Diminishing the impact of skills shortages (1)

Keeping the staff we have

In this week’s posts about shortages in the workforce, I just want to stop a minute – again speaking as an old lefty – to gloat a little about what all this means.

I was brought up to believe that there is a long-term battle between those that own capital and those that own only their labour, and the task of the politics with which I was involved was to increase the power of those that had only their labour to sell.

So I tend to regard any situation in which society is forced to the conclusion that labour is really, really important as something of a victory. And this is the lesson to be learned from workforce shortages in the NHS. The entire NHS, and through that large sections of society, now recognise that without labour – the most important institution in our society – the NHS doesn’t work.

As far as my Dad was concerned the importance of labour was a political/moral issue but in my life, much later on, I came across the labour theory of value and it became a central economic argument. The argument is that value – all value – comes from labour itself. Some of you will no doubt be disappointed to learn that I am going to resist the temptation to write a number of even longer posts on that theory although others may be pleased that their journey into work isn’t going to have to cope with reading them all.  Instead my much more limited point here is that labour – that is human beings doing things at work – plays a vital part in all aspects of our society. And that in the NHS everyone is talking about not having enough of it.

So my next three posts are based around this more general point. If we value labour this highly we should be doing more to demonstrate the fact.

Given that nearly all leaders in health and social care say that staff shortages are their biggest problem you might imagine that all the chatter at conferences is about the staff that you value and finding clever ways to keep them. But it’s not.

It’s as if there are two different scenarios here.

In one everyone agrees that there is this big problem of the lack of new staff – which we worry about all the time – and that this is the system planners’ fault for not providing us with a surplus of labour from which to select. In the other there is the day to day process of managing existing staff – which is not so much about valuing staff as about getting things done. In the first scenario people are essential and we value them; in the second they are simply resources that we must use to get things done.

However, given that getting things done in a one way seems to result in unhappy staff leaving the trusts – whereas getting things done in another means happy staff staying you would imagine that the entire NHS management would be endeavouring to retain happy staff. But it isn’t.

And this is even though the NHS, as an employer, starts with the most tremendous advantage over every other employer in the country. The institution is not only loved but it is very well known by neighbours and friends for what it does. It cares for people. When you go to work for the NHS you go to work for an organisation that cares for people.

Why is this important? Most modern management theorists agree that it is much easier to motivate staff if the organisation for which they work represents and carries out a cause. For example, major supermarkets are all the time trying to stress to their staff that they don’t just sell food, but are also getting good, high class nutrition onto families’ plates. Internet companies try to motivate their staff by telling them how their role is to help everyone to keep in touch with their friends and loved ones.

The world of commerce is replete with managers explaining to staff that what their organisations do is to meet a social need (and not just make a quick profit).

As I have said before I am an old lefty.

I remember, at 18, first coming across the theory of alienation at work. This explained that since workers feel that the output of all their work is taken from them and sold at a profit, they become alienated from the experience of work itself.

That was written mainly about private sector work because the market required employers to sell their workers’ output in the market place.

This doesn’t have to happen with NHS and social care staff. There is a clear relationship between the work that an individual staff member does and the care that people receive so NHS employees can see that the end product of their work is care for a human being – relieving their pain and distress – and are not alienated from their work.

Given what it does the NHS, unlike internet companies, doesn’t need to create motivational messages for its staff. Caring for people is what they do. It’s there all around you, all the time. Stand in the reception of any clinic and you see anxious people coming in to be cared for. Go into any hospital and there will be relatives stroking the hands of their loved ones who are being looked after by carers 24 hours a day.

No NHS provider has to cook up a social mission.

It’s always there.

When NHS workers come home and are asked by their family what they did at work today – all of them –  and I mean ALL of them – should be able to show clearly that what they did on their shift relieved real distress and pain for real people. If they can’t, it’s because they are not being managed well.

The relationship between what individual staff do and the consequence of care is the link that managers need to help people make every day. (This is what management means).  A cleaner working for any care provider is stopping infection through their work. Take away the cleaner’s work for a week and infection would tear through the place.

The admin worker is making sure that anxious people and their relatives get to the right place for their care rather than add to their distress by being in the wrong place at the wrong time. Admin staff also relieve pain and distress.

The maintenance worker ensures that the lift works so that patients get to theatre in time for their slot in the operating timetable. If that doesn’t happen neither does the operation.

All this is work by staff. All this means care for real human beings can take place.

None of this involves the slightest exaggeration of the reality of what people are doing. It is clear and obvious. It just needs saying every day by managers to staff as a part of the daily and weekly mantra about the value of the work that their staff do. “Without the hard work you put in this week tens of people would have had a harder time with their illness and dependency.”

It’s true and it’s simple.

I visited a residential care home in Birmingham that had turned around – over two years – from a fast staff turnover with a high agency spend to become a stable and happy staff group. They did this through listening to what mattered to their staff and underlining how their work – all their work – was a part of care.

Managers might respond to this by saying that it’s not that simple. They will argue that they have a whole host of productivity targets which require them to push staff harder than they might like. And that’s what causes staff unhappiness.

But there is much evidence from previous work in the NHS to show how increased productivity does not mean staff have to feel pushed around and ill at ease.

In the mid-2000s the NHS National Institute for Innovation developed, together with hospital nurses, a time and motion improvement tool called “Releasing Time to Care”. This tool used the knowledge and activity of nurses themselves to improve productivity in their wards – it gave them ‘more time to care’.

Every nurse, wherever they work, knows that there are a range of wasteful activities going on that they seem powerless to do anything about. One common example was the issue of large latex gloves. In many wards there were whole cupboards full of boxes of large pairs of latex gloves. They were there because whenever the hospital ordered more gloves they got boxes of large medium and small sizes. The medium and small were used up quickly and the boxes of large ones just stayed there. Filling cupboard after cupboard.

Just stop ordering them please.

Equally most care locations had generations of broken kit around that had been replaced and was just mouldering in corners or along corridors. No one could be bothered to shift it. So the nurses put very large signs all over them which read “THIS IS BROKEN. PLEASE MOVE IT”. Doctors doing their rounds noticed them – and got them moved.

I was part of a sales team to the US where we talked to large groups of nurses and sold this NHS tool to chains of hospitals.

Nurses themselves talked about 20-25% increases in time to care which they increased this by their own productivity actions. The result was that they did this more and felt great about making it happen themselves.

This is not an abstract issue. In 2011/12 7.1% of nurses left. In 2016/7 8.7% of nurses left. This is a difference of 5000 nurses a year. Over those three years that’s 15000 nurses leaving the NHS.

Between 2012 and 2017 the number of AHPs that were trained went up by 21%. But only 10% more went to work in the NHS. A loss to the NHS of 8000 AHPs. (At the moment there are vacancies of 45000).

The nurse turnover rate varies from between 9% and 25% in different trusts. That’s a consequence of staff being valued differently in different trusts.

The statistics demonstrate that whilst the headline represents the high level of need that NHS leaders have for labour, management practice varies enormously.

In some instances we seem to be throwing it away.


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