41.In 2018, the General Medical Council asked Professor Michael West and Dame Denise Coia to carry out a UK-wide review into the factors which impact on the mental health and wellbeing of medical students and doctors. The Report, Caring for doctors, caring for patients, highlighted an A,B,C of core work needs that had to be met to ensure wellbeing and motivation at work, and to minimise workplace stress:
42.Although Caring for doctors, caring for patients focusses on doctors, the King’s Fund published similar work that focussed on nurses and midwives. In its report, The courage of compassion the King’s Fund sets out a series of recommendations to support staff wellbeing:
43.In this chapter we consider the extent to which workplace culture in health and social care delivers on those aims to support staff. In particular, we focus on the opportunities for staff to speak up and the role of compassionate leadership in promoting a supportive culture at work.
44.During our inquiry, a number of witnesses highlighted the importance of creating a culture across the health and social care sectors where staff feel supported to speak up when they see things going wrong. The National Guardian’s Office (NGO) was established in 2016 to provide a forum for staff and receives non-identifiable information from staff through Freedom to Speak Up Guardians. In its December 2020 report the NGO published interim data which indicated that a record number of cases were brought between 1 April and 30 September 2020, although the proportion of cases that included either an element of patient safety or quality (19.4%) or an element of bullying and harassment (30.1%) were lower than the same period in the previous year. Concerns raised through the Speak Up Guardians, included social distancing; personal protective equipment (PPE); redeployment of workers and general anxiety around the pandemic (including risk to households). Worker safety and wellbeing during the pandemic was also a key theme, with some staff reluctant to speak up due to the crisis.
45.At the launch of the report, Dr Henrietta Hughes OBE, National Guardian for the NHS said:
I am so grateful for the commitment and passion of Freedom to Speak Up Guardians who continue to support workers to speak up in such challenging and difficult circumstances. Workers’ voices form a key pillar of the NHS People Plan. But it is beholden on all leaders and managers to listen to what workers are saying and act upon what they hear.
46.Freedom to Speak Up Guardians have not been established in social care, which Dr Hughes described as “a yawning gap” when she gave evidence to the Committee. Dr Hughes strongly believed that “Freedom to Speak Up, or equivalent alternative channels”, should be in place so that “workers looking after patients in whatever setting” had the ability to speak up about their concerns, safe in the knowledge that leaders would be listening, and that the right actions will be taken as a result.
47.It is imperative staff have the opportunity and the confidence to speak up. However, this needs to be matched with a culture in which organisations demonstrate that they are not just listening to, but also acting on, staff feedback. While NHS organisations have a formal structure to raise concerns through Freedom to Speak Up Guardians, there is no equivalent for adult social care. We therefore recommend that the Department develops a strategy for the creation of Freedom to Speak Up Guardians in social care.
48.Compassionate leadership was also raised during this inquiry as an important factor in encouraging positive workplace cultures. The King’s Fund defines compassionate leadership in the following terms:
[It] means leaders listening with fascination to those they lead, arriving at a shared (rather than imposed) understanding of the challenges they face, empathising with and caring for them, and then taking action to help or support them.
49.Dr Hughes, the National Guardian, said all leaders needed to see that a core part of an NHS leader’s role was “being genuinely interested in and valuing the views of your workforce”. While she acknowledged that “the vast majority of leaders” took that on board, she said that there remained some organisations that “do not take it as seriously and, for whatever reason, are less interested in the views of their staff.” Dr Hughes told us that those organisations were not seeing desired improvements in staff wellbeing, staff safety and patient safety and experience.
50.A number of witnesses highlighted barriers to providing compassionate and effective leadership. Chris Hopson, Chief Executive of NHS Providers, told us that operational targets and centralised management were two such barriers. He said that the delivery of operational targets had often come “at the expense of quality of care, staff experience and patient experience.” Under the centralised NHS system, staff at the centre wanted “huge amounts of detail” from Trusts, specifying in “lots of detail” what the frontline should be doing. He told us that the micromanaging from above undermined the ability to enable and empower staff to “lead to the best of their skills and ability.” Chris Hopson went on to say that this resulted in disempowering leaders by “tying them up in too many knots and telling them how to do their job”, which did not reflect the reality that “each one of those jobs leading the 217 trusts is different”.
