The influence of non-clinical staff on transforming the NHS will be critical but they are stifled by factors ranging from ‘a political culture of bureaucrat bashing’ to a lack of training. Andy Cowper summarises the obstacles and solutions voiced by contributors to HSJ’s inquiry on maximising the contribution of these people

Why an Inquiry into NHS non-clinical staff?

Over recent years, a remarkable consensus has formed in NHS policy that the service’s future must be one of planning and providing person-centred care services on a health and care economy-wide basis, delivered by clinically led multidisciplinary teams working together with patients beyond the traditional organisational silos.

It sounds attractive. Yet although this developed alongside an aspiration to get clinicians involved in changing care planning and provision, it has tended to include very little or nothing about the contribution and value of the 583,837 non-clinical members of the NHS’s 1,229,371 staff.

The term ‘non-clinical’ may be part of the problem. Defining any group negatively (as what it is not) is scarcely the best way to think about that group. It suggests that for all the rhetoric about teamworking, the gap and hierearchy between clinical and non-clinical staff remains every bit as polarising and unhelpful as those between and within the clinical and medical professions.

One positive outcome of this Inquiry would be to find a better descriptive term for these staff than “non-clinical”.

How HSJ readers can help

We want your case studies of good practice. We also welcome your feedback and challenges on our interim thoughts and suggestions. Your responses will help shape the remainder of our work and the final report, to be published at the HSJ Summit in November 2016. Please email us at hsjinquiry@emap.com

The invisible half of the NHS workforce

The value of clinical staff scarcely needs stating (although junior doctors might currently disagree). Contrastingly, non-clinical staff can seem and definitely feel rather invisible in discussions about workforce, training and policy.

As the NHS plans radical changes in provision with the Carter efficiency review, the 44 sustainability and transformation plans and footprints, success regimes, devolution in Manchester and new care models, its chances of success will need considered, consistent, credible and sincere engagement with all its staff groups.

If we are to see real change in the NHS, it will mean real change in how all the health and care team – clinicians, medics and non-clinical colleagues – work. It will also mean investing in training and change management capacity, particularly (though not exclusively) among non-clinical staff.

Forward-thinking clinicians have long valued all members of the health and care team, including non-clinical colleagues: it’s time everyone else did.

Patient experience

Many aspects of patients’ experience of care which they can understand and relate to their experiences of other organisations are what the non-clinical workforce does, as Paul Myatt, workforce policy lead for NHS Providers outlines.

“In terms of ‘happy’ patient experiences of receiving care, much of this is influenced by the person on reception, whether systems work properly, whether clinical staff have the right information, is the environment clean? (And of course, car parking!)

“Patient experience, as opposed to more narrow clinical outcomes, is a big contributing factor to how people think of their experience of care.”

Getting these service-type aspects consistently right contributes not only to patient-centred care, but also to making the working environment more agreeable for staff. A clean, well-maintained and calmly run atmosphere and environment will be more likely to achieve the win-win of inspiring confidence in patients and having a positive effect on staff morale.

Why non-clinical staff are undervalued

Mr Myatt points out that in the wake of the Francis Inquiries into Mid-Staffs, the regulatory and political emphasis on safe levels of clinical staffing has taken workforce directors’ attention.

“Clinical staff numbers are what regulators come and count. So in the main, HR directors’ attention is paid to clinical staff: if their organisation lacks enough of them, there are impacts immediately for quality, regulation, media attention – and of course, poorer outcomes.”

Participants in our main workshop suggest that another big factor is reluctance to highlight the value of ‘backroom’ non-clinical staff, informed by political/media hostility towards NHS bureaucracy.

Unison’s deputy head of health Sara Gorton suggests: “We’ve become reticent to talk about spend on non-direct patient care. We’ve collectively failed to make the case for the value of this work and workforce, when actually it’s the way we can help improve productivity.”

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For Skills For Health head of research and evaluation Ian Wheeler, under-valuing non-clinical staff “is part of the whole discourse of the Andrew Lansley agenda of the last six years, about getting rid of backroom staff, who have been framed and perceived as waste. That’s ludicrous: without good non-clinical colleagues and their systems, clinicians won’t know who they’re supposed to be treating for what and when”.

Director of workforce for University College London Hospitals Foundation Trust Ben Morrin notes it can be attractive to focus on brands which are easier for the public to connect with, such as doctors and nurses.

Discussing the value

Dean Royles, director of human resources and organisational development of Sheffield Teaching Hospitals Foundation Trust (and former chief executive of NHS Employers) adds “to get the best out of this part of our workforce, we need to present this as an area in which people would want to work.

