Staff in the NHS.

British Medical Journal, Jan 31, 1998 by Anne Cockroft, Sian Williams

Concerns about the well being of staff in the NHS are nothing new. Many have blamed the organisation of the NHS in the past decade, especially the purchaser-provider split, and the underfunding of the service. The white paper outlines government plans for the future of the NHS: what does it have to offer stall?

The document is long on rhetoric and short on specifics. It delineates new roles and responsibilities for several groups of staff. General practitioners and community nurses will form primary care groups and be responsible for commissioning services for local patients. Within trusts, doctors, nurses, and other senior professionals will be "much more closely involved" in designing service agreements with commissioners. The commitment to introduce more information technology will require more staff to use such technology in their work- So the new NHS will need a lot of work from its staff, some of it in areas that are unfamiliar.

Traditionally staff in the NHS have been prepared to give more than their contractual obligations because they believe they are doing something worthwhile. This willingness has been eroded over the past two decades, but it could be restored, provided that staff really feel valued and part of a process of regeneration. Major organisational change is nearly always associated with increased stress, but this can be minimised if staff have some control over the process, provided this does not itself produce a big extra workload[1]. The commitment in the white paper to increased staff involvement is therefore welcome.

The white paper includes a section about human resource management priorities. Five priorities are identified: measures to promote health at work, comprising strategies to minimise accidents, avoid violence, and address stress; recognising and dealing with racism; developing flexible, family friendly employment policies; providing reasonable standards of food and accommodation for junior doctors on call; and making sure staff can speak out when necessary, without victimisation. The measures needed to implement these priorities are not specified in the white paper. In September 1997 the minister for health, Alan Milburn, addressed the Association of Healthcare Human Resource Managers, emphasising the importance of staff in the success of the new NHS and introducing these five priorities for involving and caring for staff. A subsequent executive letter is no more specific but reminds trusts of the priorities and asks for examples of good practice.[2]

Few would dispute the importance of the identified priorities. Some of them, like minimising stress and violence, are all too obvious. Others, like food and accommodation for on call junior doctors, seem strangely specific. There is little or no mention of funding for the current review of pay systems, for reducing workload, or for training and development programmes for staff. Possibly this is because they would cost a lot of money. But so would many of the other priorities mentioned in the white paper if tackled seriously. Since the implementation of these strategies seems to be left to individual trusts with no additional funding offered, it is hard to see how trusts will manage to take action on staff issues in competition with other demands more obviously linked to patient care. If the government is serious about caring for staff so as to improve patient care, it must translate rhetoric into practice.

The NHS Executive aims to develop a strategic framework for human resources, including the five priority areas. The Partnership for the Health of the NHS Workforce[3] is due to produce its report and recommendations through the Nuffield Trust in March. Hopefully, one or both of these initiatives will produce concrete, evidence based proposals and the government can then show its commitment to staff in the NHS by providing the leadership and funding to implement them.

[1] Karasek R. Lower health risk with increased job control among white collar workers. J Org Behav 1990;11:171-85.

[2] Managing human resources in the NHS. Leeds: NHS Executive, 1997 (EL(97)73).

[3] Beecham L. Health of the NHS workforce to be reviewed. BMJ 1997;315:1314.

Occupational Health and Safety Unit, Royal Free Hospital, London NW3 2QG

Anne Cockcroft senior lecturer

Sian Williams consultant