Caring for the NHS workforce: the critical role of technology in supporting wellbeing amongst NHS staff
A submission to the Health and Social Care Select Committee ‘workforce burnout and resilience in the NHS and social care’ inquiry
WPI Strategy and VMware
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This submission is largely drawn from the policy report ‘Caring for the NHS workforce: the critical role of technology in supporting wellbeing amongst NHS staff’, published in August 2020. The full report can be viewed here.
Using data from NHS Trusts and the Health and Safety Executive (HSE), we estimate that more than 10 million working days were lost to mental ill-health in the NHS across the UK in 2019. This equates to around 38,500 full-time staff permanently absent from work, needing to be covered by other staff or temporarily replaced by agency staff. Put another way, this level of mental ill-health related sickness absence amounts, on average, to more than seven days off work a year for each employee.
It is well documented that technological inadequacies in the NHS are linked with increased workload, challenges in managing complexity of work, poor control over work, work-life balance and a lack of flexible working. As such, there are clear routes by which poor technology can impact on the mental health of the NHS workforce. A recent survey of BMA members indicated the scale of some of the issues, with four in ten respondents (37 per cent) reporting that their stress levels are affected significantly by inefficient IT and data sharing systems.
At the heart of these issues are hardware and software which are no longer fit for purpose and legacy IT systems that hinder attempts at digital transformation. A recent survey of NHS healthcare professionals found that six in ten thought that NHS IT was not fit for purpose, with many complaining of 10-minute log on times for tasks that need to be done several times a day.
This submission puts forward five recommendations to provide a strong digital foundation throughout the NHS and reduce stress and burnout exacerbated by poor IT and digital technology:
Recommendation 1) To reflect its important role in supporting the NHS workforce, digital transformation should be a core part of the NHS People Plan.
Recommendation 2) All new planned hospitals should appoint advisors from NHSX and from one or more of the Global Digital Exemplars.
Recommendation 3) The CEO of NHSX and Secretary of State should write jointly and publicly to Chairs of all NHS Trust Boards currently failing to meet the standard of having a “digital and tech leader”, confirming their expectation that a CIO or Chief Clinical Information Officer (or equivalently experienced individual with operational responsibility for digital transformation) should be on their Board and setting out a firm timeline by which this should happen.
Recommendation 4) Once the required standards and funding has been determined, the Government should ringfence part of its increased NHS investment, and bring together other existing funds focussed on investment in digital transformation, to develop a single Smart Care Fund. This should be used to ensure that investment is available to all Trusts to both achieve the required digital maturity standards and ensure they develop a future-proofed and flexible digital foundation.
Recommendation 5) The need for change is clear. As such:
Note: Our Findings and Covid-19
The research and modelling for the report on which this submission is based were undertaken between Autumn 2019 and Spring 2020 and reflect the evidence on the mental wellbeing challenges facing the NHS workforce, and their potential impacts, which were available at the time.
Since then, the Covid-19 pandemic has impacted every part of our lives. Whilst the effects of this, on individuals, society and the economy are yet to be fully understood, the NHS and its workforce have been at the epicentre of this crisis. However, given the uncertainty of these impacts, and the desperate need for clinicians and the full range of staff, organisations and suppliers who support them, to focus on tackling the pandemic, we have chosen not to update the research and analysis in this report.
These findings act as a benchmark for what we had already identified as a mental wellbeing crisis within the NHS workforce. Our assumption is that the current crisis can only act to make the challenge greater: through increased workload pressures, even more significant emotional trauma and the constant risk of putting their own lives at risk in order to try to save others, the factors that lead to poor mental health amongst NHS staff will have been amplified by the Covid-19 pandemic.
This makes the findings in this report even more important. Ultimately, if the NHS workforce is to continue to carry out the vital role they are playing both through this pandemic and beyond, their mental (and indeed physical) health must be at the centre of action to support them. Our report, and this submission, identifies clear ways in which, as a part of a broad-ranging strategy, technology can be used to ease the pressures which contribute to poor mental health for staff across the NHS. Positively, we should recognise that many Trusts are already moving at pace in response to Covid-19; pushing forward with the digitisation needed to continue to provide vital healthcare and protect their workforce at a time of crisis.
More broadly, as the pandemic continues to evolve, the strong digital foundations that we urge are created will be central to ensuring that the NHS can continue to meet the needs of the public. For those Trusts already heading in this direction, positive steps need to be cemented and built upon. For others, support will be needed to ensure that they can catch up quickly with their more digitally advanced peers.