“We have to get the national PR right about these jobs, and that ranges from thinking fully about talent management and job desirability down to things as basic as having the right job descriptions.

“Many of us know that in the NHS, we have great access to training and development opportunities, but you wouldn’t know this from outside”.

Andrew Prince, development director of the Serco Global Healthcare Centre of Excellence and a non-executive director of Frimley Park Hospitals Foundation Trust, observes that “metrics still tend to be about cost rather than value: the Carter efficiency review data on the cost of a meal per head, rather than the value to a patient’s wellbeing and recovery of a good quality meal and its contribution to a swifter ability to leave hospital.

“Likewise, we tend not to get data on the relationship between cleanliness of acute settings and prevented infections.

“We’re yet to connect the value of some of these non-clinical roles with clinical value. Until we can make those connections, decisions will be all about cost, and not about how to use the valuable resource of these staff”.

MIP’s Jon Restell reflects that those doing workforce planning need better appreciation of these staff: “Intermittently, we discuss with Health Education England the 0.01 per cent non-clinical staff NHS training budget. Depressingly, nothing changes.

“The vanguards’ work and Carter efficiency review: all riddled with requirement for skilled non-clinical staff in procurement and integration. Where’s the supportive plan for developing and retraining these staff, as you’d do for clinical staff if you’re redesigning cancer services? One vanguard staff pledge was that we will engage clinicians. Until that changes, we’ll make little headway with politicians or others.”

HFMA chief executive Paul Briddock agreed that “much of what’s needed to achieve the Carter efficiencies is highly skilled work. If we want to ‘Get Carter’, we need to get the value of support and non-clinical staff”.

Raising visibility and integrating teams

Ben Morrin highlights UCLH’s efforts to get an integrated ethos among staff from arrival: “Two thousand staff join us each year: in their first week, all the different groups come in together, and sit together at lunch and dinner, and talk together. That helps a lot, but is only the start.”

Serco’s Andrew Prince suggested that part of solving the value and visibility issue might be to get patients to help us explain this group’s importance.

“Quite a lot of these staff have expensive contact with patients – cleaners and caterers are always around, and can and do give exceptional service. Patients write in sometimes, and say: ‘That porter was really caring, and went above and beyond the call of duty’, and maybe we need to lift that feedback into more public use.’”

Feeling valued

Paul Briddock presented startling data from their recent finance staff census and members’ survey.

While 89 per cent of respondents felt they did a valuable job for their organisation, answers on how they felt valued were stark. Seventy-eight per cent felt valued by their line managers; 48 per cent by the board and 46 per cent by clinicians. When responses moved to what government, the public and patients think, 10 per cent felt valued by government and 5 per cent by patients.

Finance staff reported high levels of motivation: 71 per cent saying that they really value working in NHS and public sector ethos and 60 per cent saying that they see their primary role as trying to improve patient care.

Yet while 64 per cent say they would like to spend the rest of their career in the service (despite mounting pressure on their teams and the most challenging financial operating environment to date), many fear that the constant change and reforms mean they won’t be able to fulfil these ambitions, with only 47 per cent expecting they will continue to be employed by the NHS until they retire.

 

Questions for organisations

How valued do our support/non-clinical staff feel? How do we know this; who feels most valued and who least; and what do we do about this?

Do we understand the value these staff provide, and not just the overhead cost they represent? How do we measure it?

Do we help these staff understand how they contribute to patients’ experience, outcomes and good use of resources? How can we be sure?

How do we provide career development opportunities and skills aligned to future needs of the organisation/system? How are career development plans organised to ensure we get the staff we need at the right time?

What are our measures of job satisfaction and staff engagement, and how do we plan to enhance attention of HSJ readers on their value, at a time of economic stress getting even more intense?

How are we actively challenging upwards to system leaders around the strategic vision for this part of the workforce?

How does our board present its views on the value of these staff internally and to the wider world, articulating and celebrating contribution of this group? If the answer is by awards, what is the ratio of celebration of clinical/medical staff to non-clinical staff?

How will we evaluate emerging new support roles?

Carter and procurement – fantastic, but where is national procurement expertise and leadership and change in behaviour, and procurement development plans locally?

How have we engaged the non-clinical workforce that supports clinical workforce effectively and efficiently?

Given tight finances, is our use of non-clinical staff as efficient as it can be, within the constraints?

What are the implications of choices based on lowest cost in staff engagement and quality?

 

Questions for system leaders

Do our narratives about change highlight the importance of all parts of the NHS workforce, including those who support and enable the work of clinicians?

