The health of the health workforce: a conversation stopper

Health conversations - Aimee Wachtel/Holyrood

The NHS in Scotland is owned by the people, funded through taxation and free at the point of use.

It is also run by the people – the doctors, nurses, pharmacists, allied health professionals and other support workers – who care for those who need it.

But the responsibility of care is a two-way relationship, between patients and those who care for them. And in so doing, that mutual care is care for the NHS itself.

This is particularly true at a time when an old-fashioned system designed to treat the sick has to cope with increasing demand as people live longer and with more complex multiple conditions. 

The challenge is partly, of course, a product of the NHS’s own success, as advances in treatments and breakthroughs in public health awareness lead to better outcomes. 

As an institution, it has been most effective at treating the sick. But the sick are now living longer, and require more complicated and longer-term treatments.

And as the population changes, so too does the workforce of the NHS. It, too, is getting older and has more complicated needs and so, inevitably, the relationship between the NHS and society changes. 

People who have relied on the health service to fix them will be expected to play a greater part in ensuring they don’t break in the first place, have a recurrence or take greater responsibility for learning to manage their conditions, while the pressure is on governments to create ways to support them to do that.

Meanwhile, the shape of services must change to the extent that the staff who populate them must work in different ways or jobs to provide the kind of support that both their patients and they themselves need.

And there are more staff than ever working in the NHS. There are 160,000 in Scotland in 2017, up from 118,000 in 2012. Three-quarters of them are women.

Trade unions and other campaigners welcomed Nicola Sturgeon’s pledge to scrap the  long-established pay cap, which had led to real-term declines in wages and was undoubtedly  a factor in staff feeling less valued. But the challenges run far deeper than pay.

This summer, Audit Scotland published the first of a two-part audit of the workforce. It warned that although spending on staff was at an all-time high, workforce planning was not taking the increase in demand on hospitals into account.

“The Scottish Government and NHS boards recognise the challenges, but urgently need to improve their understanding of future demand, staff projections and associated costs, and set out in detail how they plan to create a workforce that can meet the long-term health needs of the population,” said Auditor General Caroline Gardner.

The ageing workforce is particularly true in nursing and midwifery, the largest staffing group in the NHS. Family doctors, too, fit this category.

But with health boards expected to make efficiency savings to keep overheads down, long-term workforce planning is giving way to short-term firefighting, the audit warned, with greater spending on agency cover to help meet workload requirements and exceeding staff budgets as a result.

Furthermore, workforce projections by health boards have not reflected the policy intentions of reforms such as the integration of health and social care, Audit Scotland said.
Meanwhile staff complaints are up. Holyrood spoke to two nurses on the front line to find out why.

One, Daphne, said she does shifts as an agency nurse because a permanent role comes with 12-hour shifts. “You get rostered to do three or even four in a row. I can’t do it, I’d be ill,” she says.

She describes the workforce planning of her health board as “incompetence”, when a scarcity of people willing to undertake such gruelling shifts itself perpetuates a scarcity, driving up the cost of agency staff. 

Because agencies pay more than the in-house staff ‘bank’, which boards prioritise, nurses from one health board will travel to another to do agency work and vice-versa, she tells Holyrood.

Another nurse, Freya, describes a “degree of ill-feeling” between nursing colleagues as a result.

“I’m sure my friends who do agency shifts do appropriate work that they are correctly trained to do, but many do not have the skills required of an acute nurse whilst on their allocated shifts,” she says.

“They often tell us they can’t do IV meds or pumps because they haven’t the training. It’s not a lot of help when you know your ward is paying this nurse a good sum of money whilst you run around spinning plates.”

Freya adds: “My feeling is that I came into nursing to work for the NHS and wouldn’t consider private as it goes against the grain of quality, affordable healthcare for the good of all.”

Daphne says she has experienced some bullying on wards, both as an agency staffer and working in the staff bank.  

“They use you as a punch bag sometimes for their frustrations because you can walk away from it at the end of the day and they can’t. They have to go back. We don’t.”

Improvement will require “a degree of honesty” from a management “too far away from the wards”.

“Management consultants are not nurses or medics,” she says. “They don’t get why it goes wrong when it does because they’re just doing it ‘on paper’.”

But the processes of doing things differently is exactly what was identified as needed by Paul Gray, NHS Scotland chief executive, when Holyrood interviewed him in March, ahead of the anniversary of the establishment of the integrated health and social care boards.

“There is no such thing as a culture change programme,” he said. “If anyone tells you they have one, they probably don’t. Culture is the way we do things, and if you want something to be different, you have to do different things.”

This point is contested by Professor Brendan McCormack, head of the Division of Nursing at Queen Margaret University, who is currently working with the Irish Health Service Executive on a culture change programme to embed person centeredness and quality conversations in Ireland.

“There are so many demands on people that actually, time with patients is secondary,” he tells Holyrood.

“That’s not because people want it like that, they’re sucked into this constant reporting on short-term outcomes and so on. Organisational [culture] needs to justify itself. And it’s missing the real point, which is about the culture that exists in many of the care settings, which isn’t conducive to continuous relationships, even between team members as well as service users.”

McCormack points to academic research on organisational culture to show Gray is “totally and utterly wrong” about there being no such thing as a culture change programme.

A leading theorist on it is the US scholar, Edgar Schein, he says, who describes unspoken values and patterns of behaviour that direct action whatever protocols or standards are set.

“I think it’s also difficult within teams for people to have sustained long-term relationships with each other, because there is now so much change and transitioning within those teams.

“What I see in clinical units is really little sense of a team because it is constantly changing, constantly in flux. That has a knock-on effect on the relationships with the service users.”