For all Trusts, the potential gains of creating these strong digital foundations are clear; facilitating more remote access to health care services, opening up opportunities for more flexible working within some parts of the NHS, advancing services and patient care with technology and all the time doing so within an environment that provides the right tools to the workforce and the best possible level of security for personal data.
There are approximately 1.4 million people employed throughout the NHS. Each individual plays a vital role in improving the health of the nation which has been more important than ever over the past months. But if those who care for us are to continue to carry out their jobs effectively, as a society we need to consider their health more carefully. A healthy NHS workforce is fundamental to the Government’s health and social care strategy, and it is encouraging that the Secretary of State has identified the workforce as his top priority.
This submission aims to contribute to this debate. The findings identify a crisis in mental health amongst the NHS workforce and the impacts that stress, anxiety and burnout have on healthcare workers, patients and the overall costs of the NHS. Improving the mental health of NHS workers will require a wide-ranging strategy which includes improved workforce management practices and support, and action to prevent mental ill-health occurring in the first place. This submission focusses on one important element of that strategy: technology. It highlights that, across the NHS, a weak digital foundation and outdated technology in use by the NHS workforce are contributing to work-related stress and impacting patient outcomes and the ability of the NHS to operate as efficiently as possible.
The government has vowed to move the health and care system into the 21st century. Across the country there are trailblazing hospitals which, as a result of their expertise and investment, are able to ensure both that their technology works for their staff and their digital foundation is ready for the required evolution that will be asked of them while also allowing future innovations to be tested and implemented at scale. Yet there are many hospitals which are still lagging behind. This submission highlights the need for NHSX , a new unit tasked with speeding up the digital transformation required within the NHS, to be closely involved in the NHS’s People Plan to ensure that the importance of digital transformation in helping to tackle mental ill-health amongst the NHS workforce is recognised and operationalised. It then outlines the need to create the right digital foundation across the NHS; providing a cloud environment to meet Trusts’ needs, with adaptable networking and security provided where and how needed by the NHS workforce. In practical terms this would support the adoption of technologies that can improve both workforce wellbeing and clinical outcomes and reduce costs, both now and in the future.
The scale of the mental ill-health crisis in the NHS
A wide range of evidence shows that mental ill-health is a significant issue across the professions within the NHS workforce. A related and equally significant issue is burnout. Using data from NHS Trusts and the Health and Safety Executive (HSE), our original report estimated that more than 10 million working days were lost to mental ill-health in the NHS across the UK in 2019. This equates to around 38,500 full-time staff permanently absent from work, needing to be covered by other staff or temporarily replaced by agency staff. Put another way, this level of mental ill-health related sickness absence amounts, on average, to more than seven days off work a year for each employee.
The impact of poor mental health on the NHS workforce
However, investment on its own is not enough. Our report explored key themes taken from semi structured interviews and roundtables with NHS and non-NHS leaders to show that, across the country, there is broad agreement on what needs to happen. There are three major problems:
1. Worsened clinical outcomes: A range of evidence demonstrates a clear link between mental ill-health amongst the NHS workforce and poorer clinical outcomes.
2. Higher costs: The associated costs of mental ill-health related sickness absence and presenteeism to the NHS as an employer, which we estimate amounted to around £3 billion in 2019.
3. Personal impacts: The human costs are significant; both for individuals experiencing mental ill-health and their friends, families and colleagues.
Reducing and managing workloads
There have been numerous reports highlighting these issues and NHS reviews have also focussed on them.  So, the question is what can be done? The first thing is to recognise that the drivers of mental ill-health in the NHS are not just about the often-unavoidable nature of working in healthcare; a range of organisational factors are also significant drivers. Addressing these should play an important part of a strategy to tackle the issue. Key areas highlighted by other reviews include:
Delivering on each of these areas could fundamentally change the experience of the NHS workforce. There is no single way to do this, and a multi-faceted strategy is clearly needed. As shown below, one vital part of that strategy is technology.
Technology as part of the solution
It is well documented that technological inadequacies in the NHS are linked with increased workload, challenges in managing complexity of work, poor control over work, work-life balance and a lack of flexible working. As such, there are clear routes through which poor technology can impact on the mental health of the NHS workforce. A recent survey of BMA members indicated the scale of some of the issues, with four in ten respondents (37 per cent) reporting that their stress levels are affected significantly by inefficient IT and data sharing systems.
