This is tiger country

People nod wisely when someone says (again) that sustaining and improving the NHS is mostly about sorting out the policies that impact on the people who actually work in it.

From a patient perspective, how these 1.4 million souls feel about their jobs impacts on how well they do their jobs. People are at the core of whether we get safe, effective and compassionate care.

From the taxpayer perspective, NHS staff account for the bulk of the money we put into the system, more than two thirds of our overspent hospital budget. 

If workforce policy is so important, it is strange then that standard policy parlance so often moves swiftly on to buildings, models of care, commissioning and the new favourite policy thing. The current disturbing breakdown of trust between junior doctors and the system is perhaps one very present clue as to why this is the case.  Institutions are somewhat tamer than professions and less likely to bite back when pushed about. Workforce policy is tiger country, better kept at a distance. Let sleeping doctors lie.

Perhaps as a result, what we get is a workforce policy system so labyrinthine that – as far as we can tell – our new report Fit for Purpose is the first time anyone has tried to capture it all in one document. What you see is power distributed across an architecture of more than 40 different bodies: nine professional regulators, dozens of trades unions and royal colleges, four Whitehall departments, two European Commission directorates, three Pay Review Bodies, and a clutch of Department of Health quangos: you wouldn’t want to start here.

To add further concern, while there is bilateral cooperation on particular issues, there is little evidence of effective strategic leadership of this complex world. Let’s take a simple question: ‘who leads workforce policy in England?’ It’s not clear to me. Department of Health? Health Education England? NHS England? As such, no one has articulated a nationally compelling vision of which way is north, a workforce policy pole star for England, to guide this jumble of drifting institutions towards a common strategic destination.

If most of the real workforce business was sorted locally, this would perhaps matter less. However most English workforce policy is highly centralised. Pay, pensions, terms and conditions are a deal between politicians and trade union leaders. Professional regulation sets central standards and seeks to assure national consistency of training. Workforce planning, and education and training are run nationally in England by HEE under a mandate from the Secretary of State. While successive administrations may have sought to encourage local institutional diversity and experimentation, the workforce system ensures central conformity and standardisation.

This isn’t making anyone very happy. Politicians and national leaders get frustrated with the pain and glacial speed of change. From the perspective of NHS staff, the latest staff survey in England (despite small improvements) suggests a fair way to go before people working in the NHS rediscover the “joy in work” that Don Berwick has made his rallying call. If my own team’s staff survey found the high rates of stress, violence and bullying that NHS staff are reporting, I would be deeply alarmed.

It doesn’t have to be like this; there are tantalising glimpses of what can be achieved if we approach workforce differently. The rightly celebrated Buurtzog approach to community nursing in the Netherlands has shown that re-establishing services around the intrinsic caring values and professional instincts of staff can lead to improved patient experience and save money. Jeremy Taylor talks more about this approach and the work of the Realising the Value programme, which the Health Foundation is involved with, here.

So where to start? A good place would be to think beyond financial incentives and penalties and better understand the culture, values and positive intrinsic motivations that guide NHS people every day.

For policy makers that means making policy with people working in the NHS rather than doing it to them. It will mean a longer conversation and it will be a difficult one, in which the various NHS tribes – doctors and managers in particular – will need to walk in each others’ shoes and find the common ground in which to cooperate in the interest of both patients and taxpayers.

We also need to talk about doctors: the leadership of the medical profession has an effective veto on any sustainable changes. This issue is not just confined to the UK: in the US, Kaiser Permanente have decided to establish their own medical school, so that they can recruit and train the type of doctors they think are needed for the future. As a society and a system we urgently need to revisit medical education to ensure, for both the profession and the NHS, that our future doctors can both lead and be led in adapting our health care system to the needs of patients.

If the plan for the next five years is just to scrape through by winning contractual battles - to make fewer people work harder for less money - then we are in very deep trouble. We urgently need a radically different way of working with a deeply disenchanted workforce. And, as our report published today recommends, we need to use that new relationship to build a unifying policy vision that can guide our complex system to a better place for patients.

Richard Taunt is Director of Policy at the Health Foundation @RichardTaunt

Read Richard’s comment piece in the Health Service Journal* regarding workforce. 

_{*Please note that the HSJ is subscription only.}