Ambitious promises to the NHS workforce have been enshrined in the NHS constitution. Will weasel words help employers dodge the commitments or can bargaining and hard work make them stick?

The British don't do enthusiasm. We do scepticism - believing promises only when we see them and then rather grudgingly. There have been so many false dawns, broken promises and occasional cock-ups in the way the NHS has been run that its million-plus staff can be forgiven for being more than a little worldly when another prophet arrives full of more promises and pledges.

But the next stage review of the NHS, which coincided with the publication of a draft NHS constitution, could be different. For the first time there is an explicit link between the NHS's constitutional obligation to deliver high-quality patient care with the evident truth that it cannot happen unless staff are committed, trained and honoured. The constitution only makes sense if patient care is at its centre. But that can only work with real commitments to the staff.

Ambitious plans

The ambition for the workforce in the various constitutional and Darzi documents can hardly be faulted. The NHS will strive to provide all staff with well-designed and rewarding jobs that make a difference. It will provide all staff with personal development, appropriate training and management support to enable them to succeed. It will strive to ensure staff are healthy and safe. And it will try to engage staff in decisions that affect them, both individually and through their representatives. Moreover, staff will be empowered to suggest ways to deliver better and safer services for patients and their families.

These pledges are more than just aspirational hot air: they are extracted from the staff guide to the proposed NHS constitution. As they stand they are already at the upper limits of what is considered best practice.

Most employers would be leery about commitments to provide every member of staff with well designed and rewarding jobs that make a difference and providing all staff with personal development, training and support to succeed. There are usually get-out clauses; weasel words about "affordability", "best efforts", "as many staff as possible". The only weasel word in these pledges is "strive", but even that is less weasely than most. It implies having a continued and ongoing commitment to delivering the pledged outcome even if the NHS does not always succeed.

On equal terms

There are three reasons for giving the NHS the benefit of the doubt. The first is that the staff pledges are seen as ranking equally in constitutional terms with pledges to patients. This enshrinement of staff rights is going to matter. The second is that a patient's right to, say, be treated with professional standards of care presumes that those doing the caring are doing the right jobs, which they are committed to and trained for. Staff are central to delivering the constitutional commitment.

And lastly in the accompanying documents - notably A High Quality Workforce - the Department of Health commits itself to a range of new interventions that back up its declared intent.

For example, it has agreed with the regulator the Healthcare Commission that annual staff surveys will be included in its evaluation of trusts and foundation trusts. An organisation that consistently gets poor results from its staff surveys would be under pressure to explain why and come up with planned changes.

As far as the Work Foundation can tell, no other British organisation analogous to the NHS has gone this far. Very few quoted companies publish their staff surveys, and only parts of the public sector both publish them and use them as a management and regulatory tool. It will become a major means of holding management to account for meeting their side of the bargain.

Benchmarks for staff

The "Mystaffspace" web portal will offer easily understandable information on benchmarks for staff and clinical and organisational leaders. A board member at every trust is to be charged with ensuring staff know about government funding for training and what might be available for them. There will be intense effort to develop career pathways and provide the training to pursue them. A modular system of winning credits to allow staff to build individualised careers and training funds that follow the individual will be developed.

Investment in apprentices is to double. Nurses are to be given access to more experience earlier in their career to help them become more expert faster. A clinical management for quality programme is to be launched. There is a renewed commitment to continuous professional development. An NHS leadership council is to be created, focused on developing the leadership capacity of the top 250 managers in the service.

To avoid the crisis of March 2007, when thousands of junior doctors demonstrated in London, the DH proposes two new institutions.

The first is Medical Education England, whose job will be to work with the professions, deaneries and strategic health authorities to assess whether the quantity and quality of staff being supplied in any one year is likely to correspond to the demand. It will be supported by a new Centre of Excellence, whose job it will be to try and anticipate deep-seated, long-term trends and adjust long-term recruitment and training accordingly. Sir John Tooke, who led the inquiry into the Modernising Medical Careers debacle, was sufficiently impressed to pen a foreword to the document.

Will it all work? There is a notable absence of any attempt to price what all this will cost. If that work has been done, the results have not been disclosed. Moreover workforce planning and development is a discipline that has been allowed to ossify in Britain. There is inevitably a bias towards supply and forecasts are only as good as the data put in.


A lot will depend on the Centre of Excellence being able to develop quickly methodologies that capture the likely pattern of demand. But then somebody somewhere in the system will have to contract or close down a particular medical school or training capability in order to expand another. Losers shout louder than winners and the professional bodies that will see their membership reduce or stagnate as a result will lobby madly for the decision not to go ahead.

This requires a degree of realpolitik, hard bargaining and willingness to take on the interest groups that the language of the constitution and its pledges eschew. Its tone is much more about getting the purpose and values right; that men and women of goodwill allow reason and common purpose to arrive at the right outcome.

But occasionally there is more than a hint of cold steel. Senior managers who fail let their organisations, staff and patients down, the report opines. A system of tougher regulation was contemplated and evidently rejected. But the current system in which managers can move on with few questions asked about their performance in their former role - or in which it is very difficult to move them on at all - is not satisfactory. Recruitment, selection and a more formal system for assessing whether someone is suitable for future employment given their current performance are all under consideration.

When it comes to what is expected of staff much is unexceptional if important - striving to provide high standards of care, taking up training and development opportunities and the like - plus accepting a duty not to discriminate, to be honest and accept professional accountability. But striving "to contribute to a climate where the truth can be heard and the reporting of and learning from errors is encouraged" will be counter-cultural for many.

Clinical paradoxes

The evidence in the US is that clinical units that report more errors and near misses paradoxically have better clinical outcomes than those that do not. What sits behind such systematic reporting is a whole team holding itself accountable for mistakes and learning from them.

In the frequently hierarchical NHS the notion that junior staff are willing to report errors, or senior staff willing to discuss them, will be challenging to prevailing norms.

Equally, while the commitment to patient care and experience may have brought a parallel commitment to investment in staff, it also means patient choice is going to be constitutionally enshrined. Health workers will have to accept that league tables are here to stay and likely to become more detailed. Competition is also here to stay as one of the by-products of the commitment to choice.

But those who manage the health service have committed themselves both to a bargain and to a journey. They have set out the values, rights and responsibilities of every member of Britain's NHS - whether contractor, worker, manager or clinician. The bargain is that they acknowledge the crucial role of a committed, engaged, trained and loyal workforce - and are putting in place mechanisms to deliver.

The journey will not be easy. But the commitment has been made. It will not be easy for any government of any political hue to undo.