Better leadership and staffing ‘key to fixing NHS culture’

Support for NHS leaders is crucial to creating a psychologically safe culture for nurses, while safe staffing levels also need to be mandated, a senior nurse and health policy expert has said.

Dame Anne Marie Rafferty, former Royal College of Nursing (RCN) president and professor of nursing policy at King’s College London, told an event featuring some of the country’s leading authorities on health that moral injury among nurses and other healthcare staff was driving people out of the professions.

“But this nettle’s got to be grasped about funding”

Anne Marie Rafferty

She said policymakers must “grasp the nettle” on funding the workforce, set minimum staffing levels and support leaders so they can better act on the concerns of nurses, doctors and other healthcare staff.

Dame Anne Marie made the comments at The Times Health Commission Summit 2024, held in London earlier this week, during a panel discussion on fixing the “broken” culture of the NHS.

This panel focused on how to improve transparency and reduce a “defensive” culture when a complaint is made and, ultimately, improve learning and patient care.

Also on the panel were Dr Waheed Arian, The Times’ doctor of the year and Afghan refugee, and James Titcombe, chief executive of Patient Safety Watch.

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Dame Anne Marie said improving culture would only be possible once “fundamental” workforce issues were addressed.

“According to staff surveys, almost 70% [of clinicians] say they don’t have enough staff to do their jobs properly,” said Dame Anne Marie.

“That’s got a series of cultural consequences for patients and for staff. For patients, that means missed care, poor quality care outcomes and longer waits.

“For staff at the service, this means record levels of depression, anxiety, burnout and, more recently, moral injury; that tormented feeling of guilt of not actually being able to do the job you’ve been trained to do.”

Dame Anne Marie said moral injury was “driving people out of the professions”, and compared the state of the health service as a patient with a heart condition.

“If this were one, what would we do? We would seek to stabilise the condition immediately before it deteriorates further,” she said, adding that doing this would mean setting minimum staffing levels.

She continued: “Young women [in the health service] are particularly at risk [of mental health problems], and that’s really bad news for young nurses.

“It’s absolutely ridiculous and absurd that we have [minimum staffing] ratios for dog care, child care – but not for our loved ones. That needs to change.”

Dr Arian, like Dame Anne Marie, said he and other medical staff had experienced moral injury from being in a workforce stretched to its limits.

Mr Titcombe told the event about his experiences on the other side which led him to becoming an advocate for patient safety.

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He described a defensive culture of denial among midwifery staff, after his newborn son died of sepsis when signs of the condition were missed and he and his wife’s concerns were ignored.

Mr Titcombe agreed that, to fix this closed culture, psychological safety would have to be cultivated.

Dame Anne-Marie Rafferty at The Times Health Commission Summit

Anne Marie Rafferty at The Times Health Commission Summit

Dame Anne Marie said one way to do this would be to support leaders: “A majority of staff are not confident their line managers are able to act on their concerns.

“It’s a leadership problem. More basic support for line managers and supervisors, because those are the people who need it, the whole chain of command who are looking after staff.

“[If] they don’t have the resources, they are unable to make changes.

“We can have all the organisational and cultural policies in place, but if it’s not operating at [manager] level, at the contact point with staff, patients won’t benefit either.”

She further said the culture of fear among clinicians was shared by leaders and managers, adding: “Florence Nightingale had this saying, that ‘fear is the enemy of progress’.

“So much of what we’re talking about is this embedded nature of fear.”

The Times’ event, which coincided with the launch of the commission’s report into health and social care, featured other high-profile guest speakers including health and social care secretary Victoria Atkins, AstraZeneca UK president Tom Keith-Roach and the UK’s former chief science advisor Sir Patrick Vallance.

The event focused on a discussion about the commission report’s 10 recommendations for a future government, after the probable 2024 general election.

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These recommendations included wide-ranging reforms to social care, refocusing the health service on preventative care and public health and writing off student loans for healthcare workers.

Also present were dozens of other top-ranking nurses, doctors, NHS bosses, educators, celebrities with interests in health and representatives from the pharmaceutical and private healthcare sectors.

Professor David Green, vice chancellor of the University of Worcester, asked the panel to discuss the NHS Long Term Workforce Plan as a vehicle for improving the issues they had spoken about.

Professor Green expressed concern that progress had been slow in increasing the number of training places compared to the ambitious targets laid out in the plan.

Dame Anne Marie responded that funding for the plan was the “fundamental” issue.

She said: “It doesn’t have to be like this, you know; before 2010, the NHS was pretty good at translating extra resource into boosting staff numbers and reducing waste.

“After that we’ve been dealing with austerity and the shock of the pandemic [which] we’ve been much slower to recover [from] than our European neighbours.

“But this nettle’s got to be grasped about funding. An advisory note is not good enough, we need to build hope and we need to let people know the cavalry are coming and coming soon.”

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