Written evidence submitted by Dr Peter Davies (RTR0125)

 

The Committee’s Questions:-

 

•        What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?

◦        What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?

•        What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term?

◦        What can the Government do to make it easier for staff to be recruited from countries from which it is ethically acceptable to recruit, with trusted training programmes?

•        What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors? In particular:

◦        To what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?

◦        Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?

◦        Could the training period for doctors be reduced?

◦        Should the cap on the number of medical places offered to international and domestic students be removed?

•        What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

•        Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?

•        What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?

•        To what extent are the contractual and employment models used in the health and social care sectors fit for the purpose of attracting, training, and retaining the right numbers of staff with the right skills?

•        What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?

 

 

 

 

 

 

 

 

 

 

 

 

 

Introduction

 

Thank you for running this enquiry. It is on a key topic and the key dynamic that will allow the NHS to be viable in future years. The questions asked are all valid, and I hope my submission will help the committee with its consideration of them.

 

The key issue behind all these questions is one of BELONGING.

 

Recruitment is about creating the desire in people to want to belong inside a professional role.

Training is about coming to belong in a professional role.

Retention is about maintaining, developing and deepening the feeling that you belong inside that professional and organisational role.

 

It’s about attraction, attachment and avoiding detachment.

 

Belonging is a deep sense of feeling wanted, valued, respected, supported, known, loved by those who make up the system around you. Some of these connections are local and immediate and some of them are distant and influential. You work and share the struggle with immediate colleagues and you belong to your college and your profession. The work is never just a job- take away my GMC registration and a part of me would die.

 

Belonging is made up of many parts. It starts from families. It builds up into local areas. It builds up into local organisations and clubs. It builds up into countries. It builds up into professional tribes. It builds up into the work of a department, the work of a hospital, the twin works of healing and of generating health.

 

Belonging is also about our ethnicity and whether we feel we fully belong amongst the people we are working with and living amongst. We are a multi-ethnic country and we are still learning how best to live alongside our ethnicities and each other. The more times the word “inclusive” is used the more times at least someone is thinking, “everyone…except me.”

 

People who come into the UK from other countries need to be able to come to belong to the country and within our health and social care system.

Medicine is a reasonably international language.

However there are very significant differences in how things work in the health and social care systems of one country compared to another, and of language and cultural practices. Within the NHS there are significant differences between St Hereabout’s and St Elsewhere’s. For a national system the NHS is often patchy, peculiar and parochial. So a foreign professional coming into the UK may well know their medicine well, but have to learn a lot of English language, UK hospital systems, UK medical culture, the local town or city. They may for example struggle to understand the difference in roles and practice between primary and secondary care and the division of work we have between these two parts of the system in the UK. They can know their medicine well and still run into regulatory issues because of the struggle they face adapting to the UK context of medical practice. Their basic assumptions and expectations may be different from those of UK trained staff.

Foreign graduates coming to work in the UK health and social care system need a very significant outreach making to them to help them come to belong fully and safely within our UK systems.

(And reciprocally as a UK trained and habituated doctor I would need a similar process if I went to work abroad.)

 

For health and social care staff our identity and our sense of belonging is a constantly negotiated dialogue between our personal backgrounds, our professional knowledge, our ongoing development, our relationship to the health and social care system that both helps and hinders our work. (1,2.) We do not practice our professions alone and the old idea of “rugged individualists” who are “good despite the system” we work within is one of the least supportive descriptions of our combined work. Stevie Smith’s poem (3), and its description that we are “too far out” and “not waving but drowning”, is embodied in far too many health and social care careers. (4)

 

The more the health and social care eco-system supports our work and development the more we feel we belong to the system and will stay within it. Let me describe some ways in which the health and social system deals with its staff and so how they make staff feel that they do not belong comfortably within their professional roles.

 

Look after the staff- Don’t make jobs suck

 

  1. Look after the staff well and they will look after the patients well
  2. Look after the staff well and they will make the work become attractive to others. That sorts out recruitment issues.
  3. Don’t make jobs “suck.” (5) This is why you have the recruitment issues.
  4. Whenever you hear a British employer saying “We can’t get the staff around here” you can be sure that the job sucks- either too little pay or too little support and back up.
  5. The NHS as an employer doesn’t realise in how many ways it makes jobs suck. There are inadvertent rapport breaks throughout the NHS

 

Problems with HR management

  1. HR systems are a great rapport break. The number of checks that need to be done is fine. However they need to repeated by so many others in so many places that the whole process becomes wearying.
  2. The NHS could do with one central register of staff, with key qualifications, registrations, previous jobs and competencies certified and recorded once and securely. If we need to go to HR once a year and check and confirm the record then so be it.
  3. Writing a CV should become a redundant skill as the information is recorded already and can be compiled and downloaded when necessary.
  4. NHS staff should each have a single piece of NHS ID that identifies them anywhere within the NHS and so allows them to work anywhere.
  5. The NHS ID should have on it enough assurance that employers can check the staff member’s identity and professional record and validity quickly.
  6. Emphasise belonging to the profession and the NHS and not to the various separate domains and fiefdoms of current NHS bodies.

