From ground zero to net zero

Published in Healthcare Manager 56, Summer 2023

Decarbonising healthcare will take everything we’ve got and affect everyone working in the NHS. But well-meaning national strategies are struggling to have much impact on the ground. I spoke to pioneering surgeon Aneel Bhangu about the barriers to change and ask why NHS staff and unions aren’t more involved in meeting our greatest long-term challenge.

The last report?

Published in Healthcare Manager 53, Autumn 2022

The annual deliberations of the NHS Pay Review body have been a fixture of industrial relations in the NHS for nearly 40 years. But declining trust among staff, high inflation and a marked failure to tackle spiralling staff shortages have put the NHS pay system under severe strain, writes Craig Ryan. Has the review body run out of road? And what could take its place?

Trauma at work: the shocking truth

Published in Healthcare Manager, Autumn 2019. Photo: Stefano Pollio/Unsplash

SPECIAL REPORT: In a disturbing new trend, a small but growing number of NHS managers are being diagnosed with workplace PTSD. Craig Ryan spoke to three MiP members who have paid a high price for the NHS’s failure to tackle toxic workplace bullying.

After months of bullying and extreme pressure at work, and following another traumatic meeting with her boss, Laurie, a senior manager with an NHS system body, broke down on her way home. “It was Christmas and I remember seeing the lights in the city centre,” she recalls. “I was crying and crying on the train and I tried to read a book so people couldn’t see how much I was crying. I don’t remember walking home at all.” 

Laurie was soon suffering from suicidal thoughts and “horrible dreams” in which senior managers were trying to hang her. Her GP and a psychiatrist eventually diagnosed her with Post Traumatic Stress Disorder (PTSD), and she is now on a waiting list for therapy. 

“Getting up for work would be almost impossible at the moment, so it’s really limited my life,” she explains. “I take anti-anxiety medication and anti-depressants, and I’m under a psychiatrist as well. The anti-anxiety tablets have calmed me down an awful lot, otherwise I wouldn’t even be able to have this conversation.”

Laurie believes her condition may be related to an extremely traumatic experience during her teenage years, which she disclosed to her occupational health department. Although they agreed with her PTSD diagnosis, Laurie’s employer provided no support and did nothing to tackle the bullying that brought it on. 

“Almost anything stresses me now. I clam up and freeze very easily,” she explains. “PTSD strips away trust and it becomes scary—I mean, imagine not being able to trust your own family. And dealing with a lack of trust is emotionally, and therefore physically, very tiring.”

Many readers will be horrified—even incredulous—that PTSD, a condition associated with military veterans, victims of natural disasters and witnesses to horrific events, has become an occupational hazard in the NHS. Can you really get shell shock, as PTSD used to be known, just by doing your job as a healthcare manager?

Sadly, yes. Although PTSD is traditionally defined as originating in a single traumatic event, mental health practitioners in Europe and America now recognise that the same symptoms can result from continuous exposure to very stressful situations, such as serious bullying and verbal, emotional or sexual abuse. The term ‘Complex PTSD’ (cPTSD) is increasingly used to describe this condition, and is recognised as a variant of PTSD by the support charity PTSD UK.

The symptoms of cPTSD and conventional PTSD are identical: flashbacks, nightmares, panic attacks, high anxiety, severe depression and suicidal thoughts—often accompanied by alcoholism or drug abuse. Both are psychiatric injuries which can be treated and are not related to personality disorders. 

Workplace PTSD (or cPTSD) is caused by prolonged exposure to extremely stressful situations such as bullying, abuse or harassment. Common factors in the cases known to MiP include:

  • Serious bullying by a manager or series of managers, extending over months or years, and often including gaslighting or mobbing
  • Inexplicable and sometimes bizarre behaviour by managers, which is tolerated or even encouraged within the organisation
  • Employers ignoring occupational health reports and independent medical diagnoses
  • Individuals being kept in the dark about allegations against them
  • Lack of support following previous traumatic experiences at work
  • Victimisation and blaming managers for issues outside their control 
  • Treating mental illness as a performance management issue or character flaw
  • HR and senior management backing the bully rather than the victim

MiP is aware of about a dozen members who have been diagnosed with workplace-induced PTSD. Most of them are women, reflecting the well-established finding that PTSD is more likely to affect women than men. Laurie is one of three women who agreed to share their experiences with Healthcare Manager on condition of strict anonymity. They have all been fully supported by MiP but, to protect their identities, we cannot reveal details of the support they received. 

Like many PTSD sufferers, senior nurse manager Giselle began to drink more heavily to numb her symptoms as they developed. Her doctors believe she contracted PTSD as a result of her employer failing to deal with the psychological impact of a serious patient safety incident many years earlier, and subsequent blatant bullying from a series of managers. Giselle’s condition became so severe, she was only stopped from taking her own life by police intervention.

“The PTSD diagnosis was suggested by the [cognitive behavioural] therapist and my GP, and a psychologist confirmed it,” Giselle explains. “Three times I’ve had trauma at work and then I go into this cycle of mental health deterioration… and then in the end it becomes a disaster, and I reach a crisis point.

Rather than accept responsibility, Giselle’s employer used her symptoms against her and ignored advice from occupational health. “The trust completely said this was about my behaviour; that it’s not about mental health, it’s a character flaw,” she says.