Patient story data from his work in Ireland, he says, shows people value ‘person-centred moments’ with professionals.

“What will stand out for them is that really good conversation with that nurse or doctor, that really good moment when they will say they felt they were loved at that point in time. That compensates for a lot of the shitty times.”

But when workforce planning is all about firefighting, how can managers factor in this kind of work?

“If I was to strip it all back, I’d say it is about meaningful conversations, conversations where people can genuinely feel safe enough to say what’s going on in their heads, to be honest,” he says.

McCormack still practises, and says he sees “lots of potential spaces” for such conversations.

“Instead you have these safety huddles. I said in a unit recently, ‘why don’t we have a team huddle, where we can refer to how we’re actually feeling about particular things, a reflective conversation?’ It was effectively just killed. But yes, there was time to do that.”

Ireland has seen an exodus of new nurses from overseas who cited a lack of teamwork and not feeling valued as their reasons for leaving, McCormack says, which has led to attempts to move away from a “human resource management mentality” to one which is more about facilitating people. 

Ireland is a great case study for Scotland, he suggests.

“I do honestly think that politicians have got to buy the idea of proper culture change. And I don’t mean some of the stuff that came out of the Francis report, the fairly superficial stuff, but rather having programmes that start to help clinicians to find the space for conversation.

"It’s not a huge money investment, not a huge reorganisation, it’s actually just demonstrating that this is important and valued, as much as everything else is. That’s what some clinicians don’t get. They don’t get that this is valuable. In fact, I’ve heard the opposite, that it’s not, that the value is getting things done as quickly as possible and getting them out.”

Arguably, the medical professionals who perhaps understand the value of conversation most keenly are GPs.

The second part of Audit Scotland’s examination of the workforce report is due out in 2018/19 and will explore primary care and GP workforce issues.

Dr Euan Paterson met Nicola Sturgeon in 2007 when she was Health Secretary at Govan Health Centre where he practised as a GP. On the agenda was workforce planning and whether more deprived communities might need more doctors to tackle health inequalities.

A decade later, and the whole country is in need of doctors, as a spiralling crisis in recruitment and retention of family doctors has led to gaps in health provision in many parts of Scotland.

While Sturgeon now has the top job in Scottish politics, Dr Paterson, like many GPs, has retired early, at just 58, in the face of increasing pressures and sweeping changes to primary care.

Paterson tells Holyrood it was with “great sadness” he left the profession he loved. 

Inspired by his family doctor and some good grades at school, Paterson chose general practice and entered the profession in the mid-eighties, a time he described as its “zenith”.

“From the absolute word ‘go’, I just loved it,” he remembers. “There was no feeling of constraint. Everything was possible.”

At the heart of this, he says, was the relationship with patients built up over many encounters that instils a mutual trust, where people don’t just expect competence but also care.

“Some people are very gifted but the majority of us have to work away at that and build up the feeling where people begin to think ‘he cares about me as a person, therefore, I can trust him’.”

In recent years, a perfect storm has arrived of an ageing population with more complex needs and a contracting workforce in real terms. This has led to a workload where doctors find less and less time for these meaningful conversations. 

“If you’re having to chase your tail, having to make sure you have all the hard, scientific clinical stuff, the whole art of medicine is in danger. And it is an art,” says Paterson.

The Scottish Government’s solution is to remodel primary care with a multidisciplinary team consisting of other professionals such as pharmacists and physiotherapists, backed by a new GP contract which explicitly itemises the duties of the GP.

However, Paterson says this model could threaten “the subtle stuff” which builds up trust and can often lead to patients leaving a surgery feeling better in a number of ways.

“Relationship is all. The things that were beginning to really affect me and bother me, and in part led to my decision to leave early, was that everything suggests the relationship is going to become harder and harder to create and maintain. If we lose relationship, I think we lose it all.”

The implication, he says, is that GPs will only see patients for “the really serious stuff” which will be difficult after a lack of “longitudinal serial encounters”. Some of those can be “quite spiky”, he says, like interventions on smoking or diet, but they build up a relationship to help people through the difficult times.

“I looked after a man dying a couple of years ago from motor neurone disease. I’d known him for 30 years and we’d had some terribly sticky conversations about his smoking and stuff. I mean, shouting at each other level, over the years. 

“When he was dying, he was unbelievably courageous and brave. 

“One of the things that made it work was that we’d had this proper relationship, including spats. It wasn’t just ‘oh yes, how’re you doing?’. And as he lay there, I held the cigarette to his mouth. I put it out and lit him another one.”

For Paterson, even representatives of the profession itself haven’t valued and defended the importance of relationships to general practice, including when attracting new talent. He says even seven years ago, he wouldn’t have recommended the profession to his two children, despite his pride in having “one of the most privileged, rewarding jobs there is”.

“If they really liked it and got good at it, it would have made them unhappy, because they’re going to fail. They’d fail to do well enough for their own standards. That’s not a life I want for my kids.”

While he hopes “real” general practice could “rise from the ashes” in another ten years or so, it is clear Paterson believes it will need an investment in people who have the time to practise its art.

“Not enough people value the core of this, to cherish it. I think they’ll value it when they see it disappearing, but by then it will be gone.”

The answer, according to Professor McCormack, lies in allowing professionals to flourish.

“As human beings, we have to feel we’re flourishing to feel good about ourselves and what we’re doing,” he says.

“I think that’s a message for the Scottish Government about generally embracing this idea of people working in healthcare being able to be the best that they can be. That is about feeling that what you do matters, who I am matters, that I can express myself, that I feel safe, that I can grow, take risks and that I have the support to do it all. 

“I worry so many clinicians don’t feel they’re flourishing. They’re just doing the stuff.” •

The names of the nurses were changed at their request