New NHS People Plan: The hunger for change must be matched by the appetite for risk

I feel privileged to hold a number of varied health and care positions so read the newly published People Plan with cautious optimism. Whilst undoubtedly a big ask and task to deliver, the People Plan is clearly a positive call to arms.

As Joint Director of Clinical Strategy at King’s Health Partners (KHP) and co-lead of the Implementation and Engagement theme of the Applied Research Collaboration (ARC) South London, I was heartened by how much the Plan has taken account of the system-wide learnings of Covid-19, despite us still being in the throes of the pandemic. As a clinical leader, the call for a greater emphasis on clinical leadership, which during the first wave allowed local self-governing clinical teams to do what was needed, is particularly welcome.

I felt uplifted by the promise of flexibility by default for all clinical and non-clinical posts advertised from January 2021. Having seen over the years how many brilliant colleagues have struggled to balance parenthood, caring responsibilities or simply the emotional workload of full-time hours, when an offer of more flexibility would have supported them to keep going, this feels like a gamechanger. Especially for junior doctor (and other professional) training schemes and primary care. The challenge of course is in making these deliver operationally in the short term.

As an NHS ‘lifer’, I’ve long awaited an NHS plan that gives as strong a focus on health and wellbeing of staff and promises career-long investment, not least because as well as looking after staff, it also translates into better patient care. We know that 50 per cent more staff in the NHS suffer from debilitating levels of work stress compared with the general working population as a whole. Every year in the NHS staff survey, 38 to 40 per cent of staff report being unwell as a result of work stress in the previous year. Research indicating that organisations who prioritise staff wellbeing and leadership provide higher quality patient care see higher levels of patient satisfaction, and are better able to retain the workforce they need, is not new. However, this is the first NHS plan I have read that seems to take it seriously enough to make it integral to how we work.

At the HIN, working in the business of spread and adoption, my main question remains how are we going to make it a reality?

Local innovation versus national control?

My biggest concern is that the onus on large scale organisational or systems change needed to deliver this rests with the same organisations who have said they need help. This, plus the lack of risk appetite centrally to genuinely allow local systems to be very innovative. It’s great that answers such as innovative roles, support to care homes, volunteering and the role of research are mentioned (p10), but what central levers are really in place to connect health and social care, for example? Or to ensure that NIHR (National Institute of Health Research) funding is linked to on the ground need and evaluation of rapid care system change? Or for professional bodies to rapidly collaborate and/or change how they regulate new roles?

That local plans are expected is appropriate, as this will allow systems to think collaboratively. But how much freedom and headspace will they have to create this? For example, would an Integrated Care System (ICS) be supported nationally to test some bold plans, without reams of dragging governance? Would they also ensure evaluations of workforce pilots to include return on investment in longer than two year funding cycles? There are some good early signs with small grant funding from Health Education England (HEE) but these need to be over a longer period and clearly linked to on overall policy.

Bold ideas are not useful unless there is the power, permission and possibility for the inevitable risk that comes with trying something completely new. Will the NHS prove that it actually is committed to learning by giving systems air cover to do interesting things, and with its partners in social care in our ICSs? So that providers can complete properly evaluated pilots of, for example, new roles rather than not even starting because potentially they are considered illegal and/or uninsured? Redeployment was enabled rapidly during Covid-19, especially for intensive care units (p32). Will this scale of reshuffling be so readily facilitated in a more planned way, across all specialities and sector boundaries, and for the longer term? In my own specialty of anaesthesia, which has had a workforce gap for years, I have seen the struggle to embrace new roles, such as physician assistants. Professional bodies such as the General Medical Council and Royal Colleges should, and always will be concerned with standards, but we should also be alert to professional protectionism. If we look back to the difficult detail of the never-final version of HEE’s 2017 draft workforce strategy, we can see that that a truly wicked problem exists. And has been pushed forward to this People Plan.

Whilst rapid workforce innovation might lead to some individual harm, the greater harm is likely to already be happening at a population level, as a result of not swiftly adapting. The pandemic, for all its hardship and heartbreak has forced action that would have otherwise taken years – perhaps decades – to get through bureaucracy and process. What worked was being explicit about the unknown and trusting and allowing the public to judge us. Will we approach this People Plan with the same gusto for actionable change that Covid-19 forced us into?

Hordes of new workers?

The Plan gives so many positive suggestions, such as the mention of peer-support (p41) – in my view the nation’s greatest untapped resource, alongside unpaid carers – and a call to invest in for example child and adolescent psychotherapy training schemes. But the latter provide expensive services that have been cut by commissioners, as return on investment is often realised way in the future, and/or is counterfactual, and in different parts of the economy such as the criminal justice system. Will commissioners be supported to make potential losses on such services?

There are barriers beyond money too. Data sharing, for example. If staff need to operate across boundaries, then we need to see workforce data (as well as clinical information) in others’ organisations. More significantly, perhaps, are the continued vacancy levels. A focus on people requires people to deliver it. With over 100,000 vacant roles currently in the NHS, who are we expecting to come forward? We are still to see the full effect of Brexit on staffing. We are moving towards this winter with a massive burden of longer wait lists, a huge flu vaccination programme, a potential second Covid-19 wave, plus the hope that we will be delivering a Covid-19 vaccination programme at some point.

The Plan suggests that the positive zeitgeist towards the NHS, which increased during the first wave of the pandemic (perhaps coupled with new unemployment in other areas), will translate into hordes of new workers. Will it be done in time to allow those who have worked during the pandemic to recover? And will the Government make the financial commitment required to back up the Plan’s promise of training and education for a whole career path, not to mention the better pay and conditions that will ultimately also attract and retain staff? The case that we would have been better off investing more before Covid-19 hit, has already been highlighted.

An evidence-based approach to evaluation and spread?

Perhaps the most poignant question of all – if something is a success, how will we know and how will it spread?

While heavy on positive potential, the plan is light on meaningful metrics (promised next month). The Plan cannot be appraised without them. An evidence-based approach must apply to staff wellbeing and retention, healthcare policy and delivery, as well as to clinical care, because as discussed above, these factors unquestionably affect patient outcomes. The pledge that the annual NHS survey will be linked to the NHS People Promise (which has been developed by staff) is a good start. But it would be more effective and efficient to promote successfully proven elements or practices from the People Plan.

This is where us Academic Health Science Networks (AHSNS) could come in, to support the scale and spread of models which work. The Plan doesn’t mention any partnership with, or investment from industry/charity/other sectors, which AHSNs are well-versed in facilitating. Although, hearteningly, I see early signs that others are also thinking this way.

I was interviewed last year about local workforce innovation, and said the following:

“I see an opportunity for the KCL civic university to create an exciting health and care careers offer which goes beyond the Topol review and NHS people plan to attract and retain our greatest talent. I’m interested in working with the KHP partners, Royal Colleges, Health Education England and others to enable KHP to become a world leader in true inter-disciplinary whole career journeys, integrating ‘in time’ learning and structurally enabling individuals to change fields whilst maintaining creditability, and crucially, pay. Examples could include data science, digital, engineering, psychological, and business skills.”

Whilst it seems the sentiment has been mirrored in the new People Plan, the permission to take changes forward will always come with some risk. Will we be allowed to take the chances, forge the partnerships and take the short-term financial hits to really deliver?