MiP national officer Ruth Smith, who has dealt with a number of workplace PTSD cases, says employers have been slow to recognise the condition and rarely offer the right support. “Even when they acknowledge that someone is suffering from a mental health condition, there’s an expectation it will be a ‘normal’ condition like anxiety or depression,” she explains. “The fact is that counselling and occupational health support just isn’t enough to shift PTSD.” 

In rare cases where PTSD-specific therapies—such as eye-movement desensitising reprocessing (EMDR)—have been tried, they’ve met with “considerable success,” she adds.

Ruth believes the PTSD cases known to MiP represent the thin end of the wedge. “What happened to many of these women—being bullied out of the job—is actually very common now, but we can’t often report it because people just leave and sign non-disclosure agreements,” she says. “These people have reacted psychologically very badly to something that is going on quite widely. Other people might suffer from stress and anxiety instead.”

She stresses that employers have a responsibility to take action and cannot just expect people to cope. “Too often, employers are not willing to make the reasonable adjustments needed for people with serious psychiatric injuries to return to work,” she warns. “That just puts pressure on people who are already vulnerable. Some of our members have suffered one breakdown after another because their employer has failed to take action despite knowing that they have a serious mental illness.”

Clinical manager Steph has undergone bullying and gaslighting behaviour from a senior colleague for more than 12 years. This includes spreading and encouraging false rumours about her, deliberately exaggerating problems and even making a false and malicious complaint to Steph’s professional regulator.

“She flatly just lies—that’s her usual way of operating,” says Steph. “But even when you know she’s lying, it does make you doubt yourself… I did get my line manager and a board member involved, but nobody did anything about it—they were all just pussy-footing around her.

“She was furious that I’d been to [the board member] and she came over to the office and was screaming in my face,” Steph adds. “I thought she was going to hit me.” 

Steph also experienced group bullying or ’mobbing’ at the hands of other colleagues, many of whom seemed to have been intimidated by the same manager. “I ended up in a situation where this really close clique of people were judging my every word and move,” she recalls. “It was like they were saying, ‘you’re nothing here, this is our world’. I heard them talking about other people in the same way. It was like a gang culture—an all for one and one for all kind of thing.” 

Even after occupational health had accepted she was suffering from a mental health condition as a result of previous traumatic experiences at work, Giselle was repeatedly bullied by her then chief executive, and later by her line manager, a member of the trust board. 

“I started to get micromanaged, I started to get bullied, I started to get humiliated,” she recalls. Like Steph, she feels other colleagues were intimidated into joining in. “It was almost like classic childhood bullying. You’re being bullied at school, so you become unpopular and everyone just migrates over there because it’s safer. People were thinking, ‘If it can happen to Giselle, it can happen to anyone’.” 

She found occupational health (OH)sympathetic but ultimately powerless. ”The therapists they referred me to suggested PTSD, but the trust wouldn’t engage,” says Giselle. “We asked them why they didn’t use the OH report but they just said, ‘We didn’t think it was relevant’. I mean, how could it not be relevant?… I was made to feel like I was lying, that I was making it up about having mental health issues to cover up my alcoholism.” 

No one involved with Giselle’s investigation had any knowledge of mental health issues. “One HR manager admitted that he’d made up his own diagnosis about me, even though he wasn’t qualified to make a diagnosis about anything,” she recalls.

Laurie had a similar experience. “OH recognised my condition and recommended a stress risk assessment,” she explains. “At a meeting, my manager actually had the report in his hand, but just ignored it and carried on… repeating all these allegations for which he had no evidence whatsoever.”

As she describes it, Laurie’s ordeal resembles a Kafkaesque nightmare, in which she was kept in the dark about allegations against her and left in state of confusion by her employer’s increasingly bizarre behaviour.

“They kept sending me letters that conflicted with each other,” she recalls. “One letter would conflict with the last letter, or the letter would conflict with itself, and still there was no information about what I’d done wrong, so I was utterly confused by it all.

“I thought at some point they were going to stop because it was just crazy, but it felt like they’d let it get so out of control they didn’t have a way out of it themselves. I had a schedule of allegations which my MiP rep said didn’t amount to anything—they either had no evidence or were really minor. One them was a complaint that I’d opened a window at a meeting!”

MiP’s Ruth Smith says bizarre behaviour by employers is a common feature of the most serious bullying cases. She describes one case in which a member was inexplicably threatened with performance management measures shortly after returning from maternity leave. 

“It was a high-performing service which fell apart when our member was away, because managers refused to backfill her post,” Ruth explains. “They had nine months of disaster, but within a few weeks they were putting pressure on her, asking why the department hadn’t come back into line.

“Managers suddenly started questioning whether she was too young to be in a senior post and making sexist comments about her appearance,” Ruth continues. “Our member was never told what she’d done wrong, and just couldn’t understand why this was happening to her. They were desperately trying to make out it was an issue with her performance, when there’d never been one previously.” 

These three cases fit a disturbing pattern MiP has observed in dozens of bullying cases across the NHS: evidence from the employee, their GP, therapists and even the organisation’s own occupational health services is ignored, while unsubstantiated allegations, trivial complaints and even rumours are taken seriously and used as the basis for aggressive disciplinary or capability action.