 

Problems with health and social care IT

 

  1. NHS IT is slow and underpowered. It is unnecessarily complex, with too many stand apart systems each needing separate logins.
  2. For example at LCD where I work I need a login to windows. I have a personal one on my laptop, but on site I have various generic logins. Once I am onto windows I need to log in to Horizon- the phone system with phone recording. This has a 36 character password which is not always stored in memory and it is a faff to get it reset. I then need to use duo to access the virtual private network. I then need to use my NHS smart card to log on. Then SystmOne login either by password or smart card. My email I get via Citrix after having to log onto that app twice. I have a log on to Datix when I am working reviewing incidents and complaints. I have a log in to Clinical Guardian for clinical audit purposes. I have a log in to rotamaster to manage my shifts, annual leave etc. Once in rotamaster if I want to download a document then there’s a document password to get past. If I want to check my wage slip I have to log in separately to Sage. If I want to access education then there’s Chambray to log into. If I want to go the eLFH it’s another log in. NHS Athens doesn’t let me access the full range of journals I would like for my work and learning. In short to do my work at LCD I need at least 14 separate logins. It feels to me that the system doesn’t really want to know me or greet me. I am a stranger in my own organisation. I try not to reuse the same password, but the memory needed to do these various logins get too much. The IT people nag me about information security.
  3. When can we have biometric identification and start the day with face recognition and saying, “Good morning computer” and it replying, “Good morning Doctor Davies- how nice to see you.”?
  4. My NHS net email is separate from my LCD email.
  5. There’s also various professional logins such as at BMA, RCGP, GMC. However my work computer won’t let me store these details.
  6. Thank goodness for my iPhone and its keychain security.
  7. Why not give each clinician an nhs.net email and a work phone number to use all the way through their career alongside their professional registration number?
  8. You can waste a morning’s work just logging onto systems. The complexity of current information systems make them very hard to use, and so reduces efficiency of work and actually directly impedes the flow of information around the system. This is hindering communication between colleagues and so is reducing the safety of patients as they move around the health and social care system.

 

Problems with Electronic Clinical Record Systems

 

  1. There are several in use across and around the NHS. They have been designed so that they don’t integrate easily with each other. So secondary care and primary care are in functional non-communication with each other. And they are repeating each other’s work, and the patients are fed up of repeating themselves. Just another little stress point in everyday NHS work…that eventually becomes no longer tolerable and the staff member walks away.
  2. Electronic clinical record systems. In Calderdale our practice was more or less forced to adopt SystmOne. I have never wanted this system and never enjoyed using it. I still feel that I am not at home using it and I’ve been using it over ten years now. It’s reduced my enjoyment of clinical medical practice significantly, and as it’s not intuitive to use it has made my clinical records less good than they otherwise would have been. One more rapport break between a clinician and the NHS systems that are supposed to support my work.
  3. Current NHS IT causes staff frustration whilst reducing patient safety.

 

 

Burnout- an inevitability within current working patterns

 

  1. The way the NHS makes staff work at present takes so much out of staff that they do not get time to rest, regenerate and recover before their next shift starts.
  2. Hence, burnout is endemic in the NHS. All doctors are already burnout, recovering from burnout or about to get burnt out. (6,7)
  3. The same applies to other clinical roles and many in management
  4. Insurance companies will not cover health service staff for mental health conditions on critical illness policies- they think all of us have some stress and depression issues and they would never stop paying out on claims from us.
  5. This is not an attractive description of the staff that will entice new people into the NHS.
  6. People do not burnout because the work they do is hard. They burn out because the system makes it hard for them to do the work. (5)
  7. The first duty of NHS staff is to sustain themselves in a state of mental, physical and emotional health that will allow them to concentrate on making care of the patients their first concern.
  8. The way we work in the NHS makes this very difficult to achieve.
  9. NHS staff are extremely resilient. They do not fold under strain and pressure, and burnout is not due to a lack of individual resilience.
  10. All of us run human energy balances. (8) These have elements of physical capacity, mental capacity and emotional capacity in them. Our work draws on these capacities. We need time to regenerate these capacities between shifts otherwise we run down our energy balances. Most of us in the NHS struggle to maintain these balances and many NHS staff are severely overdrawn on all three. The state of being constantly overdrawn on these balances is called burnout.
  11. There is a basic mismatch between our human capacities and the demands of the work in the NHS.

 

Satisfaction, salary, support

 

  1. All jobs are an unstable balance of satisfaction, salary and support.
  2. In NHS work the satisfaction and interest in meeting and treating people is always present. In many ways medicine is a licensed form of curiosity. As doctors we get to ask and find out things about people which no one else is allowed to even to ask.
  3. The salary in most parts of the NHS is reasonable, and the work and personal cash flow is stable.
  4. The NHS pension is deferred income and it is still a good scheme to be part of, although recent changes make it less so now.
  5. Support in the NHS has two main components- colleague relationships and when something goes wrong.
  6. Most of the time clinicians are reasonable colleagues to work with and we mostly support each other.
  7. However there are times when this support is not felt, or is withdrawn or never given. GPs who have been through partnership splits have many scars. Many CQC inadequate reports are later descriptions of the problems that have emerged from previous poor colleague relationships.
  8. Poor colleague relationships are a direct risk to patient safety and should be dealt with urgently.

