ANALYSIS
new roles are faster and less expensive to train than others; physician associates, for example, take a two year masters or postgraduate diploma, so they can enter the workforce rapidly. In principle, new and innovative professional roles might add value to teams. But some of these roles, particularly those that take on activities previously undertaken by other professional groups, have also created new challenges and risks associated with like-for-unlike substitution. The overall effects on patient safety remain largely unevaluated, and much of the available evidence, for example in nursing, already indicates that substituting less qualified staff for registered nurses is associated with worse outcomes and risks. 13 Major concern has also been raised about the effect of new roles on the training opportunities available to other clinical staff. Also unclear is whether increased role diversification will deliver all the hoped for benefits. In general practice, for example, the increased diversity of roles adds complexity: it requires sound processes for matching patients to the most appropriate professional and might also involve reassuring patients of the equivalency of care, create the potential for duplication and inefficiencies, and, perversely, may increase GP workload through the extra coordination and supervision burden. 14 -16 It is now clear that, for new roles, issues such as team and task design; scope and boundaries of practice; effects on current roles and grading of other team members; and governance and quality assurance all require substantially more consideration and consultation, including with patients and the public, than they have so far received. Careful planning, monitoring, and a research and evaluation programme are needed to more effectively plan and manage new roles, ensure clear scope of role, carry out work system design combined with safety assessments to clarify which tasks can be safety assigned to whom, design and implement appropriate regulation, and safeguard training and development opportunities across different roles. At the same time, hard policy decisions might need to be made about what can reasonably be offered to the public based on the resources available to the NHS compared with other public sector priorities, including those that are related to health such as housing and environment. New technologies Configuring the workforce for the future of the NHS is, of course, not just a matter of tackling vacancies. It also requires thinking about the work to be done and how it can be undertaken effectively and efficiently. The dynamic and often rapidly shifting nature of scientific developments, demographics, service innovation, and technology, for example, must be taken into account. Staff take a long time to train and reach peak competence, but the work they need to do might change more rapidly. New technologies, including artificial intelligence, remote care, digital health, and genomics based medicine, might be rich with opportunity but are also highly disruptive. As these innovations penetrate more fully into healthcare, agility and responsiveness will be needed in planning not just for roles but for skills and for how the design of work systems and roles can evolve in both patient centred and staff centred ways. This is likely to require far more collaborative and co-design techniques than the NHS is used to — for example to ensure that “ non-technical ” skills, operational systems, training, and communication and decision making with patients are prioritised 17 as key elements of technology deployment. More generally, workforce planning and new roles need to be treated as major, novel interventions that require consultation and rigorous design to ensure that they are specified, evaluated, managed, and regulated appropriately and rigorously, with clarity about
boundaries with existing roles, and adequate consideration of unintended consequences and risks of deepening inequities. Improving conditions Satisfaction and value Pay is an important source of dissatisfaction for NHS staff, with less than a third (31.2%) of respondents to the 2023 NHS staff survey saying that they were satisfied with their pay. 4 The survey shows that pay satisfaction remains about seven percentage points below pre-pandemic levels (2019). Among medical and dental staff, satisfaction with pay is now 23 percentage points lower than in 2020, at 32%. 4 Pay dissatisfaction is, of course, a major factor in current industrial action. Despite its importance, pay is only one of several factors that influence staff experience. 18 A sense that NHS systems do not always seem to value people as people but instead as resources to sweat is deeply implicated in issues relating to job satisfaction and retention. 18 A 2021 survey of nearly 5000 staff found that 47.5% of staff felt their work was undervalued by the government, 20.6% felt undervalued by their employer, and 17.7% by the public. 19 Forsome, working for the NHS might feel exploitative at times; only 45% of staff report that they are satisfied with the extent to which their organisations value their work. 4 Working conditions Linked to this, working conditions in the NHS are a major source of concern, with 41.7% of staff reporting feeling unwell as a result of work related stress in the past 12 months. 20 Workload pressures are often overwhelming. Many staff feel overstretched, demoralised, or burnt out. A majority (71%) of GPs, for example, report that their jobis “ extremely ” or “ very ” stressful. 21 Staff increasingly experience moral injury linked to the inability to provide the care they think they should be able to give 22 ; the sense of letting patients down is highly damaging for people ’ s experience of work. 23 Workload stress is compounded by the highly complex and demanding nature of the institutional and regulatory environment of the NHS generally, 24 which means that services, and the staff who work in them, might end up being answerable to a large number of different bodies and agencies whose rules, principles, and procedures might conflict or fail to cohere, adding to the workload. Inspections and other regulatory actions that result in unfavourable outcomes might be especially challenging for staff, with effects including fear, stigma, andshame. 25 Practical challenges are highly consequential for people ’ sability to participate in the workforce and for their experience of work. NHS staff are often expected to work unsocial hours without support for transport and childcare, with the mismatch between housing costs and NHS salaries compounding these problems. Despite NHS Employers guidance, 26 the basic needs of staff are frequently poorly met, 27 with routine workplace facilities often lacking adequate toilets, fridges, chairs, lockers, and access to food and water, and staff reporting that they feel they cannot take breaks. 28 People ’ s experiences of starting new jobs are often poor, with fundamental problems such as onboarding — setting up identity badges, IT accounts, and permissions — often taking far too long. Basic administrative infrastructure to support staff is often lacking and has huge effects. Payroll errors, for example, can compound low pay and are corrected very slowly. By contrast, Australia, for example, has fortnightly pay cycles.
the bmj | BMJ 2024;384:e079474 | doi: 10.1136/bmj-2024-079474
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