“When someone has suffered a psychiatric injury at work, it’s often a result of the way they’ve been treated by the management team,” explains Ruth. “And then we get this defensiveness on the part of the organisation. They close ranks and go to great lengths to protect the bully. And we know that this person will do it again. It’s about power. The bully is often someone who everyone is afraid to stand up against.”

Employers often seem to get locked into a cycle of defending the indefensible for fear of incurring legal liabilities, she adds. “It becomes easier to just dismiss the person who’s being bullied than to continue having them in the workplace. The amount of public money that goes on all the processes, disciplining people and fighting cases, is ridiculous.” 

The real tragedy is that the serious mental illness inflicted on these women—and the other members MiP has supported—were not just the result of the inevitable pressures of working for the NHS. They were caused by the failure of particular employers to tackle bullying at work, or to take seriously the mental health problems it can cause. For that to happen in the NHS—which more than any other employer ought to understand mental health—is a nothing short of a national disgrace.

  • The names of the MiP members participating in this story have been changed to protect their identity. To read more about MiP’s campaign against bullying in the NHS, visit the MiP website.

The get out clause

Published in Healthcare Manager, Summer 2019. Photo: Joe Green/Unsplash

Threats of dismissal for “some other substantial reason” are increasingly being used to get rid of NHS managers whose faces don’t fit. Craig Ryan spoke to two MiP national officers about recent cases and how they defend members from unfair treatment.

We all expect the law to protect us from arbitrary dismissal but it’s increasingly common for senior managers in the NHS to sacked or forced out for vague or unfair reasons – and with little chance to fight back.

Under the 1996 Employment Rights Act, “some other substantial reason” (SOSR) is one of the five legal grounds for a fair dismissal. It’s something of a catch-all, covering dismissals that fall outside the scope of the other four reasons – conduct, capability, redundancy and breaching a statutory restriction. But there’s no clear legal definition of what constitutes a “substantial reason”, which gives employers wide scope to pressure people into leaving without going through formal disciplinary, capability or redundancy procedures.

If brought before a tribunal, employers must show that their reasons are not “wholly frivolous or insignificant” and that they followed a “fair procedure”. But, as there are no set procedures for an SOSR dismissal, this can amount to little more than a discussion or consultation with the employee concerned. In reality, very few SOSR dismissals are tested in the courts.

SOSR “is certainly being threatened a lot more than it used to be in the NHS”, says Claire Pullar, the MiP national officer for Scotland and Northern Ireland. “We’re seeing a rise in a number of poor employment practices in order to show people the door at the moment.”

One reason this could be a perverse side-effect of Scotland’s ‘no redundancies’ rule, under which managers can spend years on the redeployment register doing work usually done by staff in lower bands. Pullar explains: “At some point your employer says, ‘You’ve been on the redeployment register for a while now, we’re going to dismiss you for some other substantial reason’. And, of course, SOSR comes without a payment, when they would have been entitled one if they’d been made redundant at the time.

“Employers will argue that you’ve had your redundancy payment through doing a non-job, but they’ve actually made it harder for you to move on and get a job elsewhere,” she adds.

According to George Shepherd, MiP’s national officer for the East of England, by far the most common excuse for an SOSR dismissal in England is that the board or chief executive has “lost confidence” in the manager concerned. But in most cases, he explains, the “no confidence” excuse is just “spin” to cover a clash or personalities or a desire to bring in different people.

Shepherd sees Very Senior Managers (VSMs) and Band 9 staff as being most vulnerable to SOSR, particularly following a change in leadership at the organisation. “There might be a new chief executive or chair, and they want their own team on board,” he says. “And what we often find then is scapegoating – individuals being blamed for things they don’t necessarily have responsibility for.

“I’ve had cases where the chair has phoned up the chief executive, or invited them to a fancy restaurant, and just said ‘the board has lost confidence in you and it’s time for you to go’,” he recalls. “In one case, we contacted board members and found that wasn’t true. We went to one of the national bodies and were able to get the decision reversed.”

Pullar says the “loss of confidence” excuse is less common in Scotland, although managers whose “faces don’t fit”, especially following organisational change – can find themselves “in a non-job” on protected pay, and vulnerable to SOSR dismissal further down the line.

SOSR dismissals can be very hard to fight in the courts, especially when many senior managers have a clause in their contract which requires them to maintain the confidence of the board. “If it’s really vexatious, or you’ve had really good ADRs and can prove beyond a shadow of a doubt that you weren’t responsible for any identified failings, these dismissals can be fought against ,” says Shepherd. “We have had some successes but even in those cases it can prove very difficult.”

Pullar described one tribunal case where a member due to retire in 18 months was “very badly treated” by the employer and dismissed under SOSR with just three months notice. Supported by MiP, he won his case at the Employment Tribunal but received only the legal minimum payment – less than a third of what he would have been entitled to if he’d been made redundant under Agenda for Change.

Faced with such legal obstacles, MiP negotiators generally take a pragmatic approach – taking legal advice and using any available leverage to keep the member’s job where possible, or negotiating the best way out if not.

