Chapter 4 - Valuing Our Workforce
How do we ensure that the workforce is
valued so that “Realistic Medicine” becomes
the way that we provide services in Scotland?
It is clear that health and social care professionals want to practice with a more person-centred approach as an essential component of fulfilment in their jobs. It is incredibly important that staff feel valued and enabled to lead changes in practice which will help to realise the potential of Realistic Medicine. Our workforce are our most valuable asset and it is vital that they know this and feel empowered to making changes around how we deliver care.
What matters to our staff?
“I get a sense of achievement at the end of the day, that I made a difficult experience better for somebody.”
Everyone who works in health and social care has their own motivations for doing so. Working within a health or care setting can fulfil some of the most important factors for our sense of purpose and wellbeing. At an individual level, work benefits our physical and mental health and wellbeing.  However, to gain these benefits it should be “good work”. Good work offers us meaning and personal worth. The best workplaces support us to work autonomously but as part of a team, as well as supporting our development and recognising our achievements. The challenge of providing care is finely balanced; we need professional stimulation to enable us to perform well, otherwise we can become perfunctory and our performance falls. However, if we become overwhelmed with pressure we can become stressed and disengaged.  Getting this balance right is vital for us to provide Realistic Medicine throughout health and social care in Scotland.
“I have always had a deep personal drive to be the best person I can be. I am very driven to improve the world around me. As doctors, we are immensely privileged to have the trust of our patients, and work with many talented colleagues.”
The Francis Report on the Mid Staffordshire Inquiry found that staff morale and engagement were at especially low levels. Staff had become burnt out and disconnected from the core values that took them into healthcare roles in the first place. This poor engagement and lack of energy for collective responsibility at all levels were significant factors in the acceptance of poor standards of care.  Organisational leadership placed little value and importance on warning signs highlighted by staff surveys.
It is therefore essential that we listen to our staff, particularly at a time when they continue to maintain high quality care in the midst of increasing complexity, demand, expectation and change. NHSScotland have taken steps to measure and improve staff experience. The iMatter Staff Experience continuous improvement model has been developed in collaboration with staff groups to provide a new mechanism for measuring employee engagement levels across all 22 Health Boards. This has been designed to allow individual teams, managers, directors and boards to measure and understand staff experience and make the necessary improvements based on this shared understanding. Integral to the model is the ability of individuals and teams to shape the action which is taken in response to the feedback.
Engaged staff feel their personal activity is more connected to the purpose of their team and the organisation more broadly. They feel more motivated in their role and able to face the challenges of work with greater flexibility, knowing that they are supported and valued. The correlation between engagement and improved performance is seen not only in healthcare but in many other sectors. [26, 27] A strong link has been demonstrated between NHS trusts with high engagement levels and better patient and organisational outcomes including lower mortality figures, higher patient satisfaction and lower staff absenteeism.  Effective care therefore relies on the staff who deliver it. The King’s Fund has recognised that staff engagement is reliant on a collaborative approach between leadership and staff. It relies on commitments to common objectives, actively listening to the feedback from staff  and valuing their input. Allowing staff flexibility and control towards achieving shared goals will contribute to meeting the personal drivers for them too. If this approach is effectively pursued, it will sustain a health and social care workforce to remain connected to their core values and committed to the highest patient care.
However, as highlighted by Francis, this example needs to be set by leaders at all levels of the organisation. When the workforce does not have a sense of safety or trust in their leaders, they are less likely to bring challenges and risks forward. To foster a sense of trust, the workforce need structure, clarity and dependability from leaders to feel that they are truly listening and responding.
There are a number of recent high-profile publications in the UK that remind us how staff perceive their current working experience and the challenges that they face. However, despite these challenges, over 90% of staff feel valued by their patients. 
‘If it wasn’t for the staff I don’t think I would have got there. ALL the staff are fabulous caring and professional, giving a high standard of care. …if it wasn’t for the domestics, nursing auxiliaries, nurses all bands, doctors from juniors to senior that spoke in a way I could understand and come to terms with my condition... I know you all get busy and tired but your staff always show kindness, calmness and caring and nothing was too much trouble... much appreciated’.
Workforce supply and demand pressures are compounded by the potential impact of both an aging workforce and an aging population on workforce planning.  These issues are recognised, as are the impacts that are felt by people who work in these environments, and we will address these through the implementation of our workforce plans. Scotland is the first nation in the UK to publish a national health and care workforce plan. Part 1 focuses on the acute NHS and was published last June. Part 2 covering workforce planning in social care was published jointly with COSLA in December. Part 3 on primary care staffing is being developed with our partners and will be published this year, following implementation of the new GP contract. A fully integrated health and social care workforce plan will be produced later in 2018, and annually thereafter.
‘The whole experience was very positive and calm with full support provided at every stage. It was clear that all team members were working under a very heavy workload yet everything was done to ensure my daughter and the babies were looked after. Our experience could not have been better’.
