NHS desperately needs to rework its archaic management system

Delivering healthcare to an ageing and relatively sparse population is never going to be easy, but staff across the NHS say they are frustrated with what they see as fixable problems and an outdated corporate culture which make their jobs needlessly difficult and demoralising.

Over recent months, I have spoken with dozens of doctors in Scotland, who are in, or have recently finished, their foundation training. After six years of university studies and two years of rotations as ­junior doctors in six different NHS facilities, these doctors are now fully qualified to practice and can apply for specialist training jobs.

Yet very few are ­opting to keep any kind of full-time NHS contract. In the words of one: “Every doctor I know and consider to be smart is leaving.”

Long hours and high stress

“You know you have to work long days sometimes, and weekends,” says Dr Laura Fleming*, who is in her second year of foundation training, “but it’s about getting the time back. That time back is rarely given – you’re just expected to work extra.”

Dr Hollie Cameron*, who has completed ­foundation training but is considering leaving ­medicine ­altogether, describes the psychological toll of working in understaffed and overwhelmed ­hospital departments.

“I think I do get a kick out of [emergency ­medicine], I’m a bit of an adrenaline junky, but there is a bit of a limit when you don’t feel supported … you’re ­expected to see horrific death and immediately go back to work dealing with other patients,” she says.

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For Dr Calum McIntosh*, who has just started working as a doctor in Australia, leaving was bittersweet. While he admires his colleagues in the NHS as “brilliant people working in an incredibly underserviced organisation”, he also describes being spat at, swung at and sworn at during his work in ­Edinburgh.

McIntosh and Cameron felt a total lack of respect in these extremely intense workplaces. “You feel like nobody gives a shit about you. You feel a bit like ­cannon fodder most of the time,” says Cameron.

McIntosh tells me that his move abroad allows him better pay, but far more than that – he works fewer hours, with more time dedicated to training, and more opportunities to specialise. He feels more ­appreciation and less aggression in the workplace, and, crucially, works in a system which is similar to the NHS, but properly funded.

Different conditions, or different expectations?

Anyone who has worked in a medical job will know that this kind of working environment is not new; in fact, working hours have improved for ­junior doctors since the Scottish doctors’ contract was changed in 2002.

So are claims of burnout just the “snowflake ­generation” hitting hospitals and ducking out? Or is it really worse to be a doctor than it was before?

Mark Johnson* previously worked in performance review for the health and social care partnership in Scotland. From his system overview perspective, he agrees that the source of doctors’ dissatisfaction “is often exhaustion and over-work”.

“They feel that the role that they do might be ­valued but they as ­individuals aren’t treated with any form of respect or dignity or empathy, and that comes from a corporate level all the way down.”

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Dr Susan Jones* trained in Edinburgh in the 1980s, but has been working in Auckland for the last 20 years. In this time, she has seen the influx of young doctors from the UK to New Zealand, arriving for a few years of easier rotas and time to be outdoors.

While she says that working hours have undoubtedly improved since she was a junior doctor, she sees little ­overall ­progress: “I don’t think the stress is much less, just different… [before,] ­expectations from the public were ­different – there was less desire to be involved in ­decision-making and more trust in health ­professionals.”

She also wonders whether her ­generation should have done more to demand a change in their working ­conditions. “I now think we only did it because we were too tired to question the system,” she says.

Dr Hugh Pearson, deputy chair of BMA Scotland, argues that the situation has actually deteriorated.

“Doctors have historically just put up with it because it’s always been difficult,” he says. “But it’s definitely worse now… everything is generally worse.”

Working in a struggling system

Johnson and Pearson explain the ­systemic degradation which is leading to staff dissatisfaction across Scotland, which they both trace back to funding cuts in 2008. They describe the ­reduction in NHS budgets, which reduced public health and social care services, as well as non-medical staff such as middle-management and administration staff. In their absence, the roles that these services and staff played have been transferred to the remaining ­services and staff – including doctors.

“Put doctors in the middle of that: – there are no managers so you are ­managing the services, there’s been no ­investment in any infrastructure so you have bad ­equipment … and then you have more complex cases because we haven’t been dealing with their health in the ­community,” says Pearson.

Johnson also explains that some of the work done by support and admin staff, such as system improvement and workforce management, is simply going ­undone.

“The amount of admin support to the NHS and community partners is ­incredibly low, so they don’t have access to things like statistically backed project plans – you can’t look at the data and say are things working in the way we want and if not, why not,” he says.

This has obvious implications for ­service quality but also adds to low staff morale. “In the NHS, the ability to change things is almost nonexistent” says ­Pearson. “And that’s something else that frustrates people.”

Even more frustrating is watching precious funding being wasted and misspent. Johnson describes the money lost on expensive transformation projects which lack the resources to properly assess what has worked and what hasn’t.

Pearson explains that enforcing ­unrealistically low budgets on health boards inevitably leads to crises and the need for emergency funding.

While ­Pearson and Johnson are ­optimistic about the proposed National Care Service, Johnson is concerned by ongoing uncertainty over the policy, and Pearson warns against it becoming like the healthcare restructuring in England which he calls “a massive waste of time and money and a distraction”.

Specific challenges for doctors

Pearson also argues that poor ­workforce management is specifically impacting junior doctors.

Firstly, career progression has become significantly more difficult for junior doctors in Scotland. Pearson explains that this is because of a combination of a failure to increase training positions in response to rising numbers of patients and ­medical students, and because of a ­controversial decision to remove the preference for doctors trained in the UK over internationals in applications for training posts.

While there is a debate to be had about the benefits of an international workforce and the fairness of immigration policies in general, it’s clear to see how this has made specialist training ­positions hugely competitive.

