“The cobbler’s children have no shoes” by Emma Hadley and Partha Kar

Partha Kar:

“Family must look after family”

So goes an old African proverb. Yet somehow the NHS has always struggled with the basic concept of that. Caught in the cocktail of shrinking public funds, greater desire for efficiency, increased demand from the public as well as unrealistic expectations set by politicians, the NHS has tried to be something to all – but forgotten, in the main – its own. Beyond the well-meaning hashtags, conferences or indeed documents, the desire to improve working lives of the staff themselves has rarely translated into actions and ideas such as well-being modules appear as little but tokenism to many, thus fuelling the cycle further.

Setting aside all the debate about pastoral support, a shoulder-to-cry-on etc.,…even if we look at it simply from a clinical point of view; We don’t do enough. Emma Hadley (Faculty of Medical Leadership and Management National Medical Director Fellow, working for the National Healthcare Inequalities Improvement Team at NHS England) outlines below the issues at hand. And to summarise, we have plenty of measures for the public to help with prevention or tackling the main killers such as cancer or cardiovascular death; yet little has been set aside for those who work in the NHS. If you want cervical cancer screening, you have to make your own time do so. At the same time, you also have to work extra, cover for other colleagues, stay behind after allocated hours…the maths doesn’t quite add up. Can we set something in place where we offer our own staff the support needed to have their risk factors assessed and prevent them from falling ill and blowing further holes in our workforce?

I think we can – Emma certainly highlights the need and a plan. The question is how much we think of us as a family- and how much we want to look after our own.

Emma Hadley:

“The Cobbler’s Children Have No Shoes”

If you went into a shoe shop and the shoemaker’s children had no shoes, what would you think? Would you question whether the cobbler had employed enough staff to make the shoes? Would you query whether they were being overstretched by the workload? Would you wonder whether they had depleted all the resources in making customers shoes? Perhaps you might surmise that the shoemaker is not able to afford the resources? Or maybe you might think that they were living on the margins of society?

The NHS workforce in England is reported to be in a state of crisis, and may have been for some time due to budget cuts, weak policy and poor workforce planning – in fact we have had no national NHS workforce strategy since 2003 (1). The agony of staff shortages was far more palpable during the pandemic and has the potential to become a chronic pain with ongoing staff pressures as we attempt to resume business as usual, recover waiting lists, reduce service backlogs; all alongside ‘living with COVID-19’ which ultimately may mean further infection waves on the horizon and potentially overwhelmed healthcare settings.

On top of the workforce crisis, the current staff are overstretched and consequently experiencing illness – burnout, mental health crises, COVID-19 infection, to name a few, as well as all the other illnesses that the general population experience. In fact, sickness absence rates in NHS staff are higher in comparison to the rest of the economy (2). NHS Digital reports highlight that NHS workforce sickness absence rates over the last two years have varied considerably throughout the COVID-19 pandemic, but continue to show highest rates of absence amongst ‘support to clinical staff’ groups and anxiety/stress/depression or other psychiatric illnesses are consistently the most reported reason for sickness absence (3). To set the scene, during the pandemic, a colleague of mine experienced chest pain whilst undertaking the morning ward round. The doctor was persuaded to have a diagnostic blood test, but once this was done, continued delivering a service to the patients and a busy hospital. It wasn’t until late that day the results were reviewed, and they found themselves requiring an urgent angiogram for a myocardial infarction followed by a prolonged period of sick leave from work. I am not sure whether one would feel the same pressure to continue working with chest pain in any other organisation.

The first principle that guides the NHS is ‘the NHS provides a comprehensive service, available to all’ (4). NHS staff also fall into the category of ‘all’ and have the same rights to access healthcare as the general public. But why then do we see higher rate of sickness absence in our staff? Yes, much of the NHS resources are scarce or depleted contributing to the current pressures in the NHS, but this impacts on the whole population. So perhaps the aetiology behind these rates is either a direct consequence of working for the NHS, for example, frontline exposure to COVID-19 or an indirect consequence, for example, barriers to accessing healthcare resources or working night shifts. Or, maybe both.

