What resources will we need in the future NHS? (An occasional series)

1 – Staff that enjoy their work and central guidance that engages and develops a senior local NHS leadership to feel supported and empowered.

Today I want to continue the theme of staff experience of work but from a very different perspective – the policy of national guidance and the practice of local leadership.

In my last post I wrote about a growing recognition that younger professional NHS employees probably want to work to live, rather than living to work. It continued by exploring the idea that if this is the case then how they feel about their NHS employer will have a big impact upon whether they work as a clinician for 40% or 60% of their working week. What they choose to do with that discretionary day will have a big impact upon the ability of the NHS to provide sufficient services for the population.

Training extra clinicians that would rather spend their “extra” day working for a med tech company, will not have much impact on the level of service that we all need to be delivered, so there is a clear need for NHS employers to treat their staff well and recognise that employee’s time is really precious. That extra time will be the core of any future for the NHS. To get it employers really need to cherish their staff.

Over the coming decade developing any new model of NHS care will be impossible if staff would rather spend time doing something else. This simple reality puts staff experience of their employment pretty much front and centre for any possible future of the NHS. And that’s going to be the theme of my next few posts.

In talking about this experience of employment, today I’d like to talk about the policy and political framework within which this takes place. We have just had the planning guidance issued for 2024/5. Both Steve Black and I have written about the fact this is both very late and probably needs to focus on fewer things.

Whilst this can intellectually be put in a policy/senior management box – if it is going to have any impact on patients, it will also have an impact on how staff work and their experience of employment. As I often say, the business end of the NHS is the 1 million consultations that take place every 24 hours. If the planning guidance 2024/5 has no impact on that, it’s probably achieving nothing.

So, we need to assume an impact.

On the other hand, if central planning guidance comes down from on high and is experienced as a direct instruction to clinical staff to change their practice, then – to return to yesterday’s post- it is possible that the guidance will itself be experienced as a in some way turning the screw on them. Maybe working for that med tech company (that lets you wear T shirts and shorts and provides you with breakfast and lunch, and which you experience as a wonderful employer) will look more attractive.

So, the nature of the central planning guidance and how that is communicated is, with regard to staff, not an abstract issue.

The NHS still operates primarily as a nationalised industry. The national taxation payment mechanism is an important part of the NHS. It matters to the public. The N in the NHS really matters to the public as well, so they expect it to be a national system.

In the coming months, a national general election will be fought out – with most of the public putting the NHS as their first or second most important issue.

Given the political salience of the NHS whoever wins that election will have a central government mandate which will in part be about improving the output of the NHS. They will have five years to deliver that mandate and the public will hope for rapid improvement in waiting times.

The new national Government will have a mandate to set the 2025/6 planning guidance with powerful new directions. (Or similar to older directions but with an expectation of delivery.)

And here is where the paradox of the NHS becomes key. It is of national importance; the public are right to expect national government to use their money to ensure the NHS delivers more and better services. But given the business end of the NHS is 1 million consultations every day, and given they are carried out by hundreds of thousands of local clinicians, the more that Whitehall tells them what to do, the less engaged they are likely to be. And, following on from yesterday’s post, fewer of the discretionary days that younger clinicians have a choice about will be given to the NHS.

The more the NHS behaves like the nationalised industry that the public appear to want it to be, is run from the top, the less it is likely to achieve.

For the Telegraph this is an impossible dilemma. They want both an end to the nationalised industry and to encourage local diversity of approach.  But they are wrong. The two things need to happen together.

The articulation of what the nation wants and pays for through whatever central organisation (DH in my day in Whitehall NHSE today) needs to be such that the national drive happens in such a way that it doesn’t tell clinicians what to do (and lose that discretionary day).

Nearly every aspect of that depends upon the way in which the actual local employer (Who is not the NHS but a trust, a Primary Care team, or increasingly as ICS) actually does this. If the local NHS leadership simply pass on what has been said nationally and don’t carry out the necessary national to local translation, then local clinicians will feel pushed about. (In order to provide the possibility of that translation happening it’s a good idea for the national guidance to be published more than just a few days before the start of the year in question.)

It is the task of local NHS leadership to translate and manage the national nature of the NHS that the public wants, and to translate that into the day-by-day work of clinicians in such a way as to develop that work, rather than telling people what to do.

If you want to run a nationalised industry that depends upon the labour of hundreds of thousands of clinicians, then you had better invest in the ability and capability of a tens of thousands of local leaders to carry out that translation.

The Francis report said this over a decade ago.

The Messenger report said it a few years ago.

But nothing keeps happening.

The future of the NHS now hangs on the ability of local NHS leaders to articulate the national to the local, and the local to the National and unless they do the professional employee with a choice of working an extra day for a med tech employer is likely to do so.

This can of course be achieved. But to succeed we need to seriously invest in the local leaders who we need to make it happen.