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Juggling people and politics in the NHS

Between care scandals, politicians' wranglings and missed target reports the NHS is hardly ever out of the headlines.We explore the key workforce issues affecting the NHS, both now and to come.

The NHS is a political battleground in any election, but in the run-up to this one the fighting has been particularly fierce. Shadow chancellor Ed Balls recently claimed Conservative cuts totalling £70 million would lead to NHS patients being forced to pay for healthcare.

Meanwhile prime minister David Cameron has accused Labour leader Ed Miliband of using the NHS as a “political football”, a practice he labelled “disgusting”.

Add to that the shadow still cast by the Francis report into Mid Staffordshire, not to mention reports of missed targets on A&E waiting times, and it’s not hard to see why the NHS won’t be leaving the headlines before May’s election. And with a staff of more than one million, workforce is at the eye of the storm.

Membership organisation NHS Providers represents 244 Foundation Trusts and Trusts – more than 90% of the sector – lobbying and advocating within government. With the general election only a month away and the fight over the NHS heating up, HR magazine met with NHS Providers’ policy leadership team – director of policy and strategy Saffron Cordery, head of policy Miriam Deakin and head of analysis Siva Anandaciva – to hear where workforce, leadership and HR fits in. This is a snapshot of some of the key workforce issues facing the NHS, according to NHS Providers, and over the page head of HR profession for the NHS Stephen Moir responds.

Balancing strategy and operations

It’s a situation that all business leaders, and HR in particular, can relate to: the difficulty of balancing the day-to-day operations with strategic thinking. But for the NHS, the challenge is particularly acute, in a context of austerity and increased public pressure. “If you’re an NHS board, you’re under incredible pressure to deliver your A&E target, financial sustainability for the quarter, weekly reporting on performance… that sucks up your energy,” explains Anandaciva (pictured, far left). “At the same time, you’re being told to be strategic, to think about the next five years and how your workforce and the way you deliver care is going to transform.”

The call for more strategic thinking is an opportunity for HR, believes Cordery (pictured middle). “The workforce is what makes up the NHS. There is a huge challenge and a huge opportunity for HR directors to seize this strategic and political issue.”

A common complaint about the NHS is that it is bloated with middle managers, but Anandaciva claims most clinicians see the value in good general managers and calls the top-heavy argument “overstated”. Cordery adds that of all the healthcare systems in industrialised nations, the NHS is one of the least management-heavy. “We don’t compare it to anything else because we have so few national industries,” she points out. 

National vs local

Another tension is the balance between national and local. Cordery believes terms and conditions around pay need to be loosened and given a greater degree of regional flexibility. “Organisations should have the opportunity to be able to work with a pay structure that enables them to meet what they need to deliver rather than meet what a national service needs to deliver,” she says. However, she acknowledges having  nationally agreed pay T&Cs “takes a huge burden off the shoulders of your average HR director, who wouldn’t want to be sitting there teasing out and negotiating a whole new pay structure for their organisation”.

She adds that while pay T&Cs could seem “quite granular”, they are a “massively political issue” (not too hard to believe given the recent rise in NHS industrial action) that requires strategic thinking and “greater support from those who are taking decisions around the future of the health service”.

The NHS is so complex, with such a diverse range of job roles, that devolution around the workforce side of things is particularly tricky, she says. “There are many national pressures and levers around pay, T&Cs and structures of how jobs are even carried out. To be able to assert autonomy and make devolution real, you have to be an innovative and entrepreneurial organisation and take your workforce with you. It’s so important you have a workforce that adapts to context, and that means being able to look at different shapes of the workforce, deploying it in different ways, paying it in different ways, enabling different types of productivity and flexibility.” 

Culture and leadership

Deakin (pictured, far right) says the Francis review into whistleblowing is welcome in its focus on culture and behaviour as much as policy and process. “In an organisation with the right culture and behaviour, a policy is just a backstop,” adds Cordery. “It’s not there to drive how you respond to it because organisations with good cultures don’t need to draw on their policies.”

However, she warns whistleblowing risks becoming a “catch-all term” for an activity that could be “someone simply exercising a grievance”. “Whistleblowing gets overused as a term,” she adds.

But whatever the term, culture must come first, and that stems from leadership. “HRDs as part of a board have a key role to play in making sure the framework is in place to enable healthy organisational cultures,” Cordery says. “The leadership is where it starts.”

She cites HR Most Influential Thinker and Lancaster University Management School professor Michael West’s work on collective leadership models: “His notion that heroic leadership isn’t the way to implement sustainable ways of working is absolutely right. It’s so complex, you can’t [succeed] through an individual leader.”

Anandaciva adds: “Before you could get away with working your way up, become a chief exec and run a good organisation. That’s not good enough anymore. You have to collaborate and innovate. In 10 years you’re going to have a completely different care model and will need to build relationships in a way you’ve never done before. You need a collaborative, innovative leader.”

But as Deakin pertinently points out, while a lot of NHS trusts are doing good work in this area, “these behaviours have got to be modelled at the central bodies as well as on the local level”. Politicians, listen up. 

Addressing skills shortages

With models of care dramatically changing and an ageing population requiring more medical attention than ever, strategic workforce planning is a vital issue. As it takes seven years to train a doctor, how can the NHS ensure it has the skills for the future? “Look at our population and you think ‘why did we not train more geriatricians?’” asks Anandaciva. “In 10 years’ time, you hope we won’t be thinking, ‘why didn’t we train more diabetes specialists?’”

He adds there are also issues with a lot of “single-handed GPs” reaching retirement without a successor, as the next generation of clinicians often don’t want to be “lone operators” and that serious work needs to be done to make emergency care a more attractive option.

Training and development are another area ripe for more devolution, believes Cordery. “It’s about understanding what’s needed locally,” she says. “What you need in different places varies and you need to have local providers at the table. You’re on this continual conveyor belt of training people. It’s a difficult task, identifying the shape of the workforce and training. You need to be able to source it from the bottom up. This isn’t about the system, it’s about the local providers within the system.”

Adds Anandaciva: “It comes back to that autonomy point. You can either have your model of care defined by your workforce or you find the workforce to fit the model of care.” 

A message for the next government

Stability is fundamental – whatever the colour of the next government – NHS Providers believes. “You cannot expect any system to transform and rise to the challenge if you are continually changing the structures that support it and changing the nature of regulation that impacts upon it,” points out Cordery. She urges the next government to be “as pragmatic as possible to get us through a very difficult period”.

Anandaciva references a quote from British Medical Association chairman Mark Porter: “The politicians tend to see a service that has its moments, but is just one major reorganisation away from being perfect.” In his own words, he adds: “There seems to be an idea that there is a perfect number, but we never arrive at it. It’s almost futile to keep rearranging things rather than getting on and behaving as if the system works.”