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Please Sir, I want some more

November 25, 2014

Charles Dickens, merciless satirist of Victorian institutions. I wonder where he would have stood on in the current NHS pay dispute? On the one hand, we have nurses – one of the most important groups in the whole organisation, crucial to the delivery of the safe, high quality care on which the NHS stakes its reputation. But like everyone else at the sharp end of the NHS, nurses are living on a treadmill – and unfortunately, it’s a treadmill whose speed button is permanently stuck on ‘accelerate’.

Emergency admissions to English hospitals are growing at 3-4% a year. Every year. And those extra patients are not just there for the ride – they are sicker than ever before and they are more demanding than ever before. You’d think, wouldn’t you, that staff who are coping with a workload that’s mushrooming before their very eyes – with all its attendant pressures – could at least expect a pay packet that takes account of these realities. But you’d be wrong.

Nurses’ pay is falling in real terms. Since the Coalition came to power in 2010, according to a Royal College of Nursing (RCN) report from June this year, ‘nursing pay has lagged up to eight per cent behind inflation, an average real terms cut of over £2,600 [per nurse]’. So for every penny nurses earn, they are having to work harder. And then harder still. The only way to recoup lost spending-power is by saying goodbye to any hopes of downtime, and working extra shifts. And there’s no end to this in sight; the below-inflation 2014 pay award has made the situation worse.

On the other hand, we have NHS executives. According to figures obtained under the Freedom of Information Act and included in that same RCN report, ‘while nurses, midwives and health visitors’ earnings have risen by an average of 1.6 per cent, executive costs in the trusts which responded to our request rose by over 6 per cent, with some parts of [England] seeing inflation of executive rewards running at almost 15 per cent (my italics)’. The name the RCN came up with for their report was the gratifyingly sarcastic All In It Together?. I think they’ve just given us the answer to that one.

Now I’m not going to say that there are no decent NHS executives. I’m sure that many if not most of them are very nice people. But most nurses are very nice people too, so that’s not the issue here. The issue here is whether executives are working so much harder or so much more effectively than nurses in the current difficult circumstances, that they can justify rewarding themselves with pay inflation nearly four times that of nurses on average. And I think the answer to that is ‘no’.

In a another publication from earlier this year, the King’s Fund set out to ‘survey NHS managers and clinicians about leadership, culture and compassionate care in the NHS’. Although not a huge sample size, guess what the stand-out finding was? Surprise, surprise! The executive class is living in a parallel universe – and here’s the proof. Asked whether their organisation is characterised by openness, honesty and challenge, 84% of executive directors thought it was, against 31% of nurses. Asked whether any concerns they raised would be dealt with appropriately, a whopping 90% of executives thought they would, against just 26% of nurses.

On leadership, the results were even more arresting. Even amongst executives, only around 44% felt that the overall quality of NHS leadership was good or very good (hardly a ringing endorsement, is it, especially as the figure for nurses was a pitiful 15%). But when the focus switched to quality of leadership in respondents’ own organisations, the King’s Fund reported that ‘respondents were less positive with 37 per cent – the same as the previous year – rating leadership as good or very good’. Did you get that? Even though plenty of top people admitted – they must have done, for the average figure to come out so low – that their own leadership was not only a bit crap, but not even getting any better, they still took big pay rises. What is this???

The King’s Fund made no attempt to probe respondents’ reasons for answering the way they did. It’s quite possible that their views are based on widely differing frames of reference. But according to a companion publication, big discrepancies in the way different grades of staff perceive their organisation is in itself symptomatic of poor leadership.

The King’s Fund argue that for effective transformation of the NHS to become a reality, ‘collective leadership’, characterised by ‘high levels of dialogue, debate and discussion to achieve shared understanding about quality problems and solutions’ is required. Or as Roy Lilley often puts it ‘why aren’t managers crawling to their staff on their hands and knees and begging to be told what the problems are?’.