51.Professor Jeremy Dawson, Professor of Health Management, University of Sheffield, agreed that a workplace culture that gave staff autonomy and the opportunity to influence was likely to deliver better outcomes for both patients and staff:
We have evidence that shows that organisations where there is more ability for staff to take part in making decisions and influencing how things are decided are the trusts that have lower mortality rates. They have better outcomes generally for patients and better outcomes generally for staff.
52.In a centralised system, it is vital that the national bodies in the NHS take a lead in encouraging and supporting leaders to be compassionate. However, the National Guardian’s evidence suggested that the national bodies providing oversight and direction to local systems were not exemplars of the culture that the People Plan seeks to encourage. Dr Hughes told us that while both NHS England and Improvement and the Care Quality Commission had appointed Freedom to Speak Up Guardians, the culture in those organisations, as perceived by their Guardians, was on a par with organisations rated as either “Requires improvement” or “Inadequate” by the CQC. Dr Hughes emphasised to us the importance of those organisations improving so that as national bodies they could provide support and encouragement to leaders across the NHS to better support and empower their workforce.
53.In his oral evidence, Paul Farmer, Chief Executive of Mind and representing Our Frontline, told us that one solution would be to introduce a “scorecard approach” for individual NHS and social care employers that measured mental wellbeing. The scorecard would monitor both negative factors including sickness absence due to mental ill health, and positive factors including the extent to which colleagues feel in control of their workload, or well-supported by their line manager. However, he cautioned that such an approach needed to be an incentive not a stick with which to beat organisations:
We have found from all the organisations that we have worked with that standing over people and saying, “You will behave better around your wellbeing,” does not work. It is about creating a culture of encouragement and bringing in best practice.
54.Dr Adrian James, President of the Royal College of Psychiatrists, added that quality improvement initiatives owned at the board level could also better enable staff and senior managers to raise issues and tackle them:
It starts with having board-level sign-up that it is something important, maybe with a board sponsor. In the end, it empowers staff on the ground, perhaps with a quality improvement coach, to look at what works for them.
Dr James added that empowering staff that work together on the frontline gave them “a sense of control and mastery over what they are doing”. He said that those staff “generally have the solutions, but they need high-level backing” and believed that the People Plan needed to be underpinned by a methodology to ensure that this approach was delivered.
55.The National Guardian agreed that culture needed to be prioritised:
When we get the culture right, the safety follows, and then the money follows. That has to be the order. Ensuring that all regulators are aligned in that, so that they can support the right cultures in the providers, is absolutely key.
56.Helené Donnelly OBE, Ambassador for Cultural Change at Midlands Partnership NHS Trust and former Mid Staffs whistleblower, told us that there was a “real appetite” for compassionate leadership across the service but it was undermined by managers, and in particular, middle managers being “sandwiched between their teams and trying to support them, but also trying constantly to meet targets with ever-increasing pressure.” She explained that
When the pressure is on and the blinkers are on, that goes out the window and some of the negative behaviour continues. […] certain behaviours, certain managers, certain leaders or senior clinicians even, because they are very good at getting the job done, delivering and hitting targets, almost have a free pass to behave in any way they want. That is not acceptable, and we have to stamp it out.
57.For Ms Donnelly, “role modelling” across senior leadership roles and the national bodies would produce the kind of culture change required. She told us that “if you get it right at that level, other more junior leaders will see that that is the right way to behave.
58.Ms Donnelly told the Committee that although the “vast majority of staff” throughout health and social care worked exceptionally hard, bullying remained a “real problem” that had to be acknowledged and addressed. She said that it was “in the minority” but emphasised that the results of that behaviour could be “catastrophic”. A second problem highlighted by Ms Donnelly was the practice whereby those who had behaved negatively did not leave the system altogether, but instead moved on elsewhere:
Alongside that, we need to address the issue of just moving the problem, both internally within individual organisations and across the whole NHS. We have particular individuals and characters who are known to display persistently negative bullying and intimidating behaviours, but they are too difficult to handle so they just get moved along.
Ms Donnelly concluded that this approach merely passed on the problem and led to “more and more staff to feel apathetic and disillusioned”.
