“At the end of some shifts I go home and cry because we can’t always provide the level of care we should.”
Those are the words of a staff nurse who has, on occasion, been left in charge of 24 patients – three times the broadly accepted ‘safe’ figure of eight patients.
As the NHS continues through the two months of the year where its already elevated sickness absence levels are at their height – December and January – staff can be rightly concerned about increased pressure.
The nurse, who spoke out anonymously, said: “A lot of colleagues say that when they’re due to return to work after rest days they can’t sleep the night before because of the level of anxiety over what you’re going to go into.
“Now people are living longer, the patients we have are more and more physically and emotionally dependent. The dependency level of patients means you are doing more things for each patient.
“It’s a lot of responsibility. As well as being concerned for patients generally, you’re aware it’s your registration on the line if you make a decision that turns out to be the wrong one.
“Our job is physically and emotionally draining. You’re dealing with both sides of things and I think that puts more strain on staff. There is quite a lot of sickness.”
That sickness is, in the experience of this nurse, a vicious circle of factors contributed to by low staff numbers. She has seen multiple colleagues injured on the ward due to equipment not being properly stored by busy staff as well as numerous teammates struggling with mental health pressures, contributed to by the stress of the job.
In addition, she said, staff, already conscious of letting colleagues down if they do need to call in sick, are made to feel guilty for either being ill and even for not being able to cover extra shifts at short notice when others are off.
Brexit may further increase staff shortages in the NHS
A report published in November by the National Institute of Economic and Social Research suggested those pressures are about to get worse.
‘Brexit and the Health and Social Care Workforce in the UK’ stated that there is likely to be a shortfall, in addition to current staff vacancies, of 5,000 to 10,000 nurses in the Brexit transition period to 2021. Latest figures from NHS Digital said that in March this year there were already the equivalent of almost 30,000 full time roles advertised in the NHS.
Given the lack of numbers, it’s perhaps not surprising that the 2017 NHS staff survey reported 38.4 per cent of staff felt unwell due to work related stress in the previous 12 months.
NHS absence – the statistics
Annually, the public health sector has the highest rates of sickness absence of all industries in the UK – recorded as 3.3 per cent in 2017 by the Office for National Statistics (ONS).
The average sickness rate in the UK in 2017 was 1.9 per cent (an average 4.1 sickness days per employee). In the private sector it was 1.7 per cent and 2.6 per cent in the public sector.
Of course, health sector workers are exposed to more germs than most. They also may not be able to go to work with contagious, but not debilitating, coughs and colds due to risk of exposing vulnerable patients.
Latest figures released by NHS Digital show that, in the second quarter of this year, the NHS sickness absence rate between April and June was higher still at 3.84 per cent.
Absence rates for ambulance staff and healthcare assistants have consistently been highest of all teams – going back to 2010 when records began. Between April and June this year the absence rate for ambulance staff was 5.01 per cent and healthcare assistants 5.89 per cent.
When winter illness strikes the nation, which is the traditional period for health services coming under biggest strain – staff absence also peaks. Last year, the NHS saw absence rates of 4.66 per cent in January and 4.61 per cent in December.
2018 seemed to follow the age-old trend. The highest absence rates were in January, at 5.03 per cent.
Correlation between staff ‘engagement’ and sickness absence
The real term impact of those increased figures is put into perspective in the NHS England report ‘Employee engagement, sickness absence and agency spend,’ published earlier this year.
In reference to a 0.2 per cent decrease in absence across a year, it said: “Although this may seem small, for an average-sized trust this would represent a saving of approximately 2,000 sick days per year, or around £365,000 less in salary costs lost to sickness absence.”
As the report recognises, salary costs are just one factor to consider in reference to high sickness rates. Absence leads to elevated agency staff costs, but also has, as in all industries, an impact on administration costs and productivity. The financial costs are immense but the toll it all takes on staff and risk of further increased absence is not just a spreadsheet issue.
The NHS England report concluded a correlation between how ‘engaged’ staff were and how likely they were to be absent. Engagement was a measure of how motivated, involved and how likely staff were to recommend and ‘advocate’ their place of work.
In the report, Chief Executive of NHS England, Simon Stevens, said: ‘It confirms, empirically, what common sense suggests should be true: that staff engagement is not only good for employees’ health but reduces trusts’ cost and reliance on agency staffing. So doing the ‘right thing’ also helps trusts with their budget pressures.”