While resources may be limited, surely we cannot argue that the NHS is unable to afford to protect the physical and mental wellbeing of its staff. In fact, there is a cost to the NHS if staff become unwell (not including the personal ramifications for the staff). Pre-pandemic, Public Health England estimated the cost to the NHS of staff absence due to poor health at £2.4billion/year (5). Imagine how this money could be better spent, especially if it was channelled into improving the physical and mental health of NHS staff.

To further add fuel to the fire, as already highlighted, NHS staff are members of the public and thus are not exempt from the same public issues, including health inequalities. These are unfair and avoidable differences in health across the population and different societal groups which have been getting increasingly worse, so much so that while life expectancy continues to improve for the most affluent 10% of our population, it has either stalled or fallen for the most deprived 10% – the health inequality gap (6). It comes as no surprise that tackling health inequalities is a national priority. The National Healthcare Inequalities Team at NHS England have developed a social movement approach called Core20PLUS5 with the aim of closing the health inequality gap and ensuring five years of extra healthy life expectancy by 2035, a trajectory outlined in the Long Term Plan (6,7). ‘Core20PLUS’ defines the target population for reducing health inequalities, including those of low socio-economic status and ethnic minority groups and the ‘5’ stands for 5 key clinical areas of focus that are significantly contributing to the health inequality gap (7).

This means that one compelling argument for the NHS ensuring its staff are healthy (other than it being morally the right thing to do), is to address health inequalities. In fact, health inequalities are probably experienced by a high proportion of the NHS workforce given its demographics. The NHS in England employs approximately 1.3 million people, making it the largest employer in UK (6). It is also the largest employer of Black, Asian, and Minority Ethnic people (8), with approximately 23% of NHS workforce being from all other ethnic groups combined compared to 13% of all working-age adults in the UK (9). The NHS is located in areas of low and high deprivation and according to NHS Providers, a trust’s workforce within pay bands 1-4 may comprise up to 8% of local resident population in the most deprived areas around the country (10).  Furthermore, we know the COVID-19 pandemic has exacerbated health inequalities and the disproportionate adverse impact on certain groups is mirrored in NHS workforce (11).

Sometimes, I wonder if working for the NHS can feel like being a barefooted shoemaker’s child. The charitable tendencies of the NHS workforce are exploited to fuel service provisions. The NHS’s reliance on ‘good will’ and benevolence to provide a healthcare service can leave staff bereft of the opportunities to look after themselves, in particular, their physical and mental wellbeing. But I think the big question is: who is the shoemaker? Whose responsibility is it to protect as well as improve the physical and mental wellbeing of the NHS workforce – the workforce or the NHS organisation? How about both.

Over recent years, the NHS has made considerable effort to improve services to address the mental wellbeing of the workforce, but more can be done to help protect and improve workforce physical health and tackle health inequalities. It needs to be about action, processes and safety. Here are my suggestions of what the NHS should do –

  1. Collect and disaggregate data that quantifies the proportion of staff who are experiencing health inequalities, so we have a transparent understanding of the problem.
  2. Provide an environment that cultivates a healthy lifestyle at work. For example, provisions for healthy meals 24/7, support to participate in physical activity, places to rest during a night shift.
  3. Break down barriers that impact on staff accessing medical services for their physical health at their place of work that may otherwise by inaccessible due to work commitments, for example screening appointments.
  4. Empower staff to know their own health risks and help them seek appropriate support. I propose that the NHS staff should be offered access to regular health checks. These checks should account for the Global Burden of Disease (GBD) main contributors to premature death in England, which correlate with the leading causes of mortality, including the 5 key clinical of the Core20PLUS5 approach (12). The offer should thus include: behavioural risk factors (tobacco smoking, physical activity, dietary risks), metabolic risk factors (BMI, cholesterol, glucose, blood pressure, pulse), respiratory risk factors (spirometry) and cancer (access to breast, cervical, bowel and lung screening). The health checks should be promoted, encouraged and provisions made to allow staff to attend.