Put simply, a set of objectives that is understood by and bought into by everyone is much more likely to produce good outcomes. But we don’t have that. Instead, too many of us are trapped in this ‘parallel universe’ school of management where because executives and senior managers are completely divorced from their staff, they can delude themselves into thinking that everything’s hunky-dory. And pay themselves accordingly. And don’t even get me started on the £500 million pounds a year they collectively hand over to outside ‘management consultants’. When they’re supposed to be management experts themselves.

As for Charles Dickens, we only need to read Oliver Twist to know where his sympathies lie. That scene where Oliver holds out his poor little basin to the fat, healthy workhouse master and the sleek self-satisfied Mr Bumble and tremulously asks if he might have some more.

  1. Basket Press permalink

    Here’s something about a similar report I prepared earlier:

    Oh, another whizzy new report and some nice buzz words –

    And the report itself, by The Point of Care Foundation, says “NHS chief executives appear confident about their focus on staff engagement. In our survey of chief executives, most (70 per cent) believe that staff engagement is generally improving. One in five rate staff engagement as high and 61 per cent acknowledge it as mixed.
    “Most claim it is a top priority and say they are investing in improving staff engagement. In a survey carried out by the Foundation Trust Network, nearly all trusts (97 per cent) say they have the infrastructure and systems in place to engage effectively with their staff. Nevertheless, the Chartered Institute of Personnel Development reports that engagement levels in the NHS are relatively low. Fewer than a third are actively engaged, according to its index, and only 27 per cent of nurses (compared with 37 per cent of employed people in the UK).”

    Then look at page 9 of the report, covering staff views, especially of appraisals, health and well being, listening and communication…Check the disparity with what CEOs think…

    And look at the bottom of page 13, the bit about productivity and staff engagement…Now go and have a look at the section about the NHS failing to look after its staff…

    To borrow a phrase, this isn’t rocket science, but the different planet the CEOs and the like are on is just…I don’t know what…But they certainly aren’t in the same world as most clinicians.

    Now, let us examine the following: “Clinicians, especially senior ones, sometimes get a bad name for appearing resistant to change. In fact, we know the internal environment and our specialty (sic) better than anyone, including what could work better, how best to make change happen and who needs to be involved. We also often know more of the history when there is high turnover at executive level.
    “My experience is that things work best when managers and clinicians collaborate – and have some freedom – to enable a ward to work both for staff and patients. Creating opportunities for the teams around patients to get together and reflect on how they work, particularly when the trust is facing challenging circumstances, is also really effective in creating a sense of community and shared purpose.”

    How many have come across the situations described in the first paragraph of that quotation? In which the latest fly-by-night manager insists on “change”, but doesn’t listen when clinicians point out that we tried that 5 years ago, it didn’t work and here’s why it didn’t work. And still doesn’t listen when we say we could try something else instead which stands a better chance of success, because it isn’t their idea. And yet we are castigated…And reports like this come out about a lack of staff engagement…Many of us could have told them this donkey’s years ago…If anyone had been listening, of course.

    The second paragraph is pretty unarguable. But how many have encountered the situation my former service had a couple of years ago, in which the clinicians were instructed by management to cancel all “non-essential” meetings, as defined by management, which included all clinical team, service development and professional meetings, but NOT management meetings, in order to meet the latest arbitrary targets? Were we the only ones?

    The “Round Up of Good Advice” on page 17 onwards is again pretty unarguable and most of this is already well known and should be happening already – decent appraisals? Training adequate to the role? Time and space for staff to reflect on their work? Nothing here most of us haven’t known for years.

    The better questions would be: “Why isn’t all this, which is very well known and has been for many, many, many years, STILL not being put into effect?” And why are we still getting reports from lots of high flown people stating the bleedin’ obvious? Who holds to account the managers who have not been using this sort of best practice, who have alienated clinicians, who have led to the levels of disengagement described?

    But no, those things seem to go unasked; management continues to get away unchallenged.

  2. Interesting also that while elsewhere in the NHS ‘honesty, openness and transparency’ have (rightly) become the new mantra words, seventeen English Trusts refused to provide the RCN with information about their executive pay bill and bonuses.

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