How are we ensuring providers and commissioners are collaborating to develop this part of the workforce in tandem with reform plans?

 

Questions for everyone

Can anyone think of a better term than “non-clinical staff”?

Workforce planning

The NHS consistently has what we might politely term ‘issues’ with clinical workforce planning: much the same is true of the non-clinical workforce. Dean Royles says there is “no strategic oversight of the non-clinical workforce” (which goes well beyond support roles, if we think about engineering and IT).

Unison’s Sara Gorton reflects that “rather than celebrate jobs and roles, perhaps we should celebrate skills. It’s interesting that in the Nursing & Midwifery Council vanguard work, what’s at the forefront is moving away from traditional specialist roles: not from specialist to generalist, but expecting multi-specialisms. The parallel ability for non-clinical colleagues to analyse, change and influence, whether in rostering, setting up payroll, changes in OD: these are all skills we can describe. Maybe that’s an important labelling job”.

Scarcity and career desirability

Informed by his time running NHS Employers, Dean Royles suggests that policy makers tend to have “a very London-and-South-East-centric belief that non-clinical or support staff are hard to come by: a parochial view of the labour market world. So any policies tend to be about how to deal with recruiting people with, say, long-term conditions or criminal records, or the long-term unemployed and those not in education, employment or training.

“These are very evident in South East England’s workforce planning, which is quite reliant on a wider EU/ international workforce.

“By contrast, where I work in Sheffield, non-clinical jobs in the NHS are seen as good, desirable and stable jobs, so the NHS has a good choice of staff”.

Mr Royles concludes that “the national policy focus tends to be assuming it’s hard to attract and recruit non-clinical staff, and there’s been very little attention to training and development and career prospects. There’s the occasional bit on apprenticeships.

“The policy landscape is always London-centric, where it is hard to recruit, so we’ve seen very little on encouraging non-clinical staff to move on in their careers with training and development opportunities. It shouldn’t be hard to support. Those in bands one to four end up doing 70 per cent of hands-on care”.

Skills For Health’s Ian Wheeler adds: “The workforce planning cycle often doesn’t take account of clinical support workers, who tend not to receive the training and development they should. Our paper looking at the healthcare support workforce (bit.ly/1V5JLPM) used the labour force survey data to split clinical and non-clinical workforce, and we found some suggestion investment in admin skills in the NHS is less than in the private sector.

This report found that “only a quarter of admin and secretarial workers received training and development in the past 13 weeks, compared with almost half of the workforce overall, and  a significantly lower proportion of administrative and secretarial occupations are qualified at NQF level 4 and above”.

The NHS is mostly, Mr Wheeler suggests, “not creating high-quality intermediate jobs – where people could be working at a very high-quality level. Healthcare is becoming increasingly data-driven.

“Who can get hold of, manage and maximise patient data? The processing and flows of this data, going forward, will be increasingly important”.

Ian Wheeler adds “without great administration, though it may not stir the passions, most aspects of healthcare are more difficult. So many NHS complaints are customer service-type complaints”.

Working differently

UCLH’s Ben Morrin says that the impact of the Carter efficiency review’s proposed administration spending cap of 7 per cent by 2018 and 6 per cent by 2020 implies an urgent need to review how organisations collaborate and work together.

“Can London’s NHS justify having 80 to 90 HR departments? Probably not. There are likely to be fewer and bigger shared functions, which can mean a better service for patients. STP footprints also imply potential reconfiguration”.

Unison’s Sara Gorton thinks “widening the NHS employment footprint could work on many fronts. Some specialist functions like IT may benefit from going to scale. Carter recommendations need skills to drive technological innovation, like e-rostering and proper booking systems.

“Those kind of functions don’t need to be small or England-wide: we’ll need a balance. That begs the question how we get buy-in to participate over wider footprints, and give staff security. Many of our members talk about their fears of instability, cuts, services contracted and moved, and that funding streams might just dry up.

“The ability to move some money around in new STP footprints may allow bolder decisions. Maybe new conversations with staff, where employers say ‘we can’t say where you work in five years time, but we know we’ll need your skills, so we will guarantee you work if you’ll commit to stay with us’?”

Ben Morrin suggests “if we map these staff’s contributions, we could show positive changes to care pathways and outcomes. UCLH is a clustered organisation: run by clinicians, led by four medical directors, and it’s the most empowering place to work – a big part of which is the quality of respect and commitment to roles that we’re discussing here.

“This is about trust, which depends on the quality of personal relationships, line management support, and being there when team members have tricky moments.