59.Ms Donnelly also highlighted the fact that despite the excellent work of the National Guardians, some Trusts were “still not getting it.” In those cases, “significant deep dive drills” were required to identify where the problems lay and what the barriers were. She added that “greater accountability and sanctions” were required for those who “refuse to reflect and those who persistently and consistently display bullying and intimidating behaviours, even when support has been offered.” To tackle these problems, she recommended:
60.Resetting the work/life balance for staff is also considered by witnesses to be an important factor in improving workplace culture. Rather than being an optional extra or a logistical challenge, flexible working should be seen as a means by which the NHS and social care can keep more staff in health and care careers for longer. Prerana Issar, NHS Chief People Officer, agreed with the importance of promoting flexible working as a way in which employers could demonstrate compassionate leadership. She told us that staff in the NHS wanted flexibility “whether that is working from home, when possible, or having a shift system that is not three 12-hour shifts ‘back to back’” and that the NHS was looking into “e-rostering and the flexibility apps” to support Trusts to that end.
61.Improvements to workplace culture have been made, but equally, there is more work to be done. Embedding and facilitating cultures which support compassionate leadership must be at the heart of that work. There is a strong appetite for that leadership from both managers and staff, but structural barriers remain. The Department, the NHS and individual trusts need to focus on removing those barriers so that their leaders can lead to their full potential. The establishment of statutory Integrated Care Systems provides an opportunity for those systems to lead a transformation of support for NHS leaders in their areas that includes mental health support, development of proper career structures, and a review of targets.
62.We recommend that NHS England undertake a review of the role of targets across the NHS which seeks to balance the operational grip they undoubtedly deliver to senior managers against the risks of inadvertently creating a culture which deprioritises care of both staff and patients.
64.In our Report, Delivering core NHS and care services during the pandemic and beyond we considered the specific issues and barriers faced by staff from Black, Asian and minority ethnic backgrounds, and undertook to revisit those issues in this inquiry. In this section we consider their experience of workforce culture. In the next chapter, we consider the specific impact that the pandemic had on them.
65.As at the end of March 2020, around 1.3 million people were employed by NHS trusts and clinical commissioning groups in England. Of those staff whose ethnicity was known, White staff made up 77.9% of the NHS workforce, Asian staff 10.7%, Black staff 6.5%, staff from the Other ethnic groups 2.6%, staff with Mixed ethnicity 1.9% and staff from the Chinese ethnic group 0.6%. Data published by the Department also provides information on ethnicity in relation to the roles and seniority of staff working in the NHS. The data published in January 2021 showed that:
66.In 2015, NHS England introduced the Workforce Race Equality Standard (WRES) to “hold a mirror up to the NHS and spur action to close gaps in workplace inequalities between our black and minority ethnic (BME) and white staff”. The latest WRES report (which covers 2020) indicated mixed results in closing those gaps. It found that:
However, 23.4% of NHS Trusts still had no board members from a minority ethnic background.
The Workforce Race Equality Standard report also found that:
67.The NHS Staff Survey also covered experiences of bullying, harassment and abuse at work. 595,270 NHS employees across 280 NHS organisations responded to the 2020 Survey. The results of that survey found that 13.1% of staff reported experiencing discrimination at work; that ethnic background continued to be the most common reason cited for discrimination; and that ethnic background was mentioned by 48.2% of staff that claimed to have experienced discrimination at work.
68.The Committee welcomes the Workforce Race Equality Standard (WRES), along with the People Plan, as an important step towards an NHS which offers equal opportunities to all its staff. We were pleased to hear in our oral evidence session that work had begun to provide similar information to the WRES in social care. This year’s WRES report concludes that ‘now is the time to translate the data to actions.’ We agree. Part of this must be to ensure that the boards of the new ICSs appropriately represent the populations they serve.
69.We therefore recommend that WRES data be made part of the ‘balanced basket of indicators’ we suggest for Integrated Care Systems, with the result that they become accountable for progress across their domains. As part of this process, organisations should set themselves ambitious yet achievable targets that include timings.
70.A number of written submissions to our inquiry set out the specific challenges staff from Black, Asian and minority ethnic backgrounds faced in relation to workplace culture, burnout and resilience. In oral evidence, Dr Chaand Nagpaul CBE, Chair of the BMA Council, told us that there was a:
Very definite and worrying impact on BAME doctors, who feel particularly unable to speak out and are more likely to be blamed. There is a lot of evidence that they experience worse inequalities in the NHS.
71.The Royal College of Midwives also highlighted similar experiences in relation to its members. The Royal College pointed to data from 2019 indicating that 42% of midwives had reported experiencing discrimination based on their ethnic background.
