Dame Carol Black on clinical responsibility

These changes are shaped by the attitudes and behaviours of society and of health professionals, particularly doctors, and the evolving relationships between doctors and their colleagues in the multidisciplinary environment of healthcare today.

One of the most significant changes lies in new concepts of medical professionalism and the ways doctors and society understand the nature of the profession.

Among the factors at play are questions about the nature and boundaries of responsibility of different members of clinical teams, not only within multidisciplinary teams but also within the extended NHS organisations of which the clinical team is the most local frontline element. All these matters are the subjects of lively, candid and constructive debate.

Doctors as managers

It is now accepted that there is a pressing need to support closer participation of doctors in management, with strengthened leadership at every organisational level.

The NHS workforce is not an entity apart, separate from a controlling hierarchy, though much comment might convey an impression that it is. The nature of clinical responsibility in our society, the resource implications of clinical actions and the demand for continuing improvement in all its facets demand the closer integration that Roy Griffiths thought necessary 25 years ago.

Without this unity, effective service transformation and improvement will be halting. Such change has obvious and pressing implications for the culture of the NHS and the education and training needs of its entire workforce.

Comprehensive, secure training is absolutely key to achieving the workforce integrity and motivation necessary for continuing quality improvement and more efficient service delivery.

Changing demands

Another major factor is that clinical staff are now predominantly female. Nursing staff always have been, but now women make up 61 per cent of entrants to medicine.

Contemporary attitudes to work-life balance, the changing gender distribution of the medical workforce, the career preferences of men and women and the relative appeal of acute service specialties will all require imaginative approaches to training, workforce planning and management.

Added to these is a shift in the culture of public service that has seen the adoption of business values with a growing emphasis on productivity and efficiency, as well as an unquestioned patient centredness.

Overarching these developments is a general consideration. It has to do with the health and well-being of the workforce. NHS employees take an average of 12 days off sick a year, twice that reported in the private sector.

High-pressure environment

There are other workforce issues that must also be addressed to better effect. In a recent Healthcare Commission survey, one in four NHS staff reported experiencing bullying and harassment by patients or their relatives in the previous year; 15 per cent reported being bullied by other staff.

No less disturbing, clinical staff in the NHS experience aggression and violence to a degree exceeded only in the security business. There is little doubt such events have a direct impact on health and well-being, performance, sickness absence and retention.

The NHS, like any other employer, has corporate responsibility for the health and safety of its employees. And the performance of the NHS, like any other enterprise, depends on the health and well-being of the workforce, their motivation and their morale. It is scarcely necessary to say that we look to the NHS to be an exemplar in its human resources function and in occupational health provision. This means safeguarding health, promoting good health and ensuring that staff are treated as we are expected to treat patients - with dignity and respect.

The competitive attractiveness of the NHS and of the trusts that comprise it will increasingly be determined by the care shown to staff. To compete for the best staff, the NHS and its trusts will find it increasingly necessary to nurture and support workers in all matters that affect their health and well-being and to demonstrate that they are doing so.