Wednesday 27 September 2023
Oonagh Monkhouse is a woman of gentle positivity – but, asked if staff morale has recovered since the pandemic, an uncharacteristic look of hopelessness crosses her face. “No: if you look at last year’s staff survey results, the burnout scores went the wrong way,” she says. “People spend every day working with patients: they know what it means when they have to cancel appointments, and that brings tremendous emotional pressure.”
Those pressures can become harder to bear over time, but they’re not the only factor depressing staff morale. Asked what’s driving the NHS strikes, Monkhouse replies that “you get this massive sense of staff not feeling listened to and not feeling respected”. and that people don’t feel that “their contribution, what they sacrificed, what they did over those couple of years” has been recognised by “the powers that be”. NHS workers believed, she adds, that “we were going to come out of this, and people were going to understand the value of what we do.” With the government apparently fixated on keeping down the public sector pay bill, those hopes have been dashed.
We all want the same outcome
It’s rare for employers’ representatives to express such empathy with the workforce in other sectors of the economy. Monkhouse is the director of workforce and organisational development at the UK’s leading heart and lung hospital, the Royal Papworth, and NHS Employers’ lead representative on the NHS Staff Council – which she co-chairs with UNISON’s head of health Sara Gorton.
However, the NHS “is not like industry: it’s not as if we’re out to increase profits for the shareholders,” says Monkhouse. Here, “both parties want the same outcome: engaged staff who feel that they’re being treated fairly and have a decent set of terms and conditions, and that we’re able to recruit and retain. Both sides are equally passionate about wanting to do the best for staff.”
Monkhouse joined the NHS 35 years ago in her native Northern Ireland, taking a clerical assistant’s job before soon finding her niche in HR management. “People are endlessly fascinating, it’s all about building relationships, and the problems are incredibly complex,” she comments. “No two situations are the same because the personalities involved are different – so you have to adapt, and you learn a wee bit each time. It never ceases to amaze!”
Her first job involved implementing the Fair Employment (Northern Ireland) Act 1989, designed to “address and redress all the discrimination that had gone on” in the province. And traces of her homeland’s tumultuous history are visible in her approach to HR, which she describes as “always trying to walk in another person’s shoes; and treating people with respect, regardless of whether you violently disagree”.
A lot of compromise
These principles equip her well for co-chairing the NHS Staff Council. Key to effective HR management in the NHS “is partnership working: having an ability to work with trade unions, and to find fair and equitable ways of managing such a large, diverse workforce,” she argues. “And the Staff Council, in the way it works, lays the foundations for that.”
Gathering the views of employer organisations, and working with employer-side Staff Council members, Monkhouse negotiates with union representatives to translate funding settlements and policy statements into amendments to Agenda for Change’s pay bands and working conditions. It's a complex process, and Monkhouse doesn’t pretend that every decision is faithfully observed across the NHS.
“We’re not a regulatory body,” she explains. “Employers will make their own risk assessments about whether they want to comply with a contractual term. And some things are left with flexibility for employers to work out locally, because different sectors and parts of the country have entirely different kinds of pressures or labour markets.”
In general, though, Staff Council decisions are carefully observed. And in many ways, the remarkable thing is that employers and unions can successfully broker agreement on these complex, controversial matters. “It’s always a bit of a mystery at the start, when you’re very far apart,” Monkhouse says. “But you keep talking, and if both parties have a willingness to find a way through then – as in most things in life – you’ll find a way. There’s a lot of compromise on both sides.
“Having a longer game is also important,” she adds. “You might get a couple of things sorted from a set of negotiations, but know that you’ve still got a list of other things that are unaddressed and you’ll have to come back around to. It’s about prioritising – and knowing when to stop pushing!”
That said, Monkhouse notes that “you do get people who are more combative, and then you have a different kind of relationship.” There has certainly been plenty of friction in industrial relations over recent months, alongside labour market conditions that strengthen the unions’ hand. “After the last couple of years – across a lot of industries, but particularly in health and social care – where the power sits [has shifted]. In terms of gaps of staffing, it’s not a surplus situation; it’s a deficit situation,” she comments. “So you’re competing with other sectors for staff, and that gives an added incentive to make it a place where people want to work.”
Unusual and intense
NHS strikes brought the government to the negotiating table in the spring, kicking off talks at the Department for Health and Social Care that Monkhouse describes as “very extraordinary”. Rather than NHS Employers being given a mandate to negotiate a detailed settlement, as has usually happened in the past, “a lot of the negotiations were effectively between the government and the trade unions,” she explains.
