· 3 min read · Features

Can the real NHS please stand up?


When you hear someone mention the NHS, what do you think? A failing institution, always in the media with insurmountable problems? Or an institution your friends and family speak fondly of, that delivered a seemingly miraculous recovery of a loved one? Take your pick. Which is it? Can it be both? Can the real NHS please stand up?

It’s really hard right now to have a mature debate about the NHS. On the one hand if you talk up the NHS, highlighting the wonderful things it does every day (the NHS sees about 1 million people every 36 hours), you get accused of naivety – of not understanding the size of the problem and of being in denial about the size of the changes needed.

On the other hand if you talk about some of the problems we face you get accused of denigrating a well-loved institution and of softening it up for privatisation. It's heads I lose, tails I lose, and so we struggle to call out the key problems we face and what we need to do to address them. And that means its patients who ultimately lose. We have to have the change debate.

Twitter is no help either. It is a strange observation for me but many NHS folk on Twitter seem to spend half their time defending the NHS from attack and the other half criticising its culture, its management and it regulators. I’m not trying to curtail debate, just to get some reasonable perspective.

It seems in HR we are constantly dealing with an emotional, polarised debate about people issues. So let me try to pick out some of the sensitive challenges in this seemingly endless febrile context.

First some global context. How does the NHS compare to other healthcare systems?

Recently, the Independent Commonwealth Fund said that the NHS is the top ranked healthcare system across the 11 richest countries of the world – top for quality, top for efficiency, top for access and top overall. Our narrative should be one of getting from good to great. Staff are more likely to respond to that challenge.

But we also know the NHS needs to change its model of care – even with additional funds the NHS system of today is designed for the healthcare needs of the 1950s and 1960s. Change will be unrelenting whatever the funding and whatever the Government. We need transformational change skills for managers and leaders (as well as bravery from politicians).

Raising concerns 

The public accounts committee recently reported on whistleblowing in the public sector, saying over one third of civil service employees do not know how to raise a concern. In the NHS, 90% of staff know how to raise a concern and the majority feel safe to do so.

Of those staff that had witnessed concerns about patient care, 90% said it was reported. That missing 10% is of course a worry, but more worrying is the survey that says only 56% of staff believe their concerns will be taken seriously. More for us to do on this. It remains crucial for patient care as well as staff and public confidence.


We have had a significant period of pay restraint. Affordability is clearly an issue, but we can’t just keep on holding pay down and hoping for the best, particularly as the economy picks up and skills shortages become evident.

We have to organise and discuss with trade unions a sensible plan for a smooth exit from this period of restraint that will avoid a recruitment and service crisis. This discussion is urgent. We need government and trade unions to engage with us in the debate.


The NHS is numerically diverse, with 18% of the workforce from BME backgrounds. Some 77% are women and 41% of chief executives are women. Of those staff who are medical consultants, our highest paid staff groups, 36% are BME.

But these figures belie the fact that there are hardly any board members from BME backgrounds. This has to be an urgent issue for boards but also for regulators, who have the system levers to effect change.

The numerical details can also hide some cultural challenges. BME staff consistently have poorer experiences of work and management. In the NHS we need to move the debate from simple numbers (board level excluded) and concentrate on people management that maximises the contribution of all our staff, ensuring they are valued.

If we can address these sensitive issues with confidence we get to tell a good to great story. We do our patients a disservice if we avoid the debate through fear of challenge. We can and must raise these issues thoughtfully, with confidence, to show we are neither naive nor overly optimistic – but change we must.

Dean Royles is the chief executive of NHS Employers