“You have to ask members if they really want to stay in an organisation that doesn’t want them,” explains Shepherd. Most members in this situation “really know the writing is on the wall”, he says, and prefer to negotiate a settlement agreement so they can leave at an agreed date and on fair terms, which usually include a financial settlement.

But such agreements do mean forfeiting any right to challenge the dismissal at an employment tribunal, he warns, and the threat of an SOSR dismissal is sometimes be used to pressure a manager into signing an agreement to leave. “People will be told if they don’t sign, they’re going to be unemployable or get bad references and so on, so it’s a form of bullying tactic really,” Shepherd adds.

He notes that it’s increasingly common for members to be offered a ‘secondment’ – a temporary or interim post at another NHS organisation, often a national body – as part of the settlement agreement. “But I don’t like the use of the word ‘secondment’, because with a secondment you have a right of return to your substantive post, but in these situations they’ve no intention of doing that,” says Shepherd. “In my view, they’re a fixed term contract.”

But the Government’s clampdown on public sector exit payments is making it harder to negotiate satisfactory settlement agreements for managers threatened with SOSR. “Employers often claim they can’t pay any compensation beyond the contractual period of notice – generally three months,” explains Shepherd. “In those situations, I will usually say, ‘Well, you don’t have to give the notice now, do you? You can give that in another three months’. This gives the member more time – up to six months – to find a new job,” he says.

Both Pullar and Shepherd agree that a negotiated settlement is usually better all round than going to the courts. Pullar cites one recent case, which resulted in a £32,000 settlement for an MiP member, but a legal bill of over £100,000 for the health board. “All they had to show for all that money was a poorer relationship with staff and a lack of trust from the Central Legal Office because they’d sent them to a tribunal where they were clearly in the wrong,” she explains.

“I ask employers to think about how they want to spend their money. What will be the impact on all the stakeholders, on recruitment and retention, on how the board members feel?” she adds. “If you really want someone to go, if you’re certain that’s best for the business, fair enough. But think about what’s the best way to do that without wasting money, energy and reputation.”

  • To find out more, read this excellent summary of the legal position on SOSR by Lewis Silkin Global HR Lawyers. If you have been threatened with an SOSR dismissal, contact your MiP national officer immediately.

Book review: The French Exception, by Adam Plowright

Published by Public Service Magazine, Autumn 2018. Photo: Jacques Paquier/

If you want to be French president, you usually have to be good at waiting. It’s a job for which even political giants, like Mitterrand, de Gaulle and Chirac, spent decades preparing before landing the prize. For others, like Michel Rocard and Alain Juppé, the prize never quite materialised.

But Emmanuel Macron doesn’t do waiting, and the scale and pace of his ambition is exhausting. In this book – a slightly uneasy blend of biography and tour d’horizon of French society – British journalist Adam Plowright portrays Macron as a leader belonging to the more swashbuckling tradition represented by Nicholas Sarkozy and Napoleons I and III: flashy, sharply-dressed, silver-tongued outsiders in a hurry. 

The idea of the “providential man” (or woman, in the case of Joan of Arc) who will banish the nation’s woes through sheer force of personality, is deeply embedded in the French psyche, Plowright claims. Quoting the eminent French historian Jean Garrigues, he enthuses about “a form of charisma, an ability to create a sort of collective enthusiasm, which Bonaparte and de Gaulle clearly had”, while also warning about “a Christ-like dimension, a sort of mysticism.” 

Macron emerges as surprisingly “cynical” and “manipulative”, even “quasi-monarchical”, for a modern European liberal. There is little internal democracy, Plowright points out, within Macron’s hastily-assembled political party, La Republique En Marche!, which still functions primarily as a personal political vehicle. And he describes how Macron has irked some supporters, and impressed others, with his insistence on the trappings of power – most famously with his bad-tempered rebuke to one young voter who had the temerity to call him ‘Manu’. 

For all the novelty of Macron’s youth, his “unconventional” marriage to his former arts teacher, his status as an outsider to the political process, and his sheer freshness in comparison to France’s grey and stale political class (in which some of Mitterrand’s cohorts are still active), what emerges from Plowright’s well-drawn pen portrait is a fairly conventional centrist European politician – though with his emphasis on work and efficiency, one who sounds more a bit more German than French. 

But while he offers a few vox-pops from Macron supporters, mostly small business people enthused by the prospect of it being easier to sack people, Plowright never really gets under the skin of today’s France. It remains a mystery how this pro-European, pro-business graduate of France’s elite political school managed to transcend the “sour national mood” in France, and become the unifying national figure who personified the change the nation needed.

One answer, of course is that he didn’t. By peeling away votes from the moderate left and moderate right, and sewing up the centre through his deal with veteran liberal François Bayrou, Macron scraped into the second round of the presidential poll, where, head-to-head against the neo-fascist Marine Le Pen, he was home and dry. His political future depends on holding that coalition together and forging it into something more meaningful and long-lasting.

France didn’t much take to its “normal” president, François Hollande. Yet, with Macron we see something like a palimpsest of his predecessors: the messianic qualities of Napoleon and de Gaulle, some of the cunning of Mitterrand, the centrist pan-European politics of Giscard d’Estaing, the haughtiness and faux-grandeur of Jacques Chirac and the flashy ambition of Nicholas Sarkozy. If he can avoid Hollande’s ponderousness and Pompidou’s chain-smoking, Macron – and France – might just be onto something. 