At the heart of these issues are hardware and software which are no longer fit for purpose and legacy IT systems that hinder attempts of digital transformation. A recent survey of NHS healthcare professionals found that six in ten thought that NHS IT was not fit for purpose, with many complaining of 10-minute log on times for tasks that need to be done several times a day.
Wider concerns include a lack of interoperability that means that different systems across the health and social care system and even within different departments of the same care setting, do not integrate or communicate effectively with each other. One example of the impact of this is that patients have to provide their medical histories repeatedly and clinicians may have to enter the same information several times.
This situation also comes with broader concerns. For example, interviewees for our report highlighted that medical staff are currently forced to create workarounds to save time: for instance, leaving computers logged on, or even sharing patient records over personal e-mail or WhatsApp to get an opinion from a colleague without the requisite access tools. Whilst not malicious like the recent WannaCry attack on the NHS, the impacts of such actions on security are clear; a third of NHS IT leaders identify NHS staff as a significant risk to cyber security.
Whilst these are significant issues, there are clear routes through which they can be tackled, technology improved and the NHS digitised, whilst ensuring that cyber security is at the heart of that transformation so that patient and staff information is safeguarded. One such example of this is the idea that clinicians should have the right information on a patient in front of them, on any device that they are using and at any time, with the security you would expect when accessing personal medical records. It is a simple principle, but one that demonstrates how the right technology would fundamentally change the experience of many clinicians today: saving time, easing workloads, improving patient care and, as a result, reducing workforce stress. As one CIO interviewed as part of this research commented: "…anything that can save a clinician an extra click, or extra log-on is something that provides time for them to spend more time with the patient.”
Innovation and the future of healthcare
Looking to the future, it is also clear that new forms of working, improved treatments and a wide range of future NHS innovations are part of the answer. Often referred to as the “mega trends” in healthcare these are typically driven by big data, technology and connectivity and include: AI, genomics, telemedicine, the medical Internet of Things and virtual and augmented reality. Together these trends would change the shape and nature of healthcare in the UK; moving much more to a predictive, preventative and personalised approach. They could also do this in a way that improves the working environment of the NHS workforce.
For example, it has been estimated that:
Delivering this requires the right digital foundation
This demonstrates just a few of the potential areas where improved technology, digital transformation and innovation could ease pressures on the NHS workforce and improve patient outcomes. But despite previous commitments to ensure that all NHS providers have at least a core level of digitisation by 2024, a large proportion of Trusts are currently a very long way from this level, and, without significant change, are unlikely to reach the required level in time. So, the question is then, what is getting in the way of change and preventing the investment and continued digital transformation that could deliver a step change in outcomes for clinicians and patients across the NHS?
People interviewed as part of this research, including clinicians, senior managers and technology professionals working within and outside of the NHS, identified a range of barriers, which are also echoed in the existing literature around digital transformation in the NHS. An overarching theme from these interviews was that there is currently an insufficient focus on ensuring that the NHS has a strong digital foundation. This was raised in a number of ways. For example, a number of interviewees highlighted that a focus on new and innovative technologies and applications for those on the front line was taking attention away from the fact that, without the right digital foundation, it would be near impossible to make the most of these opportunities. It was also highlighted that a failure to deliver this would likely result in a situation where similar issues with legacy IT were being faced in ten years or so.
Ultimately, interviewees argued that delivering improvements will rest on the NHS’s digital foundation. This is what underpins the ability to modernise applications today and, in the future, to adapt to, test and adopt new innovations without disrupting business operation and all the time doing this in a way that protects patient data. In practical terms, the goal for users was typically described as a foundation that enables any app, on any cloud, delivered to any device. For example, the BMA highlights that “clinicians should be able to see patients’ records, observations, results and background notes from any location, ideally in real-time”. The digital foundation must empower and support that goal in a way that allows Trusts to respond flexibly to future needs, opportunities and threats and adopt innovation, and all in a way that minimises risk and disruption and maintains security.
A range of other areas, which link with this theme, were also raised. These are summarised below.
The elements of a strong digital foundation
A strong digital foundation is central to delivering the technology that the NHS workforce need today and to ensuring that digital transformation can continue into the future. There are three core elements to a strong digital foundation.
A cloud environment to meet Trusts’ needs: As Trusts’ applications become more complex, more diverse and increasingly demanding, there are new requirements for the infrastructure that delivers the power, efficiency and interoperability to support them. Delivering this in the right way is central to reducing costs, increasing flexibility and scalability, improving efficiency and speeding up the access time to innovative services that are central to digital transformation within the NHS. Most importantly, a strong digital foundation lets Trusts choose whichever cloud environment best meets their needs, for any application, without sacrificing visibility, operational consistency, security or control.
