Resetting the narrative about “the main issue” for the NHS.

Over the next couple of weeks I will be discussing details of the NHS long-term plan but what interested me most yesterday was the beginning of the reframing of the narrative about ‘the main issue for the NHS”.

I am sure that for some in the NHS a day like yesterday, when the private discourse of their work became a very public issue, might cause some anxiety about how their work is being reframed around them and it’s true that yesterday was a day when the NHS was part of a much bigger public discourse than on other days.

But it’s also very exciting. In news programme after news programme, presenters were having to get their heads round asking questions around the difference between emergency and urgent care and trying to get to grips with the concept that the whole system needs integrating. There was palpable anxiety among news anchors – ”You mean it isn’t integrated already??”

On every other day these are internal questions for those of us in the very big bubble that is NHS and social care. But for one day everyone was trying to understand it.

And, during the course of the day, I sensed that in the middle of this public discussion one of the issues that has for the last 18 months been the big private discussion within the NHS and social care – “Where are the staff coming from?” – gradually emerged as being the main problem for the NHS.

Up until yesterday the public story had clearly been about money. The main issue that the NHS raises with the public is that it needs more money. And the public ‘gets’ that. Yesterday’s NHS long-term plan was developed and published because there was a promise of more money. If there hadn’t been yesterday would not have happened. The argument goes like this – we need more money to do things and the plan outlines how that extra money will buy extra services. (In this case 500,000 lives saved in ten years).

Money equals service. So more money equals more service.

This is good, simple stuff and has worked for decades. Our NHS needs more of our money to provide us with more services.

But yesterday, it was as if the extra money was being taken for granted.  The shift was towards the main problem being staff. It’s not that this hasn’t been seen as a problem before, but it has always been assumed that more money would buy more staff. So more staff have really been viewed as an outcome of having more money. More money = more staff.

Yesterday the public debate began to recognise that this equation might have changed. Even with extra money the extra staff might not be there. I didn’t pick up on any explanation of this new state of affairs – beyond a bit of Brexit worry – but there was a clear anxiety that the staff might not be there to deliver all these great things that were being promised. And if that’s true – well perhaps the money doesn’t matter.

I think there are many layers to this. Some are way beyond the NHS workforce. Generally people expect labour markets to work. An employer says they want more of x and advertise for more of x – and the x turns up because that’s what markets do. A demand for good, let’s say workers, conjures a supply of good workers from the population.

Generally people expect that process to work, so if extra specialist diabetes nurses are needed we demand them. Make training places available for them and they will turn up.

Much of yesterday’s narrative was trying to reassure questioners that we are on top of this. Five new medical schools = under control.

But we don’t do we? The nasty little secret that people trying to employ NHS and social care staff know is that unless people want to work for you, you can offer them all the training you like – they still won’t come.

As I’ve said previously, unless the medical schools do something to create a real attachment between potential staff and the localities they might work in, we are creating an international workforce who can work in Beijing, San Francisco or Melbourne. Or they can decide that nursing is not for them and take up ‘event organising’.

To put the problem a different way. We have this institution that most of us love – as an institution – but not enough people want to work for it.

As this plan evolves into delivery, how it tackles this issue will be the key to success.

And yesterday, for the first time I can remember, a bit of a shudder ran down the public spine in recognition of the fact that if we don’t solve this, not a lot will happen.

More on the detail in later days.

2 Replies to “Resetting the narrative about “the main issue” for the NHS.”

  1. Good article Paul, mainly because it moves away from simply fixing obvious problems and moves towards systemic understanding. For instance the call for more staff has so often been couched in where can we find them? The reality is that we have far too many staff graduating, starting work, then realising that the job is horrible. We have staff who have been there for years, realising that the job has become horrible. Stress is an important sign, and low motivation is an important indication.
    Fix the problem of a horrible job, by using simple and well known ways of creating a good job, staff wont leave, and we will probably find that we actually have enough staff.
    Replicate that methodology of analysing a part of the NHS to all other of the elements can be fixed, and they begin to work properly again. The current underlying structure is designed to deal with transactional work, and the reality of the NHS is that it is primarily led by complex and often very variable workflows. Design the NHS to allow for that complexity and cariability and it will work far better, create a great culture, and its costs will reduce from what they are today. This will then allow for all the demands that are placed on it to be successfully resolved.
    This is what I have witnessed when transforming the NHS and wider health system. Its not difficult, what is difficult is the change in paradigm and thinking that is needed.

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