Goodwill is not just a preventive force to stop bad things happening, but a positive experience for patients in their hour of greatest need. By Jessica Arnold

To run a national health service for Great Britain, it costs £115bn a year and the labour of 1.5 million members of staff. Rightly, we concentrate efforts on reducing the wastage and inefficiency within this colossal organisation, to get the most from increasingly stretched taxpayers’ money.

However, we rarely discuss in formal fora the significant amount of value added by the goodwill and “over and above” contributions of our staff.

Goodwill is intangible and cannot be measured with precision, and yet it undoubtedly adds billions more to the size of the NHS economy. We are pretty good at celebrating fantastic staff, but not thinking in a harder edged way about the reliance of the NHS on unpaid extras.

By better understanding the drivers and impact of goodwill, a question is posed about whether goodwill is a dependable as well as admirable outcome of the nature of a national health service, and whether goodwill is hiding under resourcing in many services.

In the context of mounting pressure on healthcare funding and workforce, are we taking goodwill to its limits, and without goodwill, is the NHS sustainable?

‘Running in the Red Zone’

BBC Today recently interviewed Chris Hopson, chief executive of NHS Providers, and Nick Hulme, chief executive of East Suffolk and North Essex Foundation Trust, about the crisis in Britain’s accident and emergency departments. Chris’ analysis that A&Es are “running in the red zone”, partly attributable to 100,000 NHS staff vacancies, leads to a powerful example of goodwill shunting.

Hopson explains how historically, it has been sufficiently rare for an A&E department to be so overwhelmed that staff would stay, unpaid, after the planned end of their shift to get patients seen and clear the “hangover” for the next shift. However, as their goodwill has been called upon by near daily overcapacity, staff are now saying no – we cannot stay yet again; we have to go home; for our own health and sanity, we cannot do this any longer.

“Our staff are just tired”, in summary. The outcome? Longer waiting times, longer waiting lists and regular hospital contract breaches.

Hulme goes on to convey a serious and bleak message: The perfect storm could be brewing if chronically underinvested hospitals and struggling GP practices and social care services meet with a no-deal Brexit, a virulent flu strain, and winter pressures.

Goodwill no longer feels like an added extra but a critical lifeline for the life chances of the NHS.

Understanding drivers and threats to goodwill

By thinking about how the NHS generates goodwill from it’s employees, we can better manage the threats to their value added contributions. Often, a combination of drivers motivate staff to go above and beyond their job descriptions, contracted or rota-ed hours, and pay grades.

Goodwill doesn’t just keep services going; it actively adds to the patient experience

Chris Hopson’s example covers commitment to colleagues. Commitment to patient care and job satisfaction are important – clinicians in particular have strived to study, qualify and work in the healthcare sector by a desire to help others.

With physical and verbal attacks on NHS employees being at an all-time high and linked with chronic understaffing, goodwill is under threat as our clinical staff become victims of abuse and possibly take sick leave themselves. I have spoken with doctors regularly in recent years who are afraid that if the direction of travel of diminishing workforce continues, they cannot deliver the high quality and safe patient care they aspire to.

Segue into another driver of goodwill – the pressure of high stakes and fear of litigation. With NHS clinicians experiencing a growing workload and persistent understaffing, it is not surprising that the cost of medical negligence claims is steadily increasing.

The weight of knowing that a mistake you make may harm a patient or affect professional registration provokes employees to meet the staffing gap with additional unpaid hours, mitigating the risks to patients and their own livelihoods.

Goodwill doesn’t just keep services going; it actively adds to the patient experience. Patients appreciate staff who not only do their jobs well but go beyond the job description to deliver compassionate care.

At the end of his shift, a paramedic on his way home recently called in on my relative, having been the first on the scene at a fatal accident in my relative’s home in Blackpool that morning. Just to check how he was coping and give condolences.

My friend’s midwife came out in the middle of the night to see her through labour having built a relationship with my friend and her family over recent months. Because cover from a colleague would not have felt right to the midwife.

Goodwill is not just a preventive force to stop bad things happening, but a positive experience for patients in their hour of greatest need.

Going locum in Bromley

Chris Hopson, during the same interview, went on to reference the impact of locum GPs replacing retiring GPs in Shrewsbury and Telford, where the more risk averse practises of the former are felt by the hospital to account for a 9 per cent year-on-year surge in A&E attendances.

From our first-hand research in Bromley (Bromley Primary Care Needs Assessment, 2018), we have quantified the decline of salaried and partner GP Whole Time Equivalents in favour of locum work. The young doctors and trainees that we interviewed cited the perceived “slaving away to death” of GP partners, lack of work-life balance and hours of unpaid work vis-a-vis more lucrative sessional work as the main reason for being drawn to locuming.

Feeling pushed too far, we also identified growing numbers of existing GP partners retiring in their 50s or shifting to locum work for the same reasons. Increasingly it seems, the elasticity of goodwill is being tested to the point of fracture as quality of life is threatened.

Invest to save (goodwill)

Britain’s NHS is a unique organisation, the benefits of which, when compared to other healthcare models, we should be, and usually are, very proud of as a nation. The NHS stimulates an abundance of goodwill from its clinicians, managers and support staff, on the front line and behind the scenes.

But we are now at a juncture where we have relied too greatly on unpaid work to swell the NHS economy and mask underinvestment and understaffing, that examples of staff retracting their goodwill are increasingly apparent.

To secure a sustainable NHS, the answer is not to factor out the goodwill so generously offered by our employees, but to match adequate funding and resources with our patients’ growing needs.

Under the threat of “breaking the back” of goodwill, we need to strike a balance that safeguards the joy of working for the NHS and commitment to our patients and colleagues with an organisation in equilibrium that can remain true to its founding principles for another 70 years.