NHS Providers annual conference keynote speech
Health Secretary talks about motivation, morale, leadership and flexible working in the NHS.
Without its people, the NHS is just empty buildings, unused equipment and unadministered drugs.
Fill it full of staff, you’ve got a health service.
Fill it full of NHS staff, you’ve got something really special. World class clinical practice. A willingness to go the extra mile. A level of compassion you wouldn’t believe possible in the face of huge daily pressure. People I’ve met such as:
• the A & E doctor who told me of her tears as she witnessed a 90 year old man, after 60 years of marriage, bid a last loving farewell to his wife
• or the GP I met who carefully and quietly washed the body of a patient as he waited for the undertaker to arrive
• or the nurse who tracked down in Ireland the long lost relatives of a dying patient, so that after 20 years apart, he could spend his final days not alone but surrounded by his family
Striking, yes. Moving, yes. Exceptional, no. Because as everyone here knows, the extraordinary is the everyday in our NHS.
Which is why patients and the public continue to place such confidence and trust in our health service. And why, despite the headlines, recent surveys show they believe their care has never been safer, more personal or provided with more dignity and respect.
Motivation and morale
But to make this possible our system has always depended on discretionary effort alongside the professional commitment and good will of its people. And while governments of all colours have increased funding for the NHS, they have been less successful at strategic workforce planning that is essential if people are to feel valued in their roles.
Some of these issues came out during the junior doctors’ strikes, where important issues such as rota gaps and the quality of their training were highlighted despite being quite separate to any disagreement over contracts.
Others were reinforced by the Brexit vote which made some EU nationals working in our health service worry about their future in the UK.
Other issues still have been created by the transparency we have rightly embraced in the wake of the Francis report. We’ve gone further down this road than any other country and the evidence is clear that it is driving significant improvements in quality. But it is never comfortable for anyone on the front line when their hospital goes into special measures or when they are told their mental health or diabetes provision requires improvement.
And alongside all these changes the twin tides of demographic change and scientific advance continue to rise, creating further pressure for frontline staff. We have not stood still: compared to 6 years ago, our remarkable professionals are treating 1,400 more mental health patients every day, 2,500 more A & E patients within 4 hours every day, doing 4,400 more operations every day, 16,000 more diagnostic tests every day and 26,000 more outpatient appointments every single day.
To deliver this, since May 2010, we have employed over 11,900 more doctors, and over 9,800 more nurses on the wards. This parliament we could see a further 11,000 doctors and 40,000 nurses available. From 2018, we will be creating up to 1,500 more medical student places each year, something I hope will make a significant difference in tackling the rota gaps that worry many.
But strategic workforce planning is about more than increasing recruitment. And today I want to answer 3 challenges often posed about how we prepare the NHS for the future. The first is how do we attract more people into leadership positions in the NHS; the second is how do we support and improve morale; and the third is how do we respond to changing work-life patterns to make working for the NHS more flexible and family friendly.
Let me start with leadership.
Running a hospital is one of the most difficult jobs in Britain today. You have to deliver stretching performance targets. You must balance the books. Motivate thousands of staff. Be publicly accountable through often critical media. But get a decision wrong, even a small one, and patients can die.
Sometimes we at the centre make it harder than it needs to because of the many masters that have to be answered to: the Department of Health, the CQC, NHSI, NHSE, CCGs and Healthwatch to name but a few. But at the same time there has been real progress in initiatives that make life easier: centrally-run efforts to reduce agency costs have seen rates fall by 18% for nurses and 13% for doctors in the last year; the Carter programme will save around £0.5 billion from procurement costs this year; CQC inspections are being streamlined and Tim Briggs’s GIRFT programme is significantly reducing avoidable harm as well as cutting costs.
But in the face of the pressures we face, we see in our NHS some of the most outstanding leaders in Britain today. People like Andrew Morris who has been Chief Executive at Frimley for 27 years and took Wexham Park from special measures to a CQC ‘good’ rating in just 2 years. Or Marianne Griffiths at Western Sussex who created the strongest learning culture I have seen anywhere in the NHS by modelling her Trust on Virginia Mason hospital in Seattle. Or David Dalton who made Salford Royal perhaps the safest hospital in the NHS and is now turning round Pennine Acute Trust.
But what is striking when you look at the pool of potential NHS leaders of the future is just how few have a clinical background, with clinicians representing a third of CEOs. Only 54% of the managers in our hospitals are clinicians – compared to 74% in Canada and the US, and 94% in Sweden. Nor do we tap into the skills of women and those from BME backgrounds: only 46% of chief executives or directors are female compared to 75% of the workforce as a whole; while a mere 2% of chief executives are from BME backgrounds compared to 17% of the workforce as a whole.
It’s hardly surprising that we under-exploit the talent you have so dramatically that you see one in 10 of our chief executive posts filled by interims or on a fixed term contract basis.
So it is time for urgent action to broaden and deepen the pool of people willing and able to step into NHS management roles. Given that one of the most important roles of a chief executive is to motivate a large number of able, smart but - let’s be honest - often quite headstrong clinicians we should today ask whether the NHS made a historic mistake in the 1980s by deliberately creating a manager class who were not clinicians rather than making more effort to nurture and develop the management skills of those who are.
So today I am launching a wide-ranging programme to encourage more clinicians to go into management roles. I would like to see a greater proportion of clinician chief executives raised in the next decade, allowing space for an outstanding new generation of leaders from both clinical and non-clinical backgrounds and more properly exploiting the huge talents of our female and BME workforce at the same time.
I am therefore:
• asking the Faculty of Medical Leadership and Management to work with the GMC and NMC to improve professional regulations so they encourage rather than discourage transition to management roles. Do doctors and nurses feel more exposed because their actions as CEO fall under the GMC or NMC when those by non-clinical managers do not? How can we reduce the risk of taking on management roles by making it easier for doctors and nurses who have had a spell in management return to clinical practice? I have asked for this work to be complete by the end of March 2017.
• Secondly, I can also announce that from now every year the NHS Leadership Academy will send 30 students to world-leading universities (this year Yale) as part of a new fast track development programme designed to support outstanding clinicians interested in moving into senior management positions with the knowledge, skills, attitudes and behaviours they will need. This scheme will ensure that those clinicians who want to move into senior management positions are able to do so with tailored support from both the Academy and from world-class business and management schools.
• Thirdly, I will ask HEE to examine whether doctors should be able to opt to do clinical leadership as a specialism in its own right and whether we should set up a dedicated programme to make this possible.
• Fourthly, here in Britain we will also partner with some of the best universities to offer an NHS MBA for senior professionals working in the NHS, with the first students enrolling in September 2017. Business schools prepare people for all walks of management – and we need them to be doing so for the NHS as well. We will ensure they are available to do this part time so doctors and nurses can work towards their MBA alongside clinical practice.
• Finally, we urgently need to expand the number of high calibre non-clinical graduates entering the NHS. So, from 2018, Health Education England will double the number of places available on the NHS graduate management training scheme to 200, as part of an intention to make the system truly sustainable by increasing the numbers to 1,000 places each year.
Next I want to look at the issue of morale.
We know from the new CQC inspection regime that standards of care are higher where morale is higher. The worst possible thing for morale is when doctors and nurses are not able to give the care they want to the patient in front of them which is why we must never flinch in our determination to make NHS care the safest and highest quality on the planet.
But we also know that clinical engagement is directly linked to morale. Steve Swenson, Medical Director at the Mayo Clinic’s Office of Leadership and Organization Development gave an inspiring talk to the King’s Fund annual conference last month where he explained that the way they tackle the 54% burnout rate for doctors in the US was quite simply by physician leadership and physician engagement – as he put it, bringing the joy back into the profession.
This is of course a difficult topic to broach in a year when we have had a very damaging industrial relations dispute with the BMA. But while I disagreed profoundly with their approach to the new contract, I do want to listen and respond to their broader concerns about the way training works.
So a lot of work is now underway to improve the way that junior doctors experience training.
• We’ve extended whistleblowing protection to cover junior doctors so action can be taken against HEE as well as their employer. As the BMA said in August, these new protections ‘ensure that junior doctors have full legal protection when speaking out.’
• HEE is announcing today a major review of the assessment and appraisal process to make it simpler, less stressful and more helpful for individual doctors.
• We’ve published a code of practice to ensure doctors get much better notice of their rotation schedules.
• HEE has also published new plans to better manage training and rotations to help meet the needs of couples who are in training or who have caring responsibilities.
• And I can confirm that we are making £10 million funding available for HEE to implement new plans with the Colleges to improve the support for doctors returning to training after maternity leave and approved time out.
But underlying many of these legitimate concerns is a sense that when we implemented the European Working Time Directive for junior doctors, although we rightly reduced the excessive hours they worked, in dismantling the ‘Firm’ system completely we may have thrown the baby out with the bathwater.
This government has been clear that we don’t need to be part of the EU to have strong protections for workers in place, and in our modern and flexible economy workers’ rights will be properly protected: in the NHS context that means simply that there can and must be no return to those long hours – indeed the new juniors’ contract reduces the maximum hours a doctor can be asked to work.
But, at its best, the Firm system provided continuity of training, a sense of camaraderie and a bond between consultants and trainees that has been lost. So can we bring back the ‘Firm’ or at least the best bits of it? Today I have asked HEE to work with the Royal College of Surgeons, and leading teaching hospitals and education providers, to pilot a new approach to explore whether a modern Firm structure could enhance the effectiveness of medical teams, give better support to its members, make junior doctors feel more properly valued and get better outcomes for patients.
I would like these pilots to be recruiting medics next year and will announce further details in the new year. This pilot will take the best parts of the traditional ‘firm’ into the modern hospital. With a renewed emphasis on multidisciplinary learning and longer placements for each trainee, the aim is to allow for more meaningful relationships to improve training and supervision and foster a genuine sense of mentorship.
Low paid staff
Doctors of course are our highest paid professionals. But the NHS must do right by the lowest paid as well.
But for many it is not just about money, it is about the chance to progress in a structured career. Indeed, the lack of opportunities to progress is one reason why many of our young people don’t apply for such jobs.
We have listened to employers and our healthcare support workforce when they have said entry to the nursing profession is too rigid and doesn’t give them what they want. Employers know which staff they want to keep hold of and that have the potential to progress into nursing. We are developing a ‘skills escalator’ through the apprentice route so employers can progress staff from entry level apprenticeships through to a nursing degree apprenticeship, with the nursing associate providing a staging post.
I want everyone involved in direct patient care to know there is a simple route into nursing which does not involve leaving work to study full time at a university. Becoming a registered nurse will still involve meeting the same high standards – and that requires an element of study. But this new apprenticeship route will smash the glass ceiling that currently prevents highly dedicated and able health care assistants to progress their career.
Because we need future nursing professionals to have experience of a more integrated health and care world, this route will also be available in the social care sector as much as in hospitals and NHS community settings. And I particularly want to explore whether a variation of it could be used to attract medical assistants into GP surgeries, something where we have had very helpful discussions with both the Royal College of GPs and the BMA.
To support that change, I can announce some important developments today.
• Firstly, I am pleased to announce that the Department for Education has this week approved the degree-level nursing apprenticeship standard. This could see nursing apprentices working on wards, out in communities and across clinical settings from September and will enable employers to offer an apprenticeship to new or existing staff.
• Secondly, we are continuing to work on the development of the apprenticeship standard for the new role of nursing associate. There is clearly a huge appetite from employers to make use of this new kind of role and we have already doubled the number of training places from 1,000 to 2,000 as a result.
• Thirdly, I know there has been some concern that the significant level of judgement needed to operate as a nursing associate, and their role in administering medicines, means that a stronger regime of assurance is necessary to ensure safe and effective clinical practice. Nursing associates are not there to replace registered nurses but to support and complement them. But I have listened carefully to what has been said and agree that, on balance, statutory professional regulation is a necessary and proportionate requirement for this important new role. So I have today written to the Chair of the Nursing and Midwifery Council to seek their agreement to regulate nursing associates and we will be starting work on the necessary legislation as soon as possible.
• There is a real appetite for physician associate roles in the NHS and with this comes the issue of regulation of such groups. I am therefore keen to consider this in earnest and will be consulting on the issue early next year to establish whether, as happens in other countries where the role exists, physician associates should be regulated. I also want to ensure that there is a clear progression path for nurses to reach advanced level practice and beyond so that they can develop their scope of practice in new and creative ways to meet increasingly complex patient needs. So I have asked my department to work with HEE, NHS Improvement, the NMC and the Royal Colleges to develop proposals.
• Finally I have asked the GMC, RCN, NMC and HEE to review whether we can create a smooth career path for the small number of advanced nurse practitioners who wish to become doctors. They are experienced nurses and the skills and experience they have should be properly taken into account if they wish to change their career and become doctors.
The opportunity for career progression is not just important for morale, but also boosts recruitment and retention too. So we must approach this with an open mind, conscious of the need to maintain standards but also aware that we will not get the most out of our workforce unless we are better at harnessing the ambition and motivation that everyone has inside them.
A flexible working revolution
The final question I want to address is around flexible working.
If we are to recruit and then retain a motivated workforce in the future, we need to ensure that the NHS keeps pace with the times and recognises the need for flexible working that allows better work-life balance. In the most recent staff survey only half of all NHS staff were satisfied with the opportunities available for flexible working. This disadvantages people who have caring responsibilities which, in the most caring of sectors, is not something we can afford to be doing.
Some people are getting it right. Chelsea and Westminster, where my 3 children were born, appeared in the UK’s most flexible and family friendly employers list. But for too many people the inflexibility in the way shifts are planned and a rigid attachment to 12 hour days means there has been no realistic alternative but to shift to agency or locum work, which is bad for patients – and terrible for NHS finances.
Flexible working isn’t new and there is some excellent advice on how to implement it.
But we’re not doing enough, particularly when it comes to e-rostering. In a working environment like the NHS, matching the right mix of staff to a shift or rota is a central organising principle. Lord Carter’s review of efficiency and productivity pointed to the enormous clinical and financial potential of e-rostering as a means of making best use of people’s time to the benefit of patients.
But while most trusts do now have access to e-rostering software, few are using it to its full potential. It feels a bit like gym membership – good to have one, but even better to use it to the full. Places like Stoke Mandeville, Plymouth and the Lister in Stevenage use e-rostering tools that are not just populated with real time information on the acuity of patients, but also meaningful data on the personal needs and skills of staff available so that rostering is flexible, personalised and needs-based.
Earlier this year NHSI produced a best practice guide on e-rostering, and by the end of the next calendar year I want all trusts to make sure they are meeting it. We know that NHS trusts develop world-class systems and practices all the time but that these practices aren’t diffused between trusts too often. In order to support you to do this, I am also announcing funding for a new best-practice sharing initiative to allow staff in trusts that are meeting the standard to spread their knowledge to other trusts.
All these initiatives are about supporting and motivating the single biggest asset we have in the NHS: our own staff.
So let me finish by going back to the Mayo Clinic with a story Steve Swenson used to illustrate their commitment to staff engagement. Someone approached a cleaner in his hospital and asked her what she did. The reply? ‘I save lives.’
If that’s how a cleaner sees her role then those wards are going to be very clean! Of course it feels harder to build a strong team when frontline pressures are so high – but my argument today is that building that team is the only way to deal with such pressures.
More clinical leadership, fewer glass ceilings, more career progression and more flexible working: these are the changes the NHS needs to see over the next decade if we are to turn warm sentiments about frontline staff into practical improvements that show we truly value their contribution.