ANALYSIS
A major challenge is that human resource (HR) services in the NHS are not always fit for the challenges they have to deal with. HR departments vary widely in the quality and practice of local procedures for grievances, disciplinary processes, and whistleblowing. 41 They are frequently characterised by an adversarial approach focused on organisational risk mitigation, often linked to avoiding expensive litigation processes with uncertain outcomes. Further problems arise because the seam with professional regulators is not always neatly stitched, causing confusion about which problems should be dealt with by employers and which by regulators. 33 Loss of confidence in the transparency, consistency, and fairness of professional regulatory practices and decisions is now evident, not least because of the risk of death by suicide associated with a regulatory referral. There is particular disquiet about the disproportionate rates of regulatory referral of professionals from ethnic minority backgrounds and those trained outside the UK. 42 Clearer, collaboratively built standards and the right support would be very valuable here. But also important is tackling the wider legal environment for employment practices, which is likely to be implicated in the emphasis on procedural compliance seen in NHS organisations, 41 and neither promotes positive workplace relationships nor is well suited to the specifics of healthcare environments. Enhancing career and professional development Professional development and career progression are essential both to retaining staff 43 and to ensuring that their competencies are fit for purpose. Education and training capacity is needed for all staff groups to support selection, supervision, assessment, and development and maintenance of the optimum skills and behaviours. This is expensive, and prone to cuts or to being badly implemented — for example, through poorly designed e-learning modules that staff are forced to do in their own time. More effective approaches, such as simulation and skilled debriefing, 44 are underused. The current unprecedented level of attrition from professional training pathways, including in medicine, is an increasingly important major threat to the future of the NHS. The reasons are multiple, but for doctors in specialty training, aside from the prominent issues of pay restoration and student debt, they include bureaucratised, rigid training programmes characterised by “ portfolio blight ”— burdensome, poorly designed, and inflexible requirements for documentation. Doctors in training are among the groups especially affected by the practical challenges mentioned earlier, including bad rota systems and costs and inequities associated with training requirements. 45 Because of the way training is organised through rotations, this group is especially vulnerable to experiencing transactional, unsatisfying relationships with organisations and to disruptions of their personal lives that are difficult to manage. These include limited or absent support for transport and childcare and rota scheduling that does not accommodate planning for family events. Negative experiences of training are amplified by failures to offer a sense of belonging, support, and ownership, which are so important to employee wellbeing. 46 Confusion and concern about new professional roles (such as physician and anaesthesia associates) have, in some cases, further contributed to the undermining of morale — for example, by creating the sense that these roles are competing for training opportunities, are paid better than doctors in training, and are more highly valued by employers. 47
High stress environments People in the NHS frequently have to work in highly stressful, demanding settings, while using poorly optimised work systems. 29 Healthcare professionals often spend a substantial proportion of their time doing tasks that take them away from doing the work that they ’ re qualified for, which indicates a toleration of suboptimal use of the workforce and corresponding waste. Daily work is often frustrating: only 58.5% of staff say they have adequate materials, supplies, and equipment to do their work. 4 Operational failures — ranging from poorly functioning IT systems to obscure referral pathways — are pervasive, causing frustration and damaging the daily experience of work. 30 That these challenges are also deeply problematic for patients too only adds to the sense of professional frustration, yet only 55.9% of staff feel able to make improvements in their area of work. 4 Many of these issues can be tackled through better operational management and systems improvement, with knock-on positive effects not just for staff satisfaction but for productivity — as demonstrated by work in other sectors, including manufacturing. 31 But better operational management will not occur simply by wishing for it or denigrating management as pen pushing bureaucracy. 32 It will require recognition that unglamorous, mundane problems really matter and a corresponding policy commitment to building up effective management functions in the NHS using best practices at all levels. Workplace behaviours Behaviours in the workplace — encompassing the behaviours of colleagues, patients, relatives, and the public — are a major concern for the NHS workforce. Some workplace cultures in the NHS are highly adverse, leading to poor experiences of work, mental health difficulties, and consequent negative effects on patient safety and quality, including those that erupt into organisational crises. 33 Some staff, especially those who are minoritised, are particularly at risk of experiencing poor behaviours and culture, to the extent that the NHS has been described as diverse but not inclusive. 34 Although around a quarter of NHS staff are from ethnic minority backgrounds, they are less likely to progress to senior and leadership roles, for example. 34 Reported rates of bullying and disrespect, harassment, including sexual abuse and worse, and racism and discrimination, are alarmingly high. UK REACH (a research study into ethnicity and covid-19 diagnosis and outcomes in healthcare workers) found that around a fifth (21.2%) of staff surveyed between October and December 2021 reported that they had experienced discrimination in the previous six months, either from patients, colleagues, or both, but only half of those who had experienced harassment, bullying, or abuse said that they or a colleague had reported it. 19 NHS organisations continue to show major weaknesses in tackling these problems. The NHS People Plan is clear that everyone should benefit from effective management, 35 but the realities are often very far from this aspiration. Line managers are often under-resourced and poorly trained and supported for the roles that they are asked to takeon — frequently on top of other duties. 36 Efforts to improve employee voice (speaking up and speaking out) remain highly variable in implementation and effectiveness, 37 to the extent that lack of psychological safety 38 remains a persistent problem in the NHS. Less than two thirds of staff (62.3%) feel safe to speak up about anything that concerns them, and only half (50%) are confident that their organisation would deal with their concern. 4 Interventions are now becoming available to tackle unprofessional 39 or transgressive behaviours, 40 and priority should be given to their implementation and evaluation.
the bmj | BMJ 2024;384:e079474 | doi: 10.1136/bmj-2024-079474
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