The Health and Social Care Committee are holding an evidence session as part of their inquiry into NHS and social care staff burnout and resilience.
This session examined the impact of bullying, discrimination and harassment on staff burnout, patients and services.
The session also considered the importance of leadership and workplace culture, hearing from NHS Providers and the National Guardian’s Office, which supports a network of local Freedom to Speak up Guardians so that NHS workers can speak up on workplace issues.
Topics included the current issues facing staff in the workplace, what support is available for staff as well as the potential for compassionate leadership to reduce burnout.
The second panel explored the particular experiences of NHS and social care staff from Black, Asian and minority ethnic (BAME) backgrounds and actions that can be taken to support them (see video below).
- Professor Jeremy Dawson, Professor of Health Management, Sheffield University
- Chris Hopson, Chief Executive, NHS Providers
- Helené Donnelly OBE, Ambassador for Cultural Change/Lead Freedom to Speak Up Guardian, Midlands Partnership NHS Foundation Trust
- Dr Henrietta Hughes OBE, National Guardian
- Lord Victor Adebowale, Chair, NHS Confederation
- Shilpa Ross, Fellow, The King’s Fund
- Tricia Pereira, Head of Operations Adults Social Care & Adult Safeguarding, London Borough of Merton
Dean Russell Q1: You mentioned earlier knots in the system. I am particularly interested around the challenges of red tape and how that impacts leadership. It feels to me that when you have staff who know what they are doing on the frontline, adding additional red tape to stop them doing that can be a challenge. I was interested in whether you agree with that view and what we could potentially do about it.
Chris Hopson: There is a really important balance to strike. This is an industry—sorry, that’s a terrible phrase. This is a sector of our national life where, if you get things wrong, people die. Quite rightly, there should be an appropriate degree of regulation to ensure that, for example, health professionals are registered and their practice is appropriately defined.
We have chosen in the health service to say that the 216 trusts, which are responsible for about £90 billion of the £130 billion and employ 800,000 of the 1.3 million staff in the NHS, are responsible for overseeing the delivery of secondary care services. That is 1 million patients every 36 hours. The real question is the degree to which we say we are going to trust those NHS trust boards, and the leadership and middle management teams within them, to get on with doing what they need to do, and the degree to which we are going to micromanage them and tell them, “This job needs to be done in this particular way.”
The frustration in the past has been that people have felt that NHS England and NHS Improvement and the Department of Health and Social Care have basically got the balance wrong. They have been too prescriptive. Again, it is very important that our politicians who are responsible for the NHS should be accountable to Parliament, but quite often what we hear is the CQC, NHS England and other bodies asking for the same information, and asking for it very quickly. Huge amounts of information returns need to be produced to enable that accountability to be exercised. Those are the kinds of things that frustrate people.
Dean Russell Q2: Would you say that there is too much paperwork?
Chris Hopson: Yes, I think people would definitely say that. I think we are changing. As Jeremy will know, we have a new structure in the NHS where we have, for example, a chief operating officer in NHS England and NHS Improvement who is a former trust chief executive. We have a regional structure now where two of the seven regional directors are people who come from a trust background. We are trying to cut the amount of paperwork. We are trying to let people get on with it, but, in a centralised structure, you can see why those at the centre feel themselves accountable and therefore want to get huge amounts of detail, and specify in lots of detail, about what the frontline should be doing. We need to get that balance right.
Dean Russell Q3: The reason why I ask is in part that I recently produced a report to colleagues looking at community, and volunteering in particular. I spent the day with St John Ambulance, who told me that prior to the start of lockdown last year they were never able to help on wards, even though they had the capacity and skills to do that. Once lockdown happened, some of the red tape at the bottom level, as it were, was able to be released. Agreements were put in place and they were able to help and make a big difference. I also volunteer myself at my local hospital. I have seen the impact of volunteering. Do you think that is something we should encourage, moving forward? I have proposed the scheme of an NHS cadet system, for example. Is that something that you would say would be beneficial?
Chris Hopson: I certainly believe that there is a real opportunity to harness people’s commitment to the NHS, and the skills that many volunteers have. I could point you to some very specific examples. King’s College Hospital is a very good one, where they have 1,000 volunteers who work on a very regular basis. My wife volunteers for the Royal Free Hospital, just up the road, and with a bunch of hardy volunteers has done a fantastic job to transform the garden. There is a really good opportunity to do that.
I would be the first to say that this is not something that is universally taken up by all of our members. I think we could definitely do better. The whole thing about the relationship between the NHS and the third sector is something that feels to me, and always felt, underexploited. Yes, I completely agree. Quite how formalised it is and quite how much we would leave it up to local individual organisations is an interesting debate.
Chair: I am sure that the Committee would like to put on record our thanks to Charlotte for her volunteering.
Dean Russell Q5: Absolutely, and to all volunteers. I have worked alongside some incredible volunteers. I have a question for Dr Hughes regarding the impact specifically on mental health wards. I imagine that, not just during Covid but generally, they are very high-stress environments. I wondered whether, from your work, you found that the level of stress in mental health wards for staff is something that is looked at. I imagine they must deal with really difficult situations. Are they getting the support, the counselling and the follow-up as staff to enable them to sustain that level of work?
Dr Hughes: What we have found from our surveys is that the cultures in the community and mental health trusts tend to be the better cultures across the NHS. One of the things that is significant about that is that the leaders in those organisations are familiar with dealing with people in distress. That knowledge and skill is taken forward in how they support their workforce as well. Clinical supervision also forms a really important part of that. Consistently, year on year, we have seen that the cultures in the community and mental health trusts and those who manage patients with learning disabilities are consistently better than in other types of provider.