For example, there are now nine ­applicants for every one training place in radiology, five applicants for every one training place in emergency medicine and 34 applicants for every one training place in sexual health.

Cameron expresses her ­unwillingness to progress in medicine in this ­environment: “It takes so much from you … for further applications, you have to spend the time outside work which is so precious and so little, doing audits, research papers, to study for an exam …”

While training posts are ­diminishing, doctors are increasingly concerned about the use of cheaper, ­less-qualified roles to fill gaps in the workforce. ­Particularly ­contested is the role of ­anaesthesia ­associates (AAs) and physician associates (PAs) who, with two years of ­postgraduate study compared to a six-year medical ­degree, are supposed to “support ­doctors in the diagnosis and management of ­patients”.

However, since the death of 30-year-old Emily Chesterton in England due to a PA’s failure to diagnose her condition or check her decision with a ­consultant ­doctor, the need to clarify PAs’ roles and responsibilities across the UK has ­become evident.

There is a feeling among doctors that PAs are being used as cheap ­replacements for junior doctors. And at least in ­England, there has been public confusion surrounding PAs, with a survey finding that 25% of people believe that PAs are the same as doctors. Some respondents even believed that PAs are more qualified than junior doctors (who in fact have four years more training than PAs).

McIntosh also expressed frustration that, while he and his fellow junior ­doctors rarely receive the training they are supposed to in teams which are ­constantly overworked, PAs “have more teaching hours and work fewer hours”.

In December, the chair of the BMA’s Scottish Council expressed the organisation’s concerns that “junior doctors are sometimes being placed behind AAs and PAs in the queue for access to key ­training opportunities”.

He added: “Senior doctors simply do not have the time to effectively train two ­separate ­professions and unfortunately, it is ­often the junior doctors who are being ­impacted by this – which is unacceptable, since it is our younger colleagues who will one day step into our shoes – not PAs or AAs.”

On top of the frustration of working under increasing strain with decreasing resources, with their work being undervalued and their opportunities for ­progression increasingly limited, ­Scottish junior doctors could be forgiven for ­voting to strike in 2023. And while pay restoration – reversing the 28.5% real pay cut junior doctors have experienced since 2008 – was part of the deal negotiated with the Scottish Government to avoid strikes, it is far from the whole story.

What are doctors asking for?

The existing agreement between the Scottish Government and BMA Scotland provides the first steps towards pay ­restoration and preventing future pay erosion. It also promises the ­renegotiation of the doctors’ contract which covers almost every aspect of ­doctors’ working conditions. But the doctors I spoke with were adamant that wider system changes are needed too.

“Pay is important,” says Fleming. “But it’s about much more. It’s about how much money is in the NHS for ­example like facilities and buildings and admin staff.”

“The contract won’t change the ­fundamental problems with our jobs, those are dependent on wider health ­service factors to a large extent.” says Pearson. “You can’t just renegotiate the contract and we’ll say, ‘okay, doctors are now happy … people want to work in something that’s good and functioning, and it’s not good or functioning’.”

But in that case, why go after pay? The Scottish Government is set to invest £61.3 million into the junior doctor pay deal; shouldn’t that money be used for all the support funding doctors are asking for?

Pearson argues that it’s an issue of campaign strategy: “It’s extremely difficult to gather momentum if you’re doing it on working conditions, [which is] a very ­diffuse aim. Pay signifies value in the simplest way.”

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He also argues that industrial ­action, or at least the threat of ­industrial action, was needed to capture the ­attention of a government which doesn’t want to address its looming healthcare crisis.

“This is not political game playing,” he says. “I don’t think [government] understand the scale of the problem, and potentially voters and the public don’t get the scale of the problem either.”

Johnson agrees that there is the need for greater political attention on ­healthcare’s workforce issues: “it’s a very bleak ­picture, and the lack of clear vision on how to tackle it is a problem … the lack of government attention on this building health crisis is concerning a lot of people in the industry.”

Solutions?

While nobody is pretending there is a silver bullet, there are some small changes and investments which could have a high impact on the overall service. One of the most common suggestions is increasing admin and support staff – particularly in monitoring and evaluation roles.

“What you really need is reasonably cheap, knowledgeable admin staff, but with the [moderating and evaluation] expertise to actually tell people what they should be doing,” ­Johnson argues. Even cheaper than that, he and Pearson argue for simple ­consistency in policy and funding, to ­improve the efficiency of NHS spending.

Another simple solution is ­updating ­decision-making processes, which ­Johnson says are still based around quarterly in-person committees; “In an age when we have shareable documents where we can upload and comment on docs, the fact that we still run on a quarterly committee-based decision-making process is … genuinely baffling” he says.

Almost everyone mentioned the need for better technology. Currently held back by out-of-date software and inconsistent systems, our single, combined health service could benefit hugely from even basic information management software.

This leads Pearson to discuss longer-term solutions, which inevitably require increased funding. Pearson suggests that increasing funding for the NHS will ­require a shift in public perception of our healthcare service.

“What the Government needs to do is capture the population’s imagination of what the NHS can be. It is still, in theory, probably one of the better versions of healthcare delivery in the world… it needs to be seen as a source of innovation rather than a drain on resources.”

And in the end, maybe this is all about a perspective shift from decision-makers within and outwith our healthcare system. Johnson summarises the background to the NHS decline: “Management isn’t getting worse. Management has just failed to keep up with the pace of change.”

Plenty has changed since the early days of the NHS. If it has any hopes of retaining its workforce, NHS leadership needs to stop acting as if their staff still live in the honour-culture, stiff-upper-lip, just-get-on-with-it era of Nye Bevan and move their thinking into the 21st century.

*Interviewees’ names have been changed to protect their anonymity