Projections show that we will need to increase staff numbers in future years. From our doctors in training will come the future supply of Consultants and GPs. In the Health and Social Care Delivery Plan, the Scottish Government has committed to increase medical training places by a further 100 over the course of this parliament bringing the total number in 2017 from 898 to 1038. However, an increasing number of foundation trainees are taking career breaks; currently only around 50% of foundation trainees continue directly into higher training.  Qualitative research from the Scottish Medical Education Consortium has investigated the decision making process for Foundation doctors taking a break from training. Multiple themes were identified, including organisational, occupational, personal life and simply “needing a break”. 
Whilst there remain challenges in recruitment to all available training posts, which affect some specialties such as psychiatry and general practice in particular, there is reassuring evidence that trainees do seem to return to training in the UK within two to three years: 87.5% of the 2014 F2 cohort were in specialty or GP training within three years.  There is ongoing monitoring of these trends, but we should not be complacent that this trend will continue.
Our understanding of the goals of those who have more recently joined the workforce is that gaining a sense of purpose and fulfilment from work remains a high priority. However, this is in the context of seeking greater flexibility and balance; commitment is balanced with an expectation to be supported and appreciated in return for their contributions, and to be part of a cohesive team.  In recent years the Scottish Government have implemented a number of measures to encourage a better balance between high quality training and work/life balance in relation to working patterns of doctors in training. Through listening to the concerns of doctors in training and working in partnership with BMA Scotland and NHS employers the following actions have been implemented to ensure doctors in training achieve a better work/life balance, work on safe and sustainable rota patterns and receive good quality training experience.
- Abolishing doctors in training working seven nights in a row.
- Abolishing doctors in training working for more than seven days or shifts in a row in any working pattern.
- The publication of updated New Deal monitoring guidance to ensure that every doctor in training in Scotland gets to take part in working hours monitoring exercises to report compliance with the New Deal contract.
- We will continue to work with our stakeholders to explore other options including improving rest and catering facilities for doctors in training working out of hours.
- By August 2019 the implementation of a minimum period of rest of 46 hours following any run of Full Shift night working, and joint guidance to create greater flexibility around the allocation of annual leave.
The Scottish Government has also developed a supportive improvement tool to promote safe and healthy working patterns. This initiative, the Professional Compliance Analysis Tool ( PCAT), creates an analysis and structured improvement process to address working patterns in terms of three domains:
- Patient Safety
- Trainee Health and Wellbeing
- Quality of Training
It has a clear focus on requiring collaborative working between trainees, training and service leads as a core principle to improve working patterns and achieve intelligent rota design. The PCAT is being applied across all Health Boards in NHSScotland.
The welfare of health and social care staff is critically important with every employer required to have policies in place and to comply with national policies on managing health at work, which includes mental health and wellbeing. For example, Health Boards currently have varying mechanisms in place to monitor stress in the workforce. Support includes, stress audits, staff survey results, monitoring of sickness absence, monitoring use of staff counselling service, attendance at training and skills development. The Scottish Government are working with the NHSScotland Health and Wellbeing group to test interventions focussing on both physical and mental wellbeing to help improve the health and resilience of NHS staff across Scotland. This work will include considering the initial outcomes of iMatter.
Thriving in Medicine NHS Education for Scotland recognises the need for individual support for staff as well as improvement through organisational change. A pilot course for FY1s delivering skills for ‘Thriving in Medicine’ is being evaluated. This focusses on personal development in dealing with challenges of a life in medicine. Supporting web resources have been developed for all staff.
A key aspect to ensuring staff are able to maintain their wellbeing and perform their work effectively is having a safe and supportive working environment. Ensuring that our workplaces are free from a culture of bullying and harassment is integral to this. The Royal College of Surgeons of Edinburgh is running the #LetsRemoveIt campaign to stamp out bullying and harassment which has no place within healthcare or indeed any industry. This is a culture which impacts poorly on patient safety and staff morale and must change in order to ensure an empowered and efficient workforce.
The Royal College of Surgeons of Edinburgh has some excellent resources available on their website. 
This includes resources to spread the campaign within local areas and a useful e-learning module. There is information on the legal aspects around these behaviours and information on how to raise concerns. The College recognises that few healthcare staff enter their profession with the intention of becoming a bully but identifies how poorly managed communication, particularly in high-pressure situations, can tip into aggressive, intimidating or undermining behaviour. If left unchecked such behaviour can become ingrained within work culture. To combat this, individuals are encouraged to openly reflect on their own practice to ensure they are not adopting poor practices. There is a checklist to self-check personal behaviour, advice on safely acting assertively, on how to give and receive negative feedback and on positive negotiation strategies. What is clear is that combatting bullying and harassment in the workplace is not a matter of getting rid of a few “bad apples”. It’s about changing our work practices to create a positive, constructive working environment.