With adaptable networking and security: Intrinsic security is key to ensure that Trusts build-in and unify security to protect its apps and data. This means interoperability across bare metal servers and containers, as well as on premises, public cloud, IoT edge devices, or cloud-based services. Given the sensitive nature of data and applications within use in the NHS, securing this across the cloud environment is a core requirement.
Provided where needed by the NHS workforce: Across the NHS workforce, employees want to do the work they need to do, with easy and highly available access to the tools and apps they want to use. In practice, this must be flexible to the range of devices (from mobile, desktop and tablet to IoT devices) in use across the workforce, and the range of environments (whether that is in a primary, second or secondary settings, on the move or at home) and in a way that does not sacrifice security or control.
Laying the foundations for digital transformation
The five missions of NHSX chime very well with themes in this submission. However, tackling the issues identified above, and pushing forward digital transformation at the pace required, will not be straightforward. It is also clear that, too often, digital transformation and workforce wellbeing are viewed in isolation. What our report has shown is that delivering on digital transformation is not just about improving and deploying technology: it could also be part of a strategy to tackle work-related stress and reduce the prevalence of mental ill-health and burnout amongst the NHS workforce.
As such our headline recommendation is that using digital transformation to improve the wellbeing of the NHS workforce should be a core part of the NHS People Plan. The interim plan has already made positive steps, including the creation of the Releasing Time to Care programme. The final plan should build on this foundation, provide clear routes through which NHSX can be at the heart of future plans in this area and identify investment streams that can support digital transformation.
Recommendation 1) Digital Transformation and the NHS People Plan: To reflect the important role of digital transformation in supporting the NHS workforce, it should be a core part of the NHS People Plan. The plan should also clearly set out how NHSX will be involved in future work in this area and, given the importance to the workforce, identify investment streams that can support digital transformation.
Once this focus has been established, tangible actions need to be taken forward. A range of reports highlight steps that clinical and technology staff within the NHS have highlighted as essential. We will not rehearse these here, but the recent BMA report provides a comprehensive outline. What is clear, however, is that the journey of transformation will be unique to every organisation and complex for all.
Disruptive technologies emerge faster than most organisations can absorb, which leads to increasingly complex technology environments that are hard to maintain and even harder to secure. And the pace of this change will only increase. Our report has shown that this presents a real challenge of ensuring that the right steps are taken across the NHS and in a way that does not create the legacy IT of the future. In the short term, failure to do so risks the continuation of poor mental health outcomes in many trusts across the NHS and could mean that in ten- or twenty-years’ time, technology is similarly out-dated and difficult to upgrade and transform.
What is needed is a framework within which NHSX, Trusts and the digital sector can work together to deliver the digital foundation that can facilitate the adoption of technology that supports staff both now and in the future; getting the basics right first before allowing innovation to deliver the digital NHS of the future. The next four recommendations support the delivery of a strategy to achieve the core elements of a strong digital foundation.
Recommendation 2) Digital by default: The Government’s manifesto confirmed a pledge to build and fund 40 new hospitals over the next ten years. It is essential that these are built and the investment is made to delivering the right digital foundation from the outset, ensuring that they can reach the highest levels of digital maturity and that technology can support staff, improve clinical outcomes and reduce costs now and in the future.
To do this, and building on recent announcements from NHSX, all new planned hospitals should appoint advisors from NHSX and from one or more of the Global Digital Exemplars. These advisors should report directly to the CEO of NHSX and the Secretary of State for Health and Social Care, meaning that any concerns around future digital maturity of these new hospitals can then be raised quickly to the highest level.
Recommendation 3) Change comes from the top: Digital transformation is one of the major challenges facing the NHS today. However, we heard that too often NHS Trust Boards lacked the detailed understanding of technology needed to create and drive forward a digital-first strategy. Supporting this view, the NHS Long Term Plan and, more recently, the Secretary of State have highlighted that every NHS Trust Board should have a “digital and tech leader”.
However, progress has been slow, with just 25 per cent of Trusts in England having met this ambition. To tackle this, the CEO of NHSX and Secretary of State should write jointly and publicly to Chairs of all NHS Trust Boards currently failing to meet this standard, confirming their expectation that a CIO or Chief Clinical Information Officer (or equivalently experienced individual with operational responsibility for digital transformation) should be on their Board and setting out a firm timeline by which this should happen.