There is a great deal of learning that can come from those organisations to share their experience and expertise in how they take their skills and use them to support their workforce. I agree with you that they are dealing with very difficult and stressful situations, particularly during the pandemic.
Dean Russell Q5: I would like to ask the whole panel this, but I am conscious of the time so I will start with Victor, if I may. Continuing the Covid discussion, last year there were really worrying numbers shared around the percentage of the BAME population, especially staff, who sadly died through Covid. I wondered whether there have been any studies yet into the long Covid impact across the whole of the NHS and social care staff but looking in particular at the BAME population. Has that been done yet, or is it under way?
Lord Adebowale: Thank you for that question, Dean. The first 10 people to die in the NHS were black, and that rate of disproportion has continued, so it is terrifying for frontline black staff. As far as I am aware, there has not been a study of the impact of long Covid in minority ethnic groups.
One of the things that the Observatory on Race and Health is doing at the moment, in partnership with the College of Hygiene and Tropical Medicine, is looking at both the impact of Covid and the issue of the vaccine and how we relate that to BAME communities, and what leaders need to do to reverse that needle. It is a very good point; we need to look at the impact across the piece. There are very few studies of people with long Covid. We have just started to look at the impact of long Covid as a piece, but we should look at the disproportionate impact on BAME communities because it is having a disproportionate impact.
Dean Russell Q6: Absolutely. One of the challenges there is on workforce numbers. If long Covid becomes something that is a large factor for all of the NHS and social care, but in particular, in the instance of this Select Committee, on the BAME population, my worry is what that means in terms of absence issues for individuals, long-term health concerns and so on.
Looking at it from your perspective, if that sort of work starts, to look at that, how would you see it rolling out? Are there mechanisms at the moment to be able to measure it, to get feedback and those sorts of statistics, or do new mechanisms need to be set up?
Lord Adebowale: My view is that new mechanisms need to be set up to look at it. We can build on the mechanisms—the staff surveys—and talk to the clinical frontline, which I think is vitally important. It should be remembered that we went into this crisis with reported staff shortages across the NHS and we were already challenged. This has not made it any better. All staff, black and white, are working under tremendous pressure, as you know.
We need to deal with the challenges they face on the frontline first and start removing some of those challenges. For black staff, it is the continued sense that they are on the frontline. They are literally facing the Covid virus. The anecdotal evidence, which is evidence in and of itself—in the absence of quantitative data, you only have qualitative data and there is a lot of it—is that black staff continue to feel pushed into the frontline, unable to get the protection and support that is necessary, and are still being affected in disproportionate numbers.
The way to reverse that is to start listening more carefully to those staff about supportive structures and how much control we can give them over their day-to-day work environment and the way in which they design and manage their work. The same principle applies to white staff, which is why I say it is about leaders leading all the people all the time. What we know from research about dealing with stress is that the more control you give people, the less stress they feel. The more support you give them to remove the barriers—bureaucracy and so on—the more likely it is that they will feel in control.
Those are the things that we need to do, but we need particularly to do them in relation to BAME staff because they are the people absolutely facing this on the frontline in the poorest communities, who we already know are disproportionately affected.
Dean Russell Q7: I agree wholeheartedly on the red tape issue. There was a question in the earlier session as well around the impact of that. I will not explore it further now because we covered it earlier.
We talk about frontline workers, who many people think of as doctors and nurses, but if you are a porter or a cleaner working in a hospital you are just as much in the thick of it as everyone else. In my local hospital, we have a large Filipino community. When we are talking about frontline workers and BAME, are we reaching out to all members of staff across the board, from porters through to clinicians, and all ethnicities, which may include the need for support with languages as well?
Lord Adebowale: To be absolutely clear, when I refer to black and minority ethnic workers, I include Filipino workers. When I talk about frontline workers, and certainly at the confederation, it is not just about the 44% of GPs from minority ethnic groups, or indeed just GPs; we refer to nurses, cleaners and porters, all of whom are disproportionately represented in the BAME community. I think your point is well made.
I think we should commission the research on long Covid now. Let’s not muck about—let’s do it. The question of understanding the conditions in which those people work, and the communities they come from, is critically important. There is evidence that they are the people who are least likely to be able to cope with being shielded and having to stay at home, because they are on low wages. They are more likely to live in overcrowded conditions, so there is a greater risk of spread, and they have the least flexibility over their job roles. That is not to say that they do not know. When I talk to porters, frontline workers and nurses, the amount of knowledge they have about how things could be done better is remarkable—it really is—but they are not listened to. Where there are good examples, and there are many good examples, and when they are listened to, you see the improvements immediately across the piece.
If you look at the Social Partnership Forum work that has been done by NHS Employers, frontline workers are empowered to share their experience in such a way that it leads to change. If you look at North Bristol trust’s Red Card for Racism approach, and at Rob Webster’s strategic approach in the West Yorkshire partnership around ICSs, you start to see the seeds of a shift in leadership, and leaders taking responsibility for the culture they create. The only test for a progressive culture that works is not at the top. They are the people who usually feel rock and roll. It is the people at the bottom. That is the key test. Do the people at the bottom feel that they are empowered to do the best and be experts in the work that they do? I am afraid that we have a way to go there, but the confederation is working with our members across trusts, primary care and ICSs to move the needle in that direction. That is what our reset report was all about.