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Monday 29 April 2024

Would the NHS really be a worker's paradise if we just had the right managers?

By Jon Restell

Are managers always to blame for the poor working culture in the NHS, or is that just a convenient excuse for politicians when the root causes of our problems are too hard to solve?

Jon Restell portrait 2021

Every now and then, my colleagues – our amazing national officers and equally amazing workplace reps – and I look up from our individual casework and ask what it says about the workplace culture of the NHS Sadly, the answer often leaves hearts in boots. As Sam Allen once told our summit, the NHS is one of the wonders of the world, but it’s far from perfect. The day-to-day experiences of too many members bear that out.

Bullying and harassment, race discrimination, sexual safety, flexible working, overworking, and psychological and physical safety are big issues on which the NHS does badly compared to other employers. Granted, the NHS staff survey is a more public soul-bearing exercise than other sectors would tolerate, but it clearly shows the NHS has a problem with workplace culture. Staff either hate it and stay or hate it and leave. Neither is good for patients. The evidence for the problem litters the place, from staff surveys, workforce statistics, union casework and legal judgements to the former paramedic bringing a Tesco delivery to your door.

Management is often blamed for the NHS’s poor culture. But that’s quite a stretch. Take bullying. Researchers say too much demand and too few resources create the pressures on people and systems that are the main cause of bullying. Other research suggests bullying may be endemic in healthcare throughout the world, particularly in certain settings like emergency departments or within clinical hierarchies. To cap it all, the UK’s four national health services must contend with the pressures created by short-term political demands (see our member surveys for the effect these can have), micro-management, demanding and often-contradictory regulation, and endless re-organisation.

When managers succumb to these pressures they contribute to the negative culture, but it’s missing the point to say they’re the root cause. To put it another way, how credible would it be to say that if only we had managers with the right values, training and regulation, the NHS would be a worker’s paradise—despite the huge waiting lists, staffing shortages, death by template, political diktats and continual structural upheaval? In my view, not credible at all. Yet politicians and others—inside and outside the NHS—perpetuate this convenient myth because it’s simply too hard to fix the root causes of our problems.

Some root causes will not be fixed any time soon. The next parliament will not see a Blair-style funding boost. The intrinsic pressures of healthcare will remain. Politicians will demand greater productivity. So the pressures will build, producing strong headwinds against which good culture will struggle to progress. But management can be a powerful mitigation. The latest NHS staff survey found satisfaction with line management back to pre-pandemic levels. It should be a priority—for the good of staff and patients—to support and develop managers.

No one wants to work for decades in a poor management culture. As a managers’ union, MiP’s contribution is to improve the working lives of managers so they can improve the lives of other staff and the care of patients. So what do our members and reps think can be done?

First, system leaders and managers themselves should accept that day-to-day behaviour and experience in the NHS is shaped by forces beyond the direct control of staff and employers. This will help bust the myth that managers cause poor culture. Instead, good managers mitigate pressures and need investment and support.

Second, in managing the managers, we should stop relying on values—horses that seem to fall easily at the first hurdle—and focus more on actual behaviours. Good practice in managing change, performance and concerns should be essential rather than optional. Endless suspensions, repeating investigations until they come to the ‘right’ conclusion, sham and shambolic change consultations and harsh treatment are all behaviours towards managers that other managers can stop right now without needing a shift in the tectonic plates.

Third, we need effectively co-produced codes of practice and competencies to underpin management practice; these are essential if statutory regulation comes in. MiP stands ready and able to support such change.

But, finally, codes and training will be sandcastles facing the incoming tide unless there are enough managers doing doable jobs. I get why a head of midwifery, for example, might cut management to get more midwives in the delivery suite right now. But long-term under-management creates conditions from which staff want to escape and in which mums and babies suffer harm. Leaders need to talk openly about the safe management levels needed in all healthcare settings.

  • Jon Restell is chief executive of Managers in Partnership.

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