Recommendation 4) Building the foundations for digital maturity: Based on current progress and funding, we believe that one of the major challenges for NHSX over the next four years will be supporting all Trusts to reach the necessary level of digital maturity by 2024. This will be particularly challenging for the Trusts with lowest current level of maturity, where we have already seen that the maturity gap is growing.
Another challenge will be to support all Trusts to develop the digital foundation that will ensure they are future-proofed and can harness new technology as quickly and as often as it evolves, without disrupting business operation. NHSX, NHS England and NHS Improvement are already working with providers to develop maturity standards and understand the potential investment required by Trusts to meet these.
Once the required standards and funding has been determined, the Government should ringfence part of its increased NHS investment, and bring together other existing funds focussed on investment in digital transformation, to develop a single Smart Care Fund. This should be used to ensure that investment is available to all Trusts to both achieve the required digital maturity standards and ensure they develop a future-proofed and flexible digital foundation.
Recommendation 5) Monitor performance, tackle failure: The need for change is clear and, with the right funding and support available, there is no excuse for Trusts to fail to achieve the required level of digital maturity. As such, it is encouraging the Secretary of State has committed to providing all providers with clear standards that the CQC can assess them against. Given its importance, it is vital that this work takes place rapidly and the transformation it should prompt be delivered to a fixed timescale. As such:
Taking forward these proposals, improving technology and focussing on the role it can play in improving mental health amongst the NHS workforce, will play a vital role in delivering the NHS of the future. Ultimately, we cannot expect the NHS to provide the care that people across the UK need, unless we care for the NHS workforce too, and improved technology is central to ensuring this happens.
 See: https://www.who.int/mental_health/evidence/burn-out/en/ Accessed 30/10/2020
 See: https://improvement.nhs.uk/resources/interim-nhs-people-plan/ and https://www.hee.nhs.uk/sites/default/files/documents/NHS%20(HEE)%20-%20Mental%20Wellbeing%20Commission%20Report.pdf Accessed 30/10/2020
 See: http://www.em-online.com/download/medical_article/36516_DH_083090%5B1%5D.pdf Accessed 30/10/2020
 See: https://www.theguardian.com/healthcare-network/2018/mar/20/nhs-it-health-service-staff-guardiansurvey Accessed 30/10/2020
 VMware, Intel, (2017), Securing a lifeline for the NHS: A report by VMware and Intel exploring the evolving cyber threat on the NHS and how it can better protect itself to preserve the security of the UK and its people
 Royal Free Charity, (2018), Beyond the fog: a future for public healthcare. Available here: http://vision4health.org/home/health-beyond-the-fog/ Accessed 13/12/19
 Deloitte, (2019), closing the digital gap: Shaping the future of UK healthcare. https://www2.deloitte.com/content/dam/Deloitte/uk/Documents/life-sciences-health-care/deloitte-uk-life-sciences-health-care-closing-the-digitalgap.pdf Accessed 10/12/19
 Topol, E., (2019). The Topol Review: Preparing the healthcare workforce to deliver the digital future. Available here: https://topol.hee.nhs.uk/ Accessed 30/10/2020
 See https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf Accessed 30/10/2020
 Deloitte, (2019), Closing the digital gap: shaping the future of UK healthcare, https://www2.deloitte.com/content/dam/Deloitte/uk/Documents/life-sciences-health-care/deloitte-uk-life-sciences-health-care-closing-the-digital-gap.pdf Accessed 30/10/2020
 See https://www.nhsx.nhs.uk/what-we-do Accessed 30/10/2020
 BMA, (2018). Technology, infrastructure and data supporting NHS staff. https://www.bma.org.uk/collectivevoice/policy-and-research/nhs-structure-and-delivery/technology-infrastructure-and-data-supporting-nhs-staff Accessed 30/10/2020
 See: https://www.thehtn.co.uk/2020/02/02/nhsx-to-embed-staff-in-nhs-trusts/ Accessed 30/10/2020
 See https://www.gov.uk/government/speeches/better-tech-not-a-nice-to-have-but-vital-to-have-for-the-nhs Accessed 30/10/2020
 Source: WPI Economics analysis of publicly available information on Trusts’ Board composition. Note that detail of specific roles and experience was often sparse, so we took a broad definition to produce this statistic. In practice, the overall figure that meets the Long Term Plan ambition is likely to be lower than this.