Figure 7. The Royal College of Surgeons of Edinburgh #LetsRemoveIt Campaign
There are many changes we can make locally to help change the culture, for example the use of Schwartz Rounds: group meetings for all staff where emotional and social aspects of working in healthcare are discussed. We must consistently demonstrate the attitudes that brought us into a career in health and social care and demonstrate civility, consideration and kindness throughout all roles and levels within our workplace.
“The Happiest Unit in Scotland”
ICU in NHS Grampian have made this the focus of QI projects. The aim is to maintain high team spirit, and improve staff psychological and physical wellbeing. Strands include debrief via Values Based Reflective Practice ( VBRP), staff appreciation, highlighting positives at Mortality and Morbidity ( M&M) meetings and shared charitable goals.
Effective leadership is vital in order for us to respond to and support our staff and it must be distributed across our health and care systems. A hierarchical, distant approach that does not address these needs will devalue and alienate our staff. Equally, leaders and indeed the complete health and social care workforce should understand the impact of the examples we each set; we reflect the world around us, and should consider how we want that world to look. The challenge within the workplace is to encourage flexibility and find novel solutions to meet the workforce needs and ensure health and social care remains a desirable career. All organisations that employ, train or represent our staff should find collaborative ways of working towards this goal.
The connection between excellent clinical leadership and high-quality care is now established. Research shows NHS Trusts with the highest levels of workforce engagement have had stable leadership over extended periods, with the same senior leaders continually developing their approach.  Maintaining a connection between the health and social care workforce, the core values that brought them into work and those of the NHS enables full engagement from staff. However, it is leadership at every level which is needed to bring about this engagement and shared sense of purpose. This leadership in turn will ensure the highest levels of patient safety and care that Realistic Medicine describes. Leadership needs to move from a “command and control” style into more flexible and person-centred collective leadership. 
A Whole-Board Approach
The Medical Education Directorate in NHS Lothian has taken a whole-board approach to supporting trainee wellbeing. Initiatives include near-peer mentoring the ‘Lessons Learned in Lothian ( LLiL)’ programme. This is embedded in the Foundation Teaching Programme, and build on the patient safety and human factors session at induction, ‘ LLiL’ is themed to the patient safety aspect of the FY curriculum and delivered via nine sessions in which FYs learn significant adverse event ( SAE) review in a safe, facilitated forum. Future ‘ LLiL’ development will see rollout of this to other training cohorts.
Collective leadership requires responsibility from not just leaders but the entire workforce. A collaborative and consistent approach is needed, with compassion and the aim of continual improvement evident throughout.
High expectations of performance and quality whilst undergoing transformational system change puts leaders at all levels under pressure. To achieve Realistic Medicine, our leadership must focus on promoting a culture for high level care and engagement.
Our collective leadership must have a clear, forward looking vision, shared with the whole workforce. Leaders need to match their actions to their words, and live these values every day. Strong engagement is promoted by team-working, cooperation, learning and innovation.  Leaders support the workforce to take themselves towards the shared vision instead of imposing a path. The most effective leaders generate a culture of integrity and trust. 
“The quality of clinical leadership always underpins the difference between exceptional and adequate clinical services”
Sir Bruce Keogh 2011
There are many examples within health and social care in Scotland where this culture of collective leadership is strong. We need to nurture and grow this culture where it exists, and enable all those coming into the workforce to develop their leadership potential so we can create effective leaders at all levels of care. Project Lift has been created for just this purpose.
Project Lift is a single team and digital platform, created through collaboration between Scottish Government, NHS Education for Scotland, and the Golden Jubilee Foundation.
The Project Lift mission is to establish a systemwide approach to supporting, enhancing and growing leadership at all levels to transform the public sector in Scotland and improve the experience of our people. Project Lift will coordinate and oversee 4 key elements of activity:
- Values Based recruitment – getting the right people into senior appointments who live the NHS values.
- Talent Management – tailored support for those with high potential as leaders.
- Leadership Development – multi-professional development and networks.
- Performance Management and Appraisal – giving recognition and value to transformational leadership.
Project Lift looks for all potential leaders, from whatever background, at whatever grade, in whatever role. If you are someone in the NHS who is genuinely willing to develop yourself and those around you, and if you are passionate about improving outcomes for the people of Scotland, Project Lift will commit to helping you live your potential. Please contact the team at www.projectlift.scot/
The development of Realistic Medicine began from listening to conversations across the country about what was important to staff in the way that they provided care. As our understanding of this becomes deeper each year, and as we identify the areas for prioritisation, we will continue to engage and to listen about what matters to them, and what gets in the way of being able to practice this way. Some of these will be relatively straightforward to address, some will be more complex and will take longer. Health and Social Care staff in Scotland should rightly be proud of the work they do and the care they provide. It is within our collective power to create the environment to practise Realistic Medicine, supported by an organisational culture with leaders who listen and enable everyone to fulfill their potential.
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