The NHS would not and could not exist without the people who work for it. The COVID-19 pandemic has exposed how hard people work for the NHS, their willingness to put the public needs before their own and the impact this can have on their physical and mental wellbeing. There is a great deal the NHS learns from aviation safety. Without fail, every safety check demonstration prior to take off in an aeroplane, will inform you in the event of an emergency, to put your own oxygen mask on first before attempting to help those around you. Although this might seem counter-intuitive and against any healthcare workers instinct, ultimately, you cannot help those around you if you do not look after yourself and put yourself first. The NHS may be in a state of emergency post pandemic and if we want the NHS to continue to exist and improve, then protecting its workforce must be a priority.  It is time for the NHS to ensure that every single employee is putting on their oxygen mask first and no individual nor group is left barefooted.

References

  1. NHS workforce: our position | The King’s Fund (kingsfund.org.uk)
  2. NHS sickness absence | The King’s Fund (kingsfund.org.uk)
  3. NHS Sickness Absence Rates, November 2021, Provisional Statistics – NHS Digital
  4. https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england
  5. https://www.nhsemployers.org/sites/default/files/media/NHS-Workforce-HWB%20Framework-updated-July-18_0.pdf
  6. NHS Long Term Plan
  7. NHS England » Core20PLUS5 – An approach to reducing health inequalities
  8. NHS England » We are the NHS: People Plan for 2020/21 – action for us all
  9. NHS workforce – GOV.UK Ethnicity facts and figures (ethnicity-facts-figures.service.gov.uk)
  10. population-health-framework-1f.pdf (nhsproviders.org)
  11. NHS-Reset-COVID-19-and-the-health-and-care-workforce_4.pdf (nhsconfed.org)
  12. Latest GBD results: 2019 | Institute for Health Metrics and Evaluation (healthdata.org)

Dr Emma Hadley

Dr Emma Hadley is a Geriatric and General Medical Registrar, working across Kent, Surrey and Sussex Deanery. Having undertaken leadership roles within local NHS trusts and participation in local quality improvement projects, Emma applied to the Faculty of Medical Leadership and Management (FMLM) National Medical Directors Clinical Fellow Scheme to continue to develop her leadership and management skills as well as to gain a deeper understanding and appreciation of change management within the NHS at a national level. Emma has a particular interest in the wellbeing and morale of the workforce, which has been at the centre of many of her previous QI projects and Emma feels incredibly privileged to have been placed within the Health Inequalities Team at NHS England. Emma hopes that she can bring both her medical and clinical leadership skills to the team, her holistic approach to addressing tasks and her passion for contributing to positive change, now with a new health inequalities lens.  Emma hopes to be an ambassador for the Health Inequalities Team, networking within NHSEI and liaising with the FMLM fellows across other organisations to align the health inequalities work being done nationally.

Professor Partha Kar

Professor Partha Kar is a Consultant in Diabetes & Endocrinology, Portsmouth, England and National Specialty Advisor for Diabetes for NHS England. He has led and delivered so far on (April 2016- till date):

  • Freestyle Libre being available on NHS -across country
  • NHS Right Care Diabetes pathway
  • Diabetes “Language Matters” document
  • Type 1 diabetes NHS England web-resource – on NHS choices
  • Introduction of Frailty into QoF treatment targets for diabetes care in NHS
  • Availability of CGM to all T1D pregnant patients
  • Diabetes Technology pathway development with multiple stakeholders
  • Setting up pilot projects for diabulimia treatment in London & Wessex
  • Introduction of Low Carbohydrate App into NHS Apps Library

Other work has involved input in updating of driving guidelines in relation to use of technology in those living with diabetes, helping to develop a virtual reality programme to improve hospital safety and starting work on increased mental health access for diabetes patients across the NHS. He received an OBE in the New Years Honours List, UK in 2021 for “services to diabetes care”.

Declaration of interests

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.

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