Nada Al-Hadithy reflects on what a year working as a National Medical Director’s clinical leadership fellow in the civil service taught her about how to improve working lives in the NHS

The NHS is facing a workplace crisis reflected in the number of unfilled posts in the UK. Some estimates put this at around 100,000 vacancies. A report of 400 doctors’ experiences of “petty tortures” at the hands of NHS management has highlighted the need for the NHS to rethink the way it treats its staff. Poor diversity and inclusion, bullying and sexual harassment, inflexible working patterns, poor work life balance and a lack of leadership, all contibute to workforce attrition, which ultimately impacts on patient care. My time as a National Medical Director’s Leadership fellow, working in the civil service, has given me some ideas of how this could be improved.

Poor diversity and inclusion

There is a lack of diversity in senior leadership roles in the NHS. Forty one percent of the doctors in the NHS are from BME backgrounds, yet only 17.5% of medical directors and 21% of professors are BME. Only 8% of NHS Trust chairs and non-executives are BME. Only 66% of BME applicants for consultant posts are shortlisted versus 80% of white applicants and 57% offered a post versus 77% of white applicants, regardless of the original location of primary medical degree. A substantial body of research evidence published during the past four decades, has highlighted the racism and discrimination BME staff experience, and provides compelling justification to acknowledge and address institutional racism in the NHS.

The problem is even worse for female BME NHS staff where the intersectionality of gender and race is a further impediment to career progression. A gender pay gap of 17% in favour of male doctors over female doctors, as well as the fact that 1 in 12 women in the NHS experience sexual harassment is unacceptable in a civil society. The poor representation of women in leadership roles is known to contribute to poor patient outcomes.

Workplace diversity means creating an inclusive environment which accepts each individual’s differences, embraces their strengths, and provides opportunities for all staff to achieve their full potential. The civil service has put into place measures to help it achieve diversity initiatives. From 2019, Senior Civil Service interview panels must have a diverse panel. There are well funded and executive sponsored BME, diversely abled, LGBTQI and women’s leadership programs.  

In the NHS we could improve diversity and inclusion by ensuring interview panels and Annual Review of Competence Progression (ARCPs) boards are diverse in terms of representation from all ethnic backgrounds, genders, physical abilities and sexuality. These data need to be aggregated and reported centrally. Clear consistent guidelines need to be easily accessible for pregnant employees regarding shift work and occupational hazards. Visible female role models can be put forward and celebrated. Senior leaders can sponsor those more likely to experience unconscious bias and exclusion. 

Inflexible working patterns and poor work life balance

Gaps in clinical rotas impact the delivery of care, limit access to training, and contribute to low morale among staff. Conflicting guidance from medical educators on what contributes to career progression, and training requirements, as well as inflexible working patterns, short notice for on call commitments, and being moved around the country with very short notice periods makes working for the NHS incredibly difficult.

I believe the NHS can learn from the civil service where, in my experience, the work life balance and quality of life is better than in the NHS. In terms of the way staff are managed, flexible and part-time working, job sharing, working from home, and work life balance is actively encouraged. Leave is easier to book; job plans are transparent, and project plans realistically resourced. The majority of the work happens in paid time, rather than people’s spare time. There are several other well publicised and well-resourced initiatives such as: parental leave champions, health and wellbeing advocates, and reverse mentoring schemes.

In the NHS, the advent of e-rostering should hopefully address the issues of poor notice on working schedules. However, more can be done to match work hours and patterns to individual needs and preferences. This includes greater efforts to enable working from home, which is feasible for certain admin, audit or CPD  tasks. 

Poor leadership

Leadership training in the NHS is lacking and, too often, newly appointed consultants find themselves out of their depth to implement change, even at a local level.

In the civil service, there is strategic oversight to ensure that leadership and management is embedded into individual’s objectives while still aligning with department. So, in addition to the policy work, everyone contributes to the corporate objectives of upskilling the department and showing leadership. These are not “nice to have” initiatives, but necessary, well resourced, and evaluated.

In the NHS, we could break through hierarchies and trust and develop each member of the team to develop the leadership pipeline. The civil service’s layered management structure would embed management and leadership into all doctor’s working lives. So supported and trained FY2s manage and appraise FY1s, CTs appraise FY2, registrars appraise CTs and consultants appraise registrars.

Senior leadership in each hospital could meet with all new staff and hear their experiences of best practices from other facilities and implement the relevant successful quality improvement initiatives. Everyone can call each other by their first names—regardless of seniority or position. Respectful challenge can be encouraged. Junior members can sit on senior leadership and board meetings, with an equal voice. Checking in with staff with a quick “temperature check” at team meetings would acknowledge frontline staff as human and reduce the power gradient.  More 1:1s and reverse mentoring would also ensure senior and junior staff have better working relationships.

Obviously in a clinical setting it is not always feasible to work from home and prioritise upskilling, but we could make system changes to embed best practice. As the nation’s largest employer, the NHS must offer a clear path forward and support its workforce to not only make the workforce more effective, but to help all employees fulfil their potential and make working in the NHS enjoyable again. 

Nada Al- Hadithy, is a Plastic Surgery Registrar and previous National Medical Director’s Clinical Leadership Fellow at the Department of Health (DHSC).
Twitter: @hadithynada