 

Complaints and regulation

 

  1. The other time clinicians need support is when challenges, conflicts and complaints arise. These are flashpoints in any job and if the clinician feels supported to manage such events well then they will feel supported by the NHS as a system and their loyalty to it will grow.
  2. If the NHS fails to support clinicians through such times then the clinician will feel bereft and abandoned, and unsafe and under threat. In such circumstances their loyalty to the NHS will diminish severely and they may well leave, retire or emigrate. The glue holding them to the NHS would be dissolved.
  3. Complaints processes may be necessary but the clinician complained about can all too easily become a second victim of the complaint. As in first aid one casualty is what it is, a second casualty is careless.
  4. Good supportive complaints officers are worth their weight in gold.
  5. The biggest fear of all clinicians is that they will be left exposed, holding full and individual accountability, for what is really the end stage in a series of system errors and system scarcity.  But the blame will crystallise around an individual staff member whose career will be ruined, and who will be thrown to the press. The case of Dr Bawa-Garba made such fears all too real.(9)

Value and Failure Demand

 

  1. All NHS jobs have some element of VALUE DEMAND in them and some FAILURE DEMAND  in them. (10)
  2. Value demand is where the work done directly contributes to helping the patient along their journey.
  3. Failure demand is when the clinician has to do the system’s work rather than the patient’s care. It doesn’t’ get the patient any further forward and may well tie up the clinician in an administrative task for a long time, way out of proportion to the value of the task. When clinicians complain about “paperwork” this is what they actually mean.
  4. Failure demand is what makes it hard for staff to get the work done.
  5. Failure demand has rocketed in the NHS over my career. Its low point was the Francis Report and Sir Robert’s great summary, "staff were doing the system's work, not the patient’s.” (11)
  6. In most NHS jobs there is too much work done for the system, to make the records look good, the stats look right and this takes away from doing what is right for the patient.
  7. Goodhart’s Law applies forcefully and what was once a useful measure simply becomes another target. And NHS staff are well trained target hitters. We miss the point as we hit our targets.
  8. The complexity of NHS systems means that there is a lot of failure demand in all NHS jobs.
  9. This wastes huge amounts (£billions) NHS time and resources on high friction interfaces of care.
  10. This creates attrition and friction which makes jobs suck and significantly reduces the likelihood that staff will continue.
  11. Staff frustrations are not just “the old whinges” but reflect direct risks to patient safety.
  12. They are also rapport breaks that reduce a staff member’s feeling of belonging to the NHS
  13. There is little sign that the NHS as an employer recognises this.

 

 

Conclusion

 

I began this submission by emphasising belonging and quoted Stevie Smith’s poem “Not waving, but drowning.”

 

In the main text I described some of the many ways in which the health and social care ecosystem behaves so that it breaks rapport with staff members so that they come to believe that they don’t fully belong in the system. The consequence of this lack of belonging is that they retire, leave and emigrate and actively discourage others from joining the service.

 

I want to finish with Mary Oliver’s Poem “Wild Geese” and specifically the line,

“over and over announcing your place

in the family of things.”

 

If we want to improve the recruitment, training and retention of staff in the UK health and social care ecosystem then we must keep reassuring, showing and confirming to all the staff members that they do belong and that they do have a place in the family of things. Far too many of us at present don’t have this feeling.

 

 

 

 

 

 

 

References

 

  1. Neighbour,R (2016) The Inner Physician RCGP, London
  2. Wilson, H and Cunningham,W (2014) Being a doctor. Understanding Medical practice RCGP, London
  3. Smith, S. (1972), “Not waving but drowning.”  From Collected Poems of Stevie Smith. New Directions Publishing Corporation. https://www.poetryfoundation.org/poems/46479/not-waving-but-drowning
  4. West, L (2001) Doctors on the Edge: General Practitioners, Health and Learning in the Inner-city FAB Books London
  5. zdogg MD. The Great Resignation youtube  (accessed on 19.11.21) https://zdoggmd.com/the-great-resignation
  1. Staten, A and Lawson, E (2018) GP wellbeing: Combatting burnout in General Practice. CRC Press.
  2. Gerada, C. (2021) Beneath the White Coat. Doctors, their minds and mental health. Routledge.
  3. Drummond, D. (2014) Stop Physician Burnout. What to do when working harder isn’t working. www.The HappyMD.com
  4. Hammond, P (2018)  http://www.drphilhammond.com/blog/2018/06/28/private-eye/private-eye-medicine-balls-1464-february-2-2018/ (accessed 19.1.22)
  5. Seddon, J. (2008) Systems Thinking in the Public Sector  Triarchy Press, Axminster
  6. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry (accessed 2.1.22)

 

Jan 2022