  • The French Exception: Emmanuel Macron – the Extraordinary Rise and Risk (updated edition), by Adam Plowright. Icon Books, 300pp, £8.99


The gift that keeps you guessing

Published in Healthcare Manager, Summer 2018.

The government’s NHS funding settlement brings some welcome relief for struggling services, but leaves many tough questions unresolved. Craig Ryan reports.

The NHS’s 70th birthday present from the government was a bit like one of those gift cards from posh shops that don’t tell you how much they’re worth – when you finally get to the till, it’s always a bit less than you need.

We know quite a lot about what the “long-term funding settlement”, unveiled on 18 June, is not. It’s obviously not, as Theresa May suggested, a “Brexit dividend” – that claim has been so comprehensively rubbished that there’s not need to go over it again here. Neither is it worth £600m a week, as some ministers claimed. That figure is based on the total increase in the NHS budget by 2023 — at 2023 prices, which are meaningless in 2018. In fact, right now it’s worth precisely nothing, as there won’t be a penny of new money until April. And, as another tough winter looms, for many MiP members it’s right now that counts.

Neither is it much of “settlement”, when so much remains to be settled. We don’t know where the money will come from, or if other vital services will be cut back to pay for it. We don’t know if there will be any new money for social care services that are on the brink of collapse. We don’t know much about how the new money will be spent, or how the strings attached by the Treasury will operate (see box below). And we don’t know to what extent public health services and staff education, excluded from the announcement, will continue to be starved of funds.

These issues may not be settled until November’s budget or even next year’s scheduled spending review. And with the fate of the government hanging in the balance as I write, who knows if either of those things will happen as planned? The long-term funding settlement may not be very “long-term” either.

In NHS circles, there is near-unanimous agreement on another thing the government’s “settlement” is not – and that is “enough”.

What we do know is that the government has promised to increase NHS England’s budget by £20.5bn by 2023, with corresponding increases of £2bn for NHS services in Scotland and £1.5bn for Wales. For England, this equates to real terms growth of 3.4% per year for the next five years: an undoubted relief after years of painful austerity, but actually the same level of investment made between 1979 and 1997 by those notorious tight-wads Margaret Thatcher and John Major.

“Managers will obviously welcome the easing of underfunding,” says MiP chief executive Jon Restell. “That said, the new money will not stretch to everything the government wants to do, such as investing in integrated health and social care, and moving more care out of hospital. And we’re in the dark on some important budgets such as public health, staff training and capital projects. Plenty of tough choices still remain.”

A month before the funding announcement, the Health Foundation and the widely-respected Institute for Fiscal Studies, with support from the NHS Confederation, published a comprehensive survey of health and care funding. Securing the Future made clear that funding growth of 3.3% was the absolute minimum needed to maintain current standards. 4% growth would allow for some modest improvements, the report said, but to invest properly for future health needs and to deliver the government’s own policies on things like integration and moving services into the community, above 5% will be required. The OBR more or less agrees: its projections reckon annual increases of 4.3% are the minimum needed to meet the government’s objectives.

The government’s plans “will help stem further decline but it’s simply not enough to address the fundamental challenges facing the NHS or fund essential improvements to services that are flagging”, warns Anita Charlesworth, the Health Foundation’s director of research.

The big black hole in the government’s plans remains the funding of social care. Speaker after speaker at last month’s NHS Confederation conference spelt it out: we need a comprehensive funding settlement for both health and social care. The two have been yoked together since birth (our modern social care services are also celebrating their 70th birthday this year – who knew?) and never more tightly than now.

The Health Foundation/IFS report found that social care spending will need to increase by at least 3.9% in real terms for the foreseeable future, just to maintain current (poor) levels of service. Social care underfunding “has a direct impact on the NHS”, warns the report, “including rising numbers of emergency attendances, admissions, and patients facing delayed discharge due to a severe lack of care available in the community”.

“It’s worrying that we still don’t know about funding for social care,” adds Restell. “Social care needs 4% a year in real terms. The public don’t see where social care ends and healthcare starts – but they know more money is needed. The government must make a parallel settlement for social care as a matter of urgency.”

Adding to this uncertainty is the fact that the new money applies only to NHS England’s budget, and not to all spending by the Department of Health and Social Care (DHSC). This is not a technical point – according to the Health Foundation/IFS report, this narrow definition of NHS spending is a “mistake” which has already “lead to damaging cuts to public health programmes, capital investment and the education and training of NHS staff”.

Amazingly, this means the government’s settlement ignores the area where the crisis is most acute: the training and recruitment of skilled NHS staff. At the end of March there were 92,000 vacant posts in NHS providers alone. Health Education England admits that, on current trends, the NHS will manage to recruit barely a third of the clinical staff it needs in the next ten years.

“We also need a long-term workforce strategy to support the funding settlement,” says Restell. “The NHS’s recovery will need managing very carefully, and it’s critical we now invest in our staff – including support staff and managers.”