The impact of environment and culture on absenteeism rates
Rachel Suff, Senior Policy Adviser at the Chartered Institute for Personnel and Development (CIPD), spoke of the importance of a positive work environment, in The Absenteeism Report 2018: Causes, consequences and cures, produced by HR specialist AdviserPlus.
She said: “These include a range of elements such as good people management, an inclusive culture, positive working relationships and a line management style that is
open and supportive.
“There should be opportunities for people to have a voice at work and be treated with dignity and respect. Employers should not forget the so chief social aspects of creating a positive working environment, and how team working and informal opportunities to engage with each other can help to foster creativity and a good sense of wellbeing.”
Bullying and harassment in the NHS
A former healthcare assistant who was signed off sick due to stress, along with a number of colleagues in her small team led by an ‘incompetent and bullying manager’, said the culture of the NHS is the real issue.
She said: “During a period where there was a ‘Speak Out’ policy, myself and colleagues raised an issue with HR and were told they would get the matron to speak to us. It never happened and HR didn’t even follow up.
“Even my GP warned me not to necessarily expect my complaint to be followed up in the way I might expect. The problems are so endemic.
“It seemed they didn’t want to deal with it because if they got rid of our manager, who was going to do her job?”
One in four NHS staff report they have been bullied, harassed or abused by their managers or colleagues in the last year.
‘The price of fear: Estimating the financial cost of bullying and harassment to the NHS in England,’ published in October, concluded colleague bullying and harassment within the NHS is costing the health service £2bn a year.
Regardless of the seemingly bleak statistics there are those who maintain the necessary culture change is both possible and, in part, happening.
Steps being taken to effect culture change in the NHS
In his speech, ‘Building a culture and system for improvement’, Andrew Foster, Chief Executive of Wrightington, Wigan & Leigh NHS Foundation Trust, said: “I believe most of all that, in order to be successful, you have got to get your staff with you and the thing that really inspires staff is quality improvement.”
The trust has run a ‘quality champions’ system for six years, seeing staff trained and empowered to identify and test quality improvement schemes. It has led to 365 schemes rolled out, in areas as diverse as reducing rates of catheterization of patients and the number of babies using antibiotics for too long. A total of 48 per cent of the schemes has demonstrated sustained success. In 2017 alone, the schemes led to savings of £1.5 million but, importantly, Mr Foster said they also unified staff.
In January, Mr Foster told HSJ he had also implemented a number of specific ideas to try to alleviate winter and Christmas pressure on staff. They included offering access to a financial advice service, following survey results that showed almost a third of staff faced financial pressure in the festive season, and an intention to provide Amazon lockers to allow online purchases to be delivered to the site.
Like Mr Foster, professor Michael West also believes in the link between enabling continuous improvement and creating a working culture that nurtures staff and reduces hospital costs, absenteeism and patient mortality. To his mind it is all wrapped up in the concept of ‘compassionate leadership’ – that is leaders who listen intently, empathise and act.
In a 2017 NHS Leadership Academy video he said: “The vast majority of NHS staff made a decision to dedicate an enormous part of their precious and unique lives to caring for the health and wellbeing of their fellow human beings.
“Their core work value is compassion. When NHS staff are able to deliver compassionate care, patients are more satisfied and that in turn leads to higher levels of wellbeing and commitment amongst NHS staff so we need to nurture cultures where staff can deliver high quality, continuingly improving and compassionate care and that requires NHS leaders to model compassion in their leadership.”
With NHS staff representing one in 20 of the working population in England and one million people using the NHS every 36 hours, he believes the benefits would be widespread.
He added: “The potential implications of creating compassionate cultures in healthcare are therefore really profound in our societies.”
Improvement in absenteeism rates in the NHS can happen
The belief that change can come is reflected by Suzie Bailey. She spent 26 years in the NHS, primarily as an operational manager, then four years as director of leadership, quality and improvement with NHS Improvement before, earlier this year, joining The King’s Fund – a charity dedicated to improving health and care in England.
She said: “The fundamental critical issue is around how staff are managed and the degree to which people feel supported at work so if they do have an issue around health and wellbeing there is some level of support.
“The important message is – there is hope.”