By Dr Nick Scriven, president of the Society for Acute Medicine
As we come to the end of Acute Medicine Awareness Week 2019 there needs to be a pause in the Brexit shambles and party political posturing to really consider the impact of the two recent reports on our greatest asset – the 1.3 million people who work within the NHS.
Without this massively diverse group of workers dedicated to the service we would not have what we cherish and the whole service would have fallen apart under the unrelenting pressure years ago.
The first report to be released was the ‘Closing the Gap’ paper from the Health Foundation, Nuffield Trust and Kings Fund. This paper highlighted the ongoing pressures and laid out suggestions over seven main areas covering recruitment, retention, service design and social care with particular emphasis on the major struggles facing both primary and secondary care.
The second paper was the leaked and then released ‘Interim NHS People Plan’ authored by the team led by Baroness Dido Harding. Much like the earlier report, this focused on making the NHS a better place to work and making the workforce fit to deliver the aspirations of the Long term Plan. This was welcomed as it was released but more recently there have been several critical appraisals that have not been so kind.
As a Society we fully endorse the sentiments underpinning this work but, like others, we do have some reservations about how realistic and deliverable it is as the interim plan is long on aspirations but rather short on detail and, crucially, is reliant on a still to be released financial plan.
One thing SAM clearly agrees with is the plan around developing the multidisciplinary team including both advanced care practitioners (ACPs) and physician associates (PAs). We are currently working with the Royal College of Physicians and Health Education England on a project that should really benefit and add ‘value’ (in all respects) to the ACPs working in acute medicine and we continue to support the drive to regulate the PA profession to enable them to take on further roles they will be ideal for.
We are concerned at the pace this is moving and wonder where the stumbling block is to progression but, for the sake of this dedicated and new group of workers, it must be overcome as soon as possible to prevent them becoming disillusioned in the NHS.
Furthermore, SAM is extremely disappointed at some of the headlines coming from certain areas of the medical profession in effect criticising and belittling these two groups. In my opinion, this reflects very badly on those doctors who shared their negative views and shows a profound lack of understanding in just how valuable these people are. After all, there is more than enough ‘work’ to go round.
While we acknowledge the need to train and recruit more workers, it needs to be said that these are long term plans – e.g. it takes 10 to 15 years from someone entering medical school to becoming a GP or consultant) and the real action needs to be focused on staff retention by making the NHS a better place to work.
There is a lot to be said around the current tax/pension issue catching lots of senior staff in a punitive financial trap leading to experienced staff reducing hours and being unwilling to cover gaps due to the threat of five-figure tax bills. It seems as though this particular ball is being passed around various government departments with, so far, no acceptable solution proposed and with the only glimmer of light being the health secretary Matt Hancock saying he is ‘open to talks’.
However, the biggest issue that faces the whole workforce is the culture that predominates and needs fixing from the top down. While there are many fabulous examples of trusts with great leadership and cultures, there are far too many with negative ones with staff downtrodden by covert and overt processes and diktats that range from ‘inconvenient’ to outright bullying.
It is a sad reality that while most senior boards have the right ideas they are often blind to the way in which those under them achieve results and, as a clinician, it pains me to say it is often senior clinicians in manager roles who are the worst offenders in the way they treat their teams.
The ‘inconvenient’ type of issue can be the hospital where the only form of catering after 5pm weekdays and all weekends is via vending machines – woe betide any staff member who is working evenings/nights and wants a healthy diet.
The more unsubtle issues have been raised in reports on junior doctors’ lives but it is telling that more than one CEO is reported to have said to their teams ‘this is dreadful but it isn’t here, is it?’ to be met with a total lack of eye contact and much foot shuffling.
Unfortunately, the cultural issues are more widespread than just among doctors and there are examples of how ‘difficult’ things are for all groups. One example is around mandatory training – pay progression can be limited by not achieving total compliance but wards are so stretched with staffing there is no time on shift or available computers access to do this and online systems close on multiple weekends for updating or servicing.
Moreover, if a ward manager maybe allows some leeway to take this into account they risk having their own pay progression withheld. Other examples for doctors include the non-release of rotas, inhumane rota patterns, refusal of leave due to arcane HR practices and negative environments where criticism is routine but praise rare.
Recruitment practices are another area that needs examining. I am not certain if it is just the NHS but a phenomenon that is recognised in virtually every area is the person who has been promoted out of harm’s way or has had a job ‘created’ for them to reward not excellence in care but ‘loyalty’ to the organisation that is too often the priority of those appointing to lower and middle grade managerial roles.
Lastly, we must work at creating a culture where critical thinking on all aspects of work is encouraged and people are not afraid to speak out for the fear of ‘punishment’ or retribution and the NHS must not become ‘Orwellian’ in expecting blind obedience at any cost.
They say that the first stage in solving issues is recognising the problem and the two publications mentioned have certainly done that but we need some rapid and concrete progress across the whole system to protect our workforce colleagues and make the NHS a place where people feel valued and want to work.
We in acute medicine and SAM totally understand the whole team ethos and 100% value each and every one who works in our units. We have stated our willingness to work with the NHS on workforce issues and await any invitations to do so and a last message to Mr Hancock is that there is no IT substitute for good people doing good work.