While it’s always churlish to quibble over the value of a gift, the funding announcement isn’t really a gift at all – simply a response to mounting political pressure. The public have made it clear time and time again that they expect NHS services to be properly funded, and that they are prepared to pay for it if necessary. The new money is a step in the right direction, but in many ways it simply kicks the can down the road. We shouldn’t be too polite to say so.

20 billion quid pro quo

The Treasury and the DHSC has set five “financial tests” for the NHS meet in return for the new money. At the time of writing, it remains unclear how the tests will be assessed and what will happen if they’re not met.

  • Improving productivity and efficiency
    Sources say the Treasury is pushing for a headline target of 1.8% for annual productivity growth in the NHS, more than twice the long-term average of 0.8%
  • Eliminating provider deficits
    Tight financial controls on trusts are unlikely to be loosened much, but new money means fewer trusts will find themselves in financial special measures, leading to a more intense focus on those with the deepest problems.
  • Reducing unwarranted variation in standard
    Greater use will be made of NHS Improvement’s still-embryonic Model Hospital tool, together with the Getting It Right First Time and Right Care programmes.
  • Manage demand effectively
    A vague test, which may involve channelling funding towards collaborative projects and schemes which reduce demand at health economy level.
  • Make better use of capital investment
    Capital investment was excluded from the 18 June settlement, so this test will focus on better targeting of existing schemes, including revisiting the Sustainability and Transformation Plans submitted in 2016 and tighter control of technology funding.

All in the mind

Published in Public Service Magazine, Spring 2018.

Last year’s Stevenson-Farmer report set out an ambitious agenda for improving mental health and wellbeing in the civil service. Craig Ryan explores the deep culture changes needed to make sure all civil servants can thrive at work.

In January 1974, at the height of the three-day week crisis, the head of the civil service, Sir William Armstrong, suffered a stress-induced mental breakdown. According to several accounts, Armstrong was found naked on the floor of the Downing Street waiting room, chain smoking and raving about the end of the world. The following morning he convened a meeting of his Permanent Secretary colleagues and harangued them about preparing for Armageddon. Armstrong was admitted to hospital, but was back at work within a few weeks. Three months later, he left the civil service and became chairman of Midland Bank.

Armstrong’s breakdown was hushed up and the lessons ignored. Although colleagues later said the warning signs had been there for years, Armstrong received no support and never talked about his problems. The impact of severe stress and overworking on his ability to advise the Prime Minister at a crucial juncture in Britain’s history was never considered. And the effect on Armstrong’s own health – he died just a few years later – was perhaps greater than he knew.

On the surface, the contrast with today’s civil service couldn’t be greater. Government Chief People Officer Rupert McNeil has spoken openly about his problems with anxiety and encouraged colleagues to do the same. Departments have health and wellbeing champions, and have rolled out a plethora of mental health initiatives in recent years, including mental health first aider training, expanded employee assistance programmes and networks where staff get together to talk about workplace problems and the impact on their mental wellbeing.

When Lord Dennis Stevenson and MIND chief executive Paul Farmer published their independent review of workplace mental health, Thriving at Work, in October last year, the government not only accepted all the recommendations as an employer, but designated the civil service as an ‘early adopter’ of the mental health standards laid down in the report (see box). It was, and was intended to be, a clear signal that the civil service is now taking mental health seriously.

But it still has a lot to get serious about. The Stevenson-Farmer report says the scale of the mental health challenge in Britain’s workplaces is “greater than we thought”, and the civil service is no exception. According to MIND’s Workplace Wellbeing Index, public sector workers experience poorer mental health than those in the private sector, with one in six describing their mental health as “poor” and 53% saying they regularly feel anxious at work. Research by Deloitte’s puts the cost of mental health problems to the government at around £1,500 per civil servant every year – again, higher than the average for private sector employees. 

Duncan is a senior manager with a large civil service agency who has suffered from stress-induced anxiety and depression for several years. Two years ago, he was signed off sick after visiting his GP. “I realised quite suddenly that I couldn’t cope, but the problems had been building up for a long time,” he says. “My workload was ridiculous – but so was everyone else’s. There’s this enormous pressure to be busy and to be just about coping, so I just tried deal with it. But I wasn’t sleeping properly, I was drinking a lot and things were starting to fall apart at home.”

Although Duncan’s manager was “not unsympathetic”, Duncan didn’t feel confident discussing his mental health. “I felt I couldn’t cross that threshold, admit I had a real problem. You don’t want to open up that whole can of worms – with capability reviews and assessments by [occupational health]. I was worried about my PMR, my reputation, I was worried about being made redundant – everything really.”

“Working in the civil service is demanding,” says Faye McGuinness, head of workplace wellbeing at MIND, who works with the civil service leadership on implementing the findings of the report. She cites long working hours, regular inspections, lack of interaction with colleagues, and cuts to budgets and staffing as factors that can put pressure on the mental health of all public sector workers. 

“The onus should be on employers to support their staff through the difficult times, so they can come to work at their best, and in turn get the best outcomes for the people they represent – which is why implementing the recommendations [of the report] is so important,” says McGuinness.

Work across Whitehall is being lead by Jonathan Jones, the Ministry of Justice Permanent Secretary who is also the civil service health and wellbeing champion, with support from the Civil Service Employment Policy (CSEP) unit in the Cabinet Office and wellbeing champions in each department.

