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13 June 2022

The NHS needs a cultural overhaul – this time let’s hope it happens

The health and social care leadership review is right that the service needs major change.

By Suzie Bailey

The latest review of leadership in health and social care in England is described by the Department of Health and Social Care (DHSC) as the “biggest shake-up” in a generation. If you look beyond the crowd-pleasing jabs at NHS managers that led much of the initial reporting of the review, you will find a well-considered and thoughtful piece of work. The big question is whether this simply is the latest in a series of NHS leadership reviews that have failed to achieve the changes required to deliver high-quality care for our communities.

The review was conducted by general Gordon Messenger, former vice chief of the defence staff, and Linda Pollard, chair of Leeds Teaching Hospitals, who set out to consider how health and social care is led and managed in England. It’s understandable why ministers want to review health service leadership. The Conservative Party broke its manifesto commitment not to raise taxes in part to help tackle NHS waiting lists, at a time when public satisfaction with the NHS has fallen to 36 per cent, the lowest level since 1997.

The challenges for leaders and managers across the sector cannot be underestimated. Most notable among these challenges are the chronic and widespread staff shortages that long predate the pandemic and threaten the delivery of safe care. This explains why the response to the review from many health and care organisations, including The King’s Fund, is summed up as “good leaders can only be effective if they have staff to lead”.

The House of Commons health and social care select committee concluded in its 2020 inquiry that “burnout is a widespread reality in today’s NHS”.While there are many causes of burnout, the chronic excessive workload faced by many staff is a major driver that needs to be tackled as a priority.

The 2021 NHS Staff Survey demonstrates work-related stress is at an all-time high, with nearly half of staff feeling unwell due to work in the past 12 months. Nearly three-quarters of staff said there were not enough employees in their organisation for them to do their job properly. A recent survey by the GP magazine Pulse showed nearly half of all general practitioners plan to retire by the age of 60, which is a big issue when so many of the profession are in their 50s and fast approaching that milestone.

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The NHS has one of the largest workforces in the world, and nearly half of its budget is spent on staffing. Yet it has lacked a proper workforce plan for the best part of two decades as successive governments have failed to confront the staffing crisis that has been building during that time. In the face of this inaction, a coalition of over 100 health and care organisations, including The King’s Fund, have called on the government to publish regular projections on the future supply of and demand for health and care workers. Despite the support of the current health and social care committee chair and former secretary of state for health, Jeremy Hunt, even this limited measure was voted down by the government in the House of Commons.

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Improving staff health and well-being in public services should be a high moral, social and economic priority, with a focus on addressing the underlying causes of stress, as opposed to interventions that merely seek to manage or mitigate it. Yet in his ministerial statement in response to the review, the Secretary of State for Health and Social Care, Sajid Javid, missed the opportunity to make a commitment to supporting the health and well-being of the people who work in the service.

The review’s authors rightly point out that “a one-off review cannot provide all the necessary ingredients” for a “determined cultural change from the top of the system to the front line”. However, the recommendations do underline the value of great leadership and offer some welcome and sensible new measures, including greater emphasis on principles of equality, diversity and inclusion to be embedded as the personal responsibility of every leader and every member of staff.

Also, the review has not shied away from the very real issues of bullying and harassment in the service, or the need for a clearer and more transparent approach to career development. The findings have a generally wide application, but it is disappointing that the specific and very considerable needs of social care leaders as well as GP, pharmacist and other primary care leaders are not addressed in any detail. The needs of these sectors are too often overlooked, and leadership of these services warrants urgent attention.  

Sustained action and new investment at every level of the health and care system will be needed for the changes proposed in this review to take root. Just as important will be a shift in the actions and behaviour of national leaders.

Ministers threatening to get on the phone and berate NHS leaders where they disagree with their decisions and the “off with their heads” approach to performance management adopted by some national NHS leaders are a far cry from the compassionate and inclusive leadership articulated by Gordon Messenger and Linda Pollard. Ministers and national NHS leaders would do well to consider how they too can live up to the standards this latest report sets out.

In the words of the authors, let’s hope this time there is action on the recommendations, or it will be “all for nought”.   

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