The health secretary and Treasury officials are not experts in the complex, multi-layered Agenda for Change framework – so the Staff Council “had a role in setting the context, providing information, looking at some of the options, trying to tease out what might be possible,” Monkhouse explains. Joining civil servants and unions in “technical sessions”, she and her fellow employers’ representative worked to translate the wording coming out of the talks into specific changes to pay scales, terms and conditions, and non-pay arrangements. “It was extremely unusual; very intense,” she recalls.
While the resulting deal was accepted by most of the striking unions, the Staff Council’s inbox remains full. “We’ve got a mandate now to look at travel expenses, which has been outstanding for a couple of years,” she says. And she admits that, while “there’s an issue around the way the pay scales are structured”, a resolution of the awkward overlap between Bands 7 and 8 – a long running grievance among MiP members, as it can result in people losing pay on promotion – will have to await a new pay settlement.
The long-awaited NHS Long Term Workforce Plan, published at the end of June, was presented as a way to resolve these deep-seated workforce problems by boosting morale, plugging workforce gaps and calming tense industrial relations. The commitment to training more clinical staff will be helpful in the long term, Monkhouse says, while “the rest of it brings together in one place things that have been in development over the last couple of years, or are developed”.
We need really good and clever management
Monkhouse: Bringing down waiting lists demands “really good, clever management in making best use of the amazing resources we've got, with really good operational planning and workflow. That's where the management skill comes in."
A “number of gaps” still remain, she adds. The most obvious one is management skills and capacity, on which the Plan is almost silent. It proposes major reforms to training and services, productivity improvements and the adoption of new technologies, but says little about how the management time and expertise required to deliver them will be provided. Monkhouse recognises the omission, pointing to the 2022 Messenger Review’s recommendations about “building capacity and strength among leaders and line managers”. These capabilities are key, she says, to reducing waiting lists at Royal Papworth, for example – a task that will demand “really good, clever management around how we make best use of the amazing resources we’ve got… with really good operational planning and workflow. That’s where the management skill comes in, working with the clinicians.”
Action is required to develop people’s skills in staff management, she argues: “How do you manage staff performance or staff absence? How do you do really good recruitment? How do you do a budget? How do you roster? That kind of stuff isn’t sexy, but it’s the absolute bread and butter of staff’s day-to-day experience of work.”
This applies particularly to managers with clinical backgrounds. “How we enable or support people who have started their journey in a clinical role to gain the skills and expertise and confidence in line management is a real struggle – both from an operational perspective in terms of work throughput, but also in helping them to see it as an important part of their job as well as being really excellent in clinical,” she comments. Appraisal systems, she adds, “should have as much emphasis on them being good managers as good clinicians.”
The Workforce Plan calls for managers to have regular conversations with every staff member on a wide range of topics including wellbeing, flexible working and career progression. “None of that is new, and I would say the vehicle for it is really good staff appraisals,” Monkhouse says. But for that, managers need both the time, and “to be skilled and feel confident in how to do a good appraisal, and what to do with the outputs. If you added up all the components of our jobs, 10% this and 10% that, it would come to well over 100%: that’s a problem!”
Similarly, Monkhouse firmly supports the Plan’s goals on apprenticeships. “It offers such great potential,” she says. “But there’s a lot of detail missing there, again, and there are obstacles present that I think all employers find difficult.” These include how best to use apprenticeships to recruit fresh staff – as opposed to training existing ones – and the funding of backfill costs when apprentices are out of the workplace. “That’s a major stumbling block at the moment, and [the Plan is] silent about how it might be addressed,” she notes.
‘It’s back to line managers’
So the Workforce Plan does provide a helpful set of long-term goals around reform, productivity and workforce management; but it’s not clear how trusts will build the management capacity, funding and systems to realise them. It also promises a long-term improvement in clinical capacity, although in the meantime, says Monkhouse, the NHS must rely on international recruitment, “which we’re all utilising, and it’s brilliant: we’re bringing so much talent into the NHS by that.”
And in the short to medium term? “We keep trying; we keep doing the best we can,” she replies. “We keep trying to find ways to be more productive, and doing what we can with the resources that we’ve got.” Finally, I ask how can we break out of today’s vicious circle whereby jobs become ever more pressurised, prompting people to leave the workforce and piling yet more pressure on those who remain? “Personally speaking, it’s back to line managers,” she replies. “Back to finding ways to release their time and give them the training.
“We need to recognise and give people the credit for being a really good line manager. It should deserve as much kudos, as much recognition and as much pride as being an excellent clinician or an excellent scientist,” she concludes. “Nothing will change unless we do that; we’ll just keep going round and round in the same circle.”
Photos: Tim George/UNP