Jones tells PSM that he has “identified strategic priorities to change the culture towards health and wellbeing in the civil service… These include emphasising visible leadership, enabling honest and open conversations about mental health and encouraging an all-round healthy lifestyle.”

Work is already underway in 18 departments to benchmark existing programmes against the standards set in Thriving at Work . The report identified areas of existing good practice and those where collective improvement was needed, Jones explains, “including how we communicate our offer on mental health to employees, how we continue to build line manager skill and confidence, and how we consistently support people with mental health conditions within the recruitment process.” 

The newly rebranded Ministry of Housing, Communities and Local Government (MHCLG) is widely recognised in Whitehall for being ahead of the curve on supporting workforce mental health. “When I joined the department in 2016, what really struck me was the openness within the [health and wellbeing] network, but also more broadly to talking about mental health issues,” says Jillian Kay, the ministry’s health and wellbeing champion. 

“There were events going on where people were sharing their own lived experiences quite comfortably and openly, and similarly people sharing their own experiences online,” she recalls. “So I sensed that in terms of breaking the stigma it’s certainly a place where lots of people felt safe to share their stories, which felt like a really positive thing.” 

In 2015, The department introduced mental health first aid training and a mental health ambassador listening and support service. MHCLG now has 150 trained mental health first aiders and has a thriving health and wellbeing staff network, and last year was it chosen to design and deliver the mental health awareness workshop at Civil Service Live.

Kay emphasises that the engagement of senior managers is crucial to shifting the workplace culture towards improving mental health. “I was a bit surprised to see members of the SCS on the mental health first aid training when I joined, but actually we’ve now trained 12 SCS members,” she says. “More than 40 first aiders have gone on to become mental health ambassadors, and they provide a listening and advice service to people who need it, including line managers who want to support their staff.” The ministry also runs specialised wellbeing workshops for senior leaders, including one recently facilitated by FDA national officer Jane Cockram. 

Staff resilience and good mental health is very much a live issue for Kay as a manager. In her ‘day job’, she leads for the department on Grenfell recovery and resilience. “Some of our teams have been working with Kensington and Chelsea Council on support for all those affected by the fire. So I’ve get a set of staff who’ve had to be quite resilient over the last year,” she says.

“It really brings home the point that we’re trying to get across in the civil service that we all have good and bad mental health at different times depending on what we’re experiencing. An important part of this is making sure that mental health isn’t a kind of niche agenda, it’s something that’s relevant to everyone – and it became really relevant to all of us over the last year.”

At the same time, the civil service needs to identify and meet the needs of staff who are at a higher risk of developing mental health problems because of the nature of their work, which may include “mainstream” civil servants like Jillian Kay’s MHCLG staff, as well as more obvious candidates like people working for the security services or the National Crime Agency. 

“Departments are being supported centrally to identify teams where there may be a higher risk of stress and trauma, [and] to in turn identify tools and best practice to help all departments address these issues,” explains Jonathan Jones. “Because the support may vary according to the types of work, it’s right that departments lead this work as they’re closer to the detail.” 

One of the persistent themes in the Stevenson-Farmer report is the need for employers to move away from the traditional ‘performance management’ approach, where mental health problems – if they were discussed at all – were tackled as issues of individual capability. This lead to a ‘culture of silence’, where employees kept quiet about mental health problems for fear of demotion, reprimand – or worse.

Instead, says McGuinness, employers need “to create a culture where staff feel able to talk openly about stress and mental health, and know that if they do, they’ll be be met with support and understanding rather than stigma and discrimination.”

This also means managers taking some responsibility for the mental wellbeing of their staff, something that is reflected in one of the Stevenson-Farmer’s most striking recommendations: that civil service leaders should have the mental wellbeing of their staff enshrined in their performance objectives.

“It’s important that Permanent Secretaries and Chief Executives lead by example, and consider how they can be held accountable for the wellbeing of their staff,” says McGuinness. “Having performance objectives relating to employee mental health is one way they can do this… Showing staff that employee mental health is a key priority, and one that they are willing to be measured against, is a step towards creating a positive culture where… staff feel able to talk about their mental health problems.” 

This would certainly be a unprecedented step, with big potential to drive meaningful change. “It’s difficult for us to talk about how this would be implemented as this is based on how they manage this internally. We don’t yet have any other examples of this being done before,” adds McGuinness.

Since returning to work, Duncan says he has benefited from some adjustments to his workload and from taking part in a staff wellbeing network. “Colleagues have been much more supportive than I expected and [management] have been willing to make some changes, which have definitely helped me,” he says. But he still fears his career has suffered, and doesn’t feel confident about pursuing promotion opportunities in the near future. “I still feel there’s this bit of a stigma hanging over me,” he adds. 

Duncan still doubts many of his colleagues would be willing to discuss mental health problems openly with senior managers. “Maybe more managers are willing to have that kind of [supportive] conversation now, but I don’t think it’s enough to change the way people feel,” he says.

Whitehall has come a long way since Sir Robert Armstrong was reduced to rolling around on the Downing Street floor, and mental health problems are being discussed in a way that would have been unthinkable a generation ago. MIND’s Faye McGuinness, who has monthly meetings with civil service leaders to monitor progress, says: “We know there is a long way to go, and that change doesn’t happen overnight. But it’s positive that Government, and in turn, civil service employers, have accepted all the recommendations from the review and see the value in implementing them.” 