72.Lord Adebowale told us that “leaders in the NHS, who are mainly white, generally are not held accountable for leading all the people all the time”. He described this situation as a “systemic issue” in which in the 20% of the workforce that come from Black, Asian and minority ethnic backgrounds are not being adequately represented by their leaders. He explained the problem in the following terms:
In business, if 20% of your workforce were receiving more bullying, were not being promoted, were refusing to work in the NHS and were working for agencies, costing the NHS money, were dying disproportionately and where repeated staff surveys showed that they were unhappy—that is an understatement—you would make it part of the generality of what you held leaders accountable for.
73.Lord Adebowale told us that although the Workforce Race Equality Standard had made a positive impact on culture, significant problems remained. He highlighted the “20% of our staff feeling disengaged or under-led” and that the NHS had to “make the people we put in leadership positions lead all the people all the time.”
74.Lord Adebowale also highlighted the need for leaders to be held accountable; and that it needed to be “a core measure of system performance and individual performance”. While he supported the work of the CQC, he found it “astonishing” that a trust could be rated “Outstanding” while 30% of its BAME staff stated that they were performing below standard because of bullying and harassment.
75.Looking forward to the establishment of Integrated Care Systems (ICSs), Lord Adebowale said that the accountability of leaders also needed to be applied to those in social care. He said that leaders of ICSs needed data from trusts, primary care, community trusts, mental health trusts and the voluntary sector in their system to enable them to identify “where the leadership gaps are and how that relates to performance in population health”. If that information was available, he believed that you could “bring on board” the 20% of staff that feel that they are “not part of the leadership debate, not part of the patient debate and not part of the forward view of the NHS and social care system”. He also emphasised that addressing the issues faced by staff from Black, Asian and minority ethnic backgrounds - such as inequity in vaccine take-up - could not be seen as a side issue and that it was not “reasonable” to expect “black staff to solve their problems”.
76.One definition of institutional racism, used in the Macpherson report into the death of Stephen Lawrence, is:
The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people.
77.When he came before us, we questioned Dr Nagpaul on whether the NHS could be described as institutionally racist. While Dr Nagpaul did not use that phrasing, he said that there were “definite structural factors” that resulted in inequalities for doctors from a BAME background and those inequalities increased for doctors that came overseas.
78.The King’s Fund’s report Workforce race inequalities and inclusion in NHS providers, published in July 2020, examined three case studies that had implemented similar interventions aimed at addressing race inequalities and inclusion. Those interventions included:
79.The King’s Fund said that the combination of those interventions could support ethnic minority staff in feeling their organisations were committing to making positive changes. However, it cautioned that there was potential for some staff to react negatively to them. For example, the King’s Fund noted that while interventions made it safer to talk about race, it meant “being prepared to hear about and confront some ugly truths about behaviours between colleagues.” Furthermore, the King’s Fund noted that leadership for race equality and inclusion created an emotional burden on leaders.
80.Tricia Pereira, Head of Operations Adults Social Care & Adult Safeguarding, London Borough of Merton. gave a similar picture of the situation in social care. She told us that:
The experiences of [Black, Asian and minority ethnic] staff are the same, no matter what part of the sector they work in. The systemic racism and inequalities are exactly the same.
However, she highlighted the fact that the “visibility, the value and the parity” was not in place in social care as it was in the NHS, adding that:
When you talk about leadership and aspiration, there are very few visible senior leaders in social care, even less so perhaps than in the NHS. For people who are aspiring, if the visibility is not there, they feel that perhaps they would not belong in those particular roles. If the systems are not there, but there are barriers or challenges for you to progress into certain roles, that is what we need to address and tackle.
She believed that any focus on the NHS should be expanded to include social care, stating that: “We want to be included, and we want parity. We want to be the same.”
81.We heard that colleagues from Black, Asian and minority ethnic backgrounds across the NHS and social care continue to face additional challenges. As stated above, we welcome the commitments of the People Plan to a truly inclusive workforce, and the accountability brought by the WRES. But the People Plan does not include social care, which means there are no plans in place to tackle discrimination in a workforce of over 1.6 million people.
