pleased to see the Plan acknowledge that staff are best placed to offer solutions. One of the pleasures of the Surgery & Emotion project has been the chance to talk to practitioners about their experiences of working in the healthcare system. At our upcoming event with the Royal College of Nursing (details TBC), we’ll be using breakout groups to explore with participants how to remedy some of the challenges surrounding the emotional health of the NHS workforce.

So given the lack of precise details, what ‘next steps’ does the Plan announce? It states that Higher Education England (HEE), NHS Improvement, and NHS England will collaborate to establish a national workforce group concentrating on the delivery of workforce actions. The report also announced the creation of a new role – Chief People Officer (CPO) – who will work with the workforce group to improve health and wellbeing among NHS staff, support flexible working, and set expectations about the help staff should receive when they want to raise concerns. The CPO is also supposed to strengthen equality and diversity in the workforce.  

Unveiling the plan in Parliament, Health Secretary Matt Hancock announced that Conservative peer Baroness Harding of Winscombe (Chair of NHS Improvement) would oversee the development of this new workforce plan. With soundbites on cue, he promised the plan would put ‘NHS people at the heart of NHS policy and delivery’. Baroness Harding is set to provide interim recommendations by the end of March on how to tackle challenges surrounding staff supply, culture and leadership, with final recommendations scheduled for later in the year.

Responding to the Plan, the RCS highlighted that staffing issues were a major concern, referring to the prevalence of burnout. The College suggested that many practitioners would be ‘understandably cynical’ about whether the plans were ‘attainable’. It called on the Government to publish a more detailed workforce plan as soon as possible, given the urgency with which the current pressures need to be resolved. The Royal College of Surgeons of Edinburgh also released a statement emphasising workforce problems. It similarly referred to staff shortages, and called on NHS policymakers to ring-fence training budgets and time for training, and to implement a more supportive migration policy for overseas staff. It called for ‘an open and honest conversation’ about the resources needed to meet demands, including workforce planning.

Surgery & Emotion also awaits further specificity about how the workforce will be supported and the employment culture improved. We will be monitoring how any new developments will affect the personal and professional lives of surgeons and their colleagues. A historical perspective encourages us to be sceptical about the utility of short-term initiatives designed to tackle long-standing problems, and we hope to see real change that moves beyond current buzzwords about wellbeing. At our upcoming event with the RCN, we’ll be talking to members of the NHS workforce about the systemic changes they feel are needed to support healthcare practitioners in the face of current and future pressures.