For Duncan, the big challenge is ending the culture of silence around mental health, and that takes time: “In the end, it’s not about what support programmes there are, but whether people have trust and confidence to use them. I don’t think we’re quite there yet,” he says.

Stevenson-Farmer: key recommendations for the civil service

  • Permanent secretaries and agency chief executives to have performance objectives relating to employee mental health
  • Commitments to mental health standards to be written into Single Departmental Plans
  • Routine monitoring of employee mental health
  • Enhanced mental health training for staff at all grades, especially for line managers
  • Employers to identify staff and higher risk of stress or trauma and develop a national framework of support
  • Tailored in-house mental health support with signposting to clinical support
  • Encourage open conversations about mental health and the support available to staff

Book review: Citizen Clem by John Bew

Published in Public Service Magazine, Autumn 2017. Photo: National Library of Australia (CC)

For someone often cited as our greatest prime minister, something of a reverse cult of personality surrounds Clement Attlee. The aura of heroism attaches more readily to his government than to the man himself. Who knows much now, for example, about Attlee’s distinguished service in World War I, when he was, as John Bew gleefully tells us in this classy new biography, “shot in the buttocks as he carried the red flag over the top”?

That red flag was the flag of his regiment, the South Lancashires, not the socialist standard sung about at Labour conferences. Bew argues convincingly that Attlee’s deep sense of patriotism and loyalty is the key to understanding his enduring political achievements. As a “social patriot” his patriotism, “meant not fidelity to caste or cohort, but to the commonwealth”. Attlee himself said his proudest achievement was not the NHS, but taking Labour into the wartime coalition with his friend Winston Churchill.

Bew explains how Attlee “matured into socialism” – developing the sense of purpose and steely determination that turned this shy and diffident man into the great achiever of the British left. Attlee “went left by going east”: his politics were forged in the years he spent as an East End social worker, subsisting in a garret above the youth club – an experience that Bew says inured him to the “Fabian aloofness” that infected many of his comrades.

Attlee’s genuine modesty led almost everyone to underestimate him (but not Churchill who, while often rude about his rival on the stump, deeply respected Attlee and defended him fiercely in private), and historians have long puzzled over how he survived 20 tumultuous years as Labour leader. While admitting that luck catapulted Attlee into the leadership in 1935, Bew suggests he was simply better than anyone else: “One of his undoubted skills was the navigate around the larger egos surrounding him, without letting disputes over personality get in the way of the swift execution of government policy.”

Like most effective revolutionaries – Thatcher, Lenin, Napoleon – Attlee was well read but always more of a doer than a thinker. Rejecting Marxism early on, he doggedly disputed the idea that socialism demanded an abrupt and complete break with Britain’s history and traditions, accusing more doctrinaire and impatient colleagues, like Harold Laski and Nye Bevan, of “demanding a caesarean section rather than a natural birth” for socialism. Poverty and inequality were a “national problem” which required the attention of the state. Attlee may have been a gradualist, but he knew where he wanted to go.

Without ever setting down a doctrine, Attlee painstakingly accumulated a bag of ideas about how democratic socialism should work, which he assembled into a distinctly British programme for government in the post-war years. They included a firm commitment to social justice, a balance between radicalism and pragmatism, a deep sense of patriotism, an emphasis on personal probity and loyalty, and a willingness to work with other traditions within society: Attlee knew that conservatism and socialism were different, but not opposites.

For today’s Labour Party, looking to combine radical socialism with electoral credibility, Bew’s book is a great place to start. Bew is right to argue that Attlee’s was a quintessentially 20th century project – 1945 cannot be repeated – and Labour would do better to learn from Attlee’s ethos rather than just basking in the reflected glow of his government’s achievements. After all, Attlee’s socialism – democratic but patriotic, principled but pragmatic – is the only kind of socialism that ever really worked.

The clock’s still ticking

Published in Public Service Magazine, Summer 2017. Image: Chapman Design.

With Brexit Day just 21 months away, Britain’s government, parliament and civil service face perhaps their greatest peacetime challenge. Craig Ryan asks the experts if we have the resources, skills and time we need to make Brexit work.

If Brexit was hard before, how much harder is it now? Theresa May’s government now faces the greatest policy and legislative challenge since 1945 without a clear mandate or a majority in parliament, and with the prospect of a change of leadership or a fresh election constantly hanging in the air. And with the smallest civil service since the war to boot.

“For the civil service, the problem is the Brexit clock is still ticking,” says Sir Paul Jenkins, Treasury Solicitor and head of the Government Legal Department from 2006 to 2014. “When will they be able to get on with negotiating and will they even get near having something they can implement before the end of the Article 50 period?”

If the parliamentary arithmetic doesn’t change, or moves further against the Government, Jenkins warns that it’s far from certain that any Brexit deal negotiated with Brussels will be approved – increasing both the risk of a ‘cliff-edge’ exit and the need for parallel planning. “With time running out fast, the civil service urgently needs clarity and direction from ministers. It appears they’re getting neither at the moment. But, who