83.The health and social care sector depends on the contribution of workers from outside the UK. When he gave oral evidence, Dr Chaand Nagpaul CBE, Chair of the BMA Council, told us that the NHS’s medical workforce relied on that contribution, and that the UK needed to provide doctors with better induction, support and the time to “understand the NHS”. He explained that that staff from overseas received only a half a day General Medical Council induction and were then “thrown into a ward or a GP practice”. That lack of training and support, he believed, resulted in some running into difficulties, which he described as “a major issue”.
84.Professor Michael West agreed. He identified three issues that needed to be addressed for overseas workers:
85.Several written submissions raised concerns about the ability to recruit sufficient numbers of staff from overseas to both the NHS and the care sector as a result of immigration reform and/or Brexit, in the context of the challenge posed by the covid-19 pandemic. In oral evidence Anita Charlesworth from the Health Foundation told us that, due to the covid-19 pandemic and subsequent constraints on travel, numbers coming from overseas and joining the professional register for nursing in the six months up to September  were 2,000 - a third of the rate for the previous six months. She argued that the NHS needed a “national policy framework around migration, as does social care” because the UK would still need “international recruitment for a period.”
86.Oonagh Smyth from Skills for Care told us that although adult social care employed around 113,000 workers from the EU and around 134,000 from outside of the EU, care workers were not listed as an eligible occupation in the skilled workers route. In the context of “112,000 vacancies every day”, and with increasing demand in that sector, we needed to be “clear” about where we were going to recruit people from.
87.On 14 January 2021, Lord Bethell, Minister for Innovation in the Department for Health and Social Care, acknowledged in response to a Parliamentary Question about care home staff that “occupations such as direct care roles which do not meet the skills and salary threshold” would not be eligible for the new Skilled Worker route. He noted that fewer than 5% of all workers joining the sector in a direct care role in 2019–20 had arrived from the EU in the previous 12 months; and that the Government therefore expected employers to be able to “recruit domestically to outnumber any decreased flow of workers from the EU.”
88.Anita Charlesworth told us that the post-covid-19 pandemic presented the Government with an opportunity to tackle the shortfall in domestic recruitment. She said that the NHS had experienced a “huge increase” in the number of people from the UK applying for both jobs and training opportunities in the NHS and that the Government needed to capitalise on that. In relation to social care, Anita Charlesworth said that the pandemic has “essentially, fast-tracked structural changes” that had resulted in a large number of people with skills in customer care and in human relationships but without employment. She said that those skills would be “very valuable in social care” and that the Government needed to invest in training them in social care. However, she added that the training needed to ensure that employment in social care was “not a temporary job while you are looking for the long term”, but became “a career for people where they feel valued and they can earn a decent living.”
89.When she came before us, Helen Whately, the Minister for Care, acknowledged the challenges facing the health and care sector in recruiting the necessary numbers of staff and told us that the Government valued “the input and work of international recruits”. However, she said that in terms of reducing the vacancies and the gaps in the social care workforce, the Government’s focus was on “encouraging and supporting those in the UK to take on those jobs”.
90.Staff from overseas play a key role in enabling the NHS and social care to function. Whatever role overseas staff will play in the long-term, they are essential to the health and social care system in the short-term and medium-long term because any move to shift to more domestic supply is likely to take time. Workforce planning, in both the NHS and social care therefore will need to include strategies for the recruitment, transition, and training of overseas workers in the health and care sector.
91.We recommend that the Department develops an NHS and social care national policy framework around migration to support national and local workforce planning and identify the balance between domestic and international recruitment in the short, medium and long-term.
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114 , Tricia Pereira, Head of Operations Adults Social Care & Adult Safeguarding, London Borough of Merton
115 , Dr Chaand Nagpaul CBE, Chair, BMA Council
116 , Dr Chaand Nagpaul CBE, Chair, BMA Council
117 , Dr Chaand Nagpaul CBE, Chair, BMA Council
118 , Professor Michael West, Senior Visiting Fellow, The King’s Fund
119 NHS Providers (), Care England (), Royal College of Midwives ()
120 , Anita Charlesworth, Director of Research and REAL Centre, The Health Foundation
121 , Oonagh Smyth, Chief Executive Officer, Skills for Care
122 [on care homes: migrant workers] 14 January 2021
123 , Anita Charlesworth, Director of Research and REAL Centre, The Health Foundation
124 , Helen Whately MP, Minister of State for Care, Department of Health and Social Care