“However provision is organised in future, if we’re asking staff to give up their own, known team to run services differently and at greater scale for a population, that comes down to one point: trust – in line management, individual managers and ultimately in the chief executive. Without that trust, plans for change will be deeply flawed”.

Lack of clarity

Skills For Health’s Ian Wheeler adds that other obstacles to progress are the quality of appraisals; a dearth of information about NHS productivity; and the consequent failure to link the contribution of good processes, system analyst skills and operation skills.

Serco’s Andrew Prince reflects that we lack clarity about the required skills. Skills for traditional and notionally competing healthcare FT-type organisations are more decentralised ones. Skills needed to redesign provision across the 44 STP footprints are more integration-transformation skills – yet Carter envisages centralising, efficiency-driving skills.

Sara Gorton speculates this may mean equipping clinical staff with some process and change management skills traditionally seen as those of support/admin staff.

“Timing, and depth of staff engagement, are crucial. All the current big changes, even Vanguard innovations, feel as if they’re been foisted on the system from above.

“Some of these transformational skills, like the ability to lead change without disrupting clinical influence, and be integrators and facilitators of systems – risk being bolted on mid-way.

“There are many good examples of clumsy behaviour of both HR and local trades unions to poorly thought-through proposals, which could have been thought through and problems anticipated if staff were involved early. It’ll be interesting to see if NMCs Vanguards really engage staff about system design”.

HFMA’s Paul Briddock reflects that as clinical behaviour and choices drive spending in the vast majority of budgets in the NHS, to change these decisions, “we need intelligence, and with good-quality information, so we can challenge inappropriate clinical decisions. Non-clinical support staff are the ones with benchmarks, metrics and ability.

“They’re vital to give us a solid foundation on which we can challenge clinical performance, outcomes, and also examine patient satisfaction in different ways. Are we providing good value? We need non-clinical staff to be able to answer that question”.

Culture club

All participants agree over-directive, target-driven NHS approaches forge a negative working culture, driven by fear and blame.

Serco’s Douglas Ritchie suggests changing systems “will fail unless we can change behaviour. You can’t enforce change from policy, you must get commitment to new organisational ways of working and flexibility”.

MIP’s Jon Restell agrees: “Maybe this Inquiry should be not just be ‘the nuts and bolts of non-clinical workforce planning’, but also describe a new, more positive working culture that we want to see”.

Sara Gorton adds that changing culture and working patterns is also a system issue: “By its very nature, commissioning and contract functions are usually in an individual organisation’s best interest to draw close and keep their own identity and competitive edge. Now, we need to share culture across organisational footprints and get people to work in roles with wider utility.

“We need well-designed jobs, and opportunities for skills and development. We need to look at the people who’ll be potentially running the system in twenty years’ time, and say ‘here are some of the skills you’ll need; here’s where you can find training and help; and we’ll move you around the system in your career to benefit you with the right experience’.”

UCLH’s Ben Morrin suggests “the basis of culture is in consistently clarifying and communicating what organisations value and reward. Staff need to be open when they see bad practice and do something about it without fear.

“When that’s in place, that’ll be a sign of a good culture: when someone’s done something wrong, staff won’t just throw their hands up and walk away. In my part of this workforce, we regard supporting and promoting those who confront bad practice as just decent line management, which we think is as important as patient experience”.

Serco’s Andrew Prince concludes that “we need to focus on continuity: the 44 STP footprints are a real opportunity to create new locus of planning and funding transformation to redesign care pathways.

“How will we reconcile individual financial reporting by organisations with redesigning care pathways across STP footprints?”

UCLH’s Ben Morrin agrees that reconciling these financial and redesign requirements “presents system leaders with a national unlocking opportunity”.

 

Acknowledgements

Paul Briddock, chief executive, Healthcare Financial Managers’ Association

Sara Gorton, deputy head of health, Unison

Dame Julie Moore, University Hospitals of Birmingham FT

Ben Morrin, director of workforce, UCLH Foundation Trust

Paul Myatt, workforce policy lead, NHS Providers

Andrew Prince, development director, Serco Global Healthcare Centre of Excellence

Jon Restell, chief executive, Managers In Partnership

Douglas Ritchie, business development director, Serco Health

Dean Royles, director of HR and OD of Sheffield Teaching Hospitals Foundation Trust, and former chief executive of NHS Employers

Ian Wheeler, head of research and evaluation, Skills For Health

This report was compiled, organised and written by Andy Cowper, comment editor of HSJ, with sincere thanks to all contributors. Any errors or misinterpretations are his.