Wellbeing of NHS staff a concern for the foreseeable future (and a warning on the use of composite measures of well-being)

Written by Professor Jeremy Dawson, Professor of Health Management, Institute of Work Psychology, Sheffield University Management School

From the “clap for carers” initiative in the first lockdown, through to a strong media backlash about the fact that nurses would only receive a 1% pay rise next year (barely covering inflation), the public mood showing strong support for NHS workers has recognised the extra pressure under which they've been working.

The pandemic has exacerbated what was an already dire situation, with nearly 90,000 vacancies across England at the last count, and many more NHS staff missing through illness or isolation due to COVID-19. A current Health & Social Care Select Committee inquiry has focussed on burnout amongst NHS staff, and has identified many problematic areas.

So, when the results of the annual NHS staff survey were published in March 2021, it may have come as a surprise to many that many areas of the survey seemed not only to show things not getting worse, but even improvements in some areas of staff experience. In particular, scores on two key indicators of staff well-being – the “Engagement” theme and the “Health and well-being” theme – increased, suggesting that staff well-being was perhaps even improving. Does this suggest that the narrative around NHS workers’ burnout is being exaggerated?

Not at all. In fact, what these findings show is the folly of relying on such composite “theme” indicator scores to explain what is happening. To fully understand the picture, it is important to look at the underlying scores, which can sometimes move in opposite directions.

For example, the “Engagement” theme includes three separate scores – measuring motivation (equivalent to the psychological concept of work engagement), involvement/proactivity in decision-making, and advocacy (being prepared to speak up for your employer as a place to work or receive treatment).

They are often very highly correlated, but while both the motivation and involvement dimensions worsened between 2019 and 2020, the advocacy dimension increased substantially, leading to an overall improvement in this measurement of engagement. This improvement in advocacy almost certainly reflects the increased pride in working for the NHS over the last year despite the very trying circumstances.

Likewise, on the theme of “Health and well-being”, there have been significant improvements in the offering of flexible working for many staff, attention given by employers towards health and well-being, and most notably of all, far fewer staff turning up for work when they are sick themselves. This has obscured significant rises in the numbers of staff suffering musculoskeletal injuries, and work-related stress.

The stress finding is particularly worrying. Over the past five years, the proportion of NHS staff reporting feeling unwell from work-related stress has risen from an already high 37% in 2015 to an astonishing 44% in 2020. This has been a steady rise, accelerating in the past year, and is clearly unsustainable. 

High stress levels are likely to lead to more turnover, and further vacancies, creating a vicious circle that will persist until substantial action is taken to address the high vacancy rate. Patient experience is strongly associated with staff work pressure, meaning that patient experience is likely to suffer even further – and while there has been a superhuman effort by NHS staff to get through COVID so far, this cannot be kept up indefinitely.

So, two key messages arise from this. The first is that the NHS has performed wonders in the last 12 months, but is in real danger in the medium-term future as backlogs in many non-COVID areas begin to be addressed. The pressure on employees will not ease, and it would not be a surprise to see staff turnover increase.

The second is that we should always be careful to examine claims made on the basis of composite indicators. In “normal” times, these composite theme indicators (particularly engagement) have a habit of working well at giving us an overall picture. But in extraordinary times such as these, that can break down.

I am a fervent supporter of the NHS staff survey, having worked on it extensively between 2003 and 2011, but we always need to be careful to look at the numbers thoroughly. It may well be worth examining other routine data in a similar way to understand how things are changing in this pandemic-struck world.