In autumn 2016, I stepped out of my clinical training to become a leadership and management fellow at Health Education England (HEE), with the aim of gaining a different view on healthcare. In already-crowded curricula, there is limited time to expose junior doctors to leadership and management, despite its notable presence in the job descriptions of senior clinicians. In many junior doctors’ eyes, positions in leadership and management are perceived as part of the “dark” side of the NHS with more money and less compassion.
During the junior doctors’ contract dispute, these feelings became apparent and were further exacerbated by the media stirring a heated cauldron of emotions. While the importance of scrutinising those in positions of responsibility and holding them to account is irrefutable, perceptions of leaders and managers as less moral or solely incentivised by financial gains are typically inaccurate and damaging. This year my experience of working with this group of colleagues has not supported this narrative. Part of my appreciation for them has grown from understanding the necessity for those in NHS-affiliated organisations to work in alignment with government policies and manage expectations of the Department of Health.
These insights highlighted to me the importance of bridging the gap between clinicians and managers, rather than allowing divisive stereotypes to perpetuate and deter our collective efforts to improve overall productivity and patient care. Reassuringly, this year I have found that senior leaders do care about junior doctors’ morale, as demonstrated by their enthusiasm and commitment to support work on the issue.  Indeed, they acknowledge the inadequacy of the system to enact the NHS Constitution’s 3rd central principle:
“Respect, dignity, compassion and care should be at the core of how patients and staff are treated — not only because that is the right thing to do, but because patient safety, experience and outcomes are all improved when staff are valued, empowered and supported.”
This year, HEE listening exercise, triangulated with existing data on junior doctors’ morale, yielded three key themes for why morale is low.  They all relate to the 3rd central principle:
- Not feeling supported
- Not feeling valued and
- Not having autonomy
When faced with burnout and working in resource-constrained environments, it’s difficult to know where to begin to fix these problems. Importantly many junior doctors do have experiences of good training and working environments with correspondingly higher morale, features of which were outlined in the listening exercise.  This led our team of fellows to initiate a project with NHS Improvement to gather examples of good practice and understand how they were achieved, what constraints were overcome and what resources were required. Success often included a pro-active executive team, providing space for managers and junior doctors to listen to each other and find solutions together. These case studies have been uploaded to the NHS Improvement Hub, and are being distributed widely to expedite improvements to morale.  The examples collected include interventions such as:
- Whittington Hospital’s rostering system which reduces fatigue for staff, effectively builds in training and personal commitments and reduces locum spend through redeployment of existing staff, while maintaining full-service cover. 
- Wrightington, Wigan and Leigh NHS Trust developed a ‘Steps 4 Wellness’ programme for improving physical health, mental health, making healthy choices and socialising at work. 
- Imperial College Healthcare NHS Trust’s paired learning pilot programme to “buddy up” band 6 and 7 healthcare managers and specialist registrars to learn from each other’s expertise and experience and jointly improve services; this had unanimously positive feedback with “lessons for life.” 
The HEE Listening Exercise outlines initiatives across the NHS at a macro-level that are being implemented to improve morale; how these approaches trickle down to cash-strapped hospitals is a different challenge but it is heartening to know that this issue is taken seriously by leaders and that there are real changes taking place. 
Shiv Chande was part of the National Medical Director’s Clinical Fellowship 2016-17 cohort and am a current GP trainee in West London.
- Junior Doctors’ Morale: Understanding Best Practice working environments. Health Education England 2017. Available from: https://www.hee.nhs.uk/sites/default/files/documents/Junior%20Doctors%27%20Morale%20-%20understanding%20best%20practice%20working%20environments.pdf
- Engaging, supporting and valuing doctors in training | NHS Improvement. NHS Improvement Hub 2017. Available from: https://improvement.nhs.uk/resources/engaging-supporting-and-valuing-doctors-in-training/
- Engaging, supporting and valuing doctors in training: improving wellbeing and support | NHS Improvement. NHS Improvement Hub 2017. Available from: https://improvement.nhs.uk/resources/Engaging-supporting-and-valuing-doctors-in-training-improving-wellbeing-and-support/
- Engaging, supporting and valuing doctors in training: better engagement | NHS Improvement. NHS Improvement Hub 2017. Available from: https://improvement.nhs.uk/resources/Engaging-supporting-and-valuing-doctors-in-training-improving-better-engagement/