Written evidence submitted by The King’s Fund (WBR0017)

 

Introduction

The King’s Fund is an independent charitable organisation working to improve health and care in England. Our vision is that the best possible health and care is available to all. We aim to be a catalyst for change and to inspire improvements in health and care by:

We welcome the opportunity to provide evidence to this inquiry. Our evidence particularly draws on our forthcoming report The courage of compassion, on the health and wellbeing of nurses and midwives commissioned by the RCN Foundation (an independent charity and part of the Royal College of Nursing (RCN) Group), which we will provide to the Committee when published. We would be happy to provide oral evidence and to answer any questions that the Committee has related to this submission.

We have structured our submission in three sections, covering:

 

Resilience of the NHS and social care workforce

Since 2018, we have argued that workforce challenges are an even greater risk to the NHS in England than the long-standing concerns of funding and access, and are having a direct impact on patient care and staff wellbeing. With consistently around 100,000 vacancies, the NHS workforce is overstretched and could not realistically be described as resilient. Furthermore, a number of key causes of this fragility have been either failing to improve or getting worse, including:

The NHS Long-term Plan acknowledged the impact of workforce shortages and promised a national workforce strategy – an NHS People Plan. These promising steps were however subject to several delays, including delay due to the coronavirus pandemic, and the recently published People Plan is another stop-gap that falls a long way short of the workforce strategy needed.

The English adult social care workforce is distributed across about 18,500 providers, many of which are small, and are not supported by a comparable infrastructure to the NHS (such as workforce planning processes, national leadership or a national staff survey). As a result, the health and care workforces are traditionally overseen in separate, different ways – even though they are inter-dependent. The sector offers notably low pay and limited opportunities for career progression, at the same time as (like the NHS) asking its staff to provide increasingly high-intensity care for people with complex needs. With some 120,000 vacancies and a turnover rate of 30%, the social care workforce is if anything even more fragile than the NHS. But because it does not operate as a single national system in the same way as the NHS and has less data available at the national level, its fragility has been less visible in national media and policy debate.

Overall, before the pandemic it was a picture of significant fragility in both the NHS and social care workforces which had not been managed effectively at a national level.

The pandemic re-set that context. It highlighted the exceptional personal resilience and commitment of staff that enabled the health and care system to cope. It also highlighted further areas of fragility which were perhaps previously discounted or normalised. Examples include:

These examples illustrate the need to think about resilience in terms of underlying stressors (excessive workload, basic facilities, discrimination); ways of managing stressors (supportive teamworking); and ways of mitigating stressors (psychological support). Tackling underlying stressors is clearly the most important and there is a need to address all of these at the organisation and system levels rather than relying only on individuals being more resilient.

As the first stages of the pandemic recede and attention switches to the urgent backlog that has built up, it is not currently clear how the system will re-engage with the potentially promising policy developments arising from the NHS Long-term Plan or how it will ensure the capacity to learn from experience in order to increase workforce resilience.

 

Burnout

NHS staff are 50% more likely to experience high levels of work-related stress compared with the general working population and this both damages their health and affects care quality and organisational performance. As well as affecting individuals, poor staff health and wellbeing in NHS trusts is associated with poorer care quality, patient satisfaction, financial performance and higher levels of staff absenteeism, turnover and intention to quit, and in the acute sector, higher levels of patient mortality.

Research has shown a number of key factors which contribute to stress and burnout in the health and care workforce.

There are however known strategies and interventions which can help reduce stress and burnout. These are not theoretical interventions: we can point to examples where progress is already being made in NHS and social care organisations. In our view, the most important are those which address the causes of stress, as opposed to interventions to manage or mitigate stress. For example:

These are just some examples, but they illustrate that there is much that can already be done without the need for long lead-in times or further research. They indicate that action is needed on a wide rather than narrow front, and will often involve practical steps which also intentionally influence workplace culture.

In addition, although they have not yet been evaluated, anecdotally there have been many examples during the pandemic which appear to have helped staff avoid overwhelming stress in both the NHS and social care. These could be developed further and embedded. Examples include:

 

Implications for national policy

It is essential that national policy addresses the fundamental importance of reducing stress in the health and care workforce and the need to instil a supportive, compassionate and inclusive workplace culture. These priorities have been identified for some time in national policies, but so far with little impact and insufficient commitment. The NHS People Plan for 2020/21 also clearly identifies them as priorities but it seems likely to repeat this pattern again: as its title implies, its focus is only for the remaining seven months of this financial year and its scope is only the NHS. There is a need for greater ambition across the NHS and social care, action as well as words over the long term, and accountability for measurable change.

Workforce planning and purposeful culture change inherently require a long-term perspective and progress will inevitably be limited if the approach is to build up change through a series of short-term steps. Previous incremental attempts to address them have not achieved radical improvement. Furthermore, as the NHS staff survey in particular illustrates, many of the issues that need consideration – such as ending the discrimination that ethnic minority staff experience – have continued and even been normalised over many years. There is a need for long-term investment at a level commensurate with the urgent need for improvement – not just single year settlements. But by no means all of the issues that we identify in this submission are dependent on funding and sustained leadership and support by national bodies and ministers are just as important to keep up momentum.

Within a long-term approach, it is clear that improving working conditions and pay in social care will ultimately require reform and transformation of the sector itself. That will mean addressing more than just how social care services are commissioned and how they work with the wider local health and care systems: changes to funding – including the amount of funding, as well as the mechanisms for delivering it – will be the key issue in transforming social care.

In this submission we have repeatedly stressed that only limited evidence about the impact of stressors on social care staff is available at a national level. Although the need for the NHS People Plan has been recognised, there is no sign of a national workforce strategy for social care. While we have pointed to extensive data in the NHS, much of it is in fact limited to NHS trusts and does not include primary care services such as general practice. It is of course possible to make progress in NHS trusts, primary care and social care separately – these sectors all have significant differences. But a strategic approach across the whole of the health and care sector is likely to be far more efficient and effective, and to align better with emerging thinking about the role of ICSs, than treating the social care and primary care workforces as after-thoughts to NHS trusts. Better national data on the primary care and social care workforces will be important and we underline that implementing workforce policy across all sectors will require proper resourcing of both capacity and capability in ICSs.

Within a long-term, cross-sector approach, we believe national policy should set ambitions and ensure accountability in the following key areas. Some health and care organisations are already progressing some of these: the issue is not to design policy that is radically new, but to bring together and promote existing good practice, and to ensure progress on all of these fronts rather than only a few.

Finally, we note that concerns about stress, burnout and resilience are not unique to England and should be priorities for all four UK countries. There is potential to further develop the ways in which English workforce policy learns from (and contributes to) workforce policy in Scotland, Wales and Northern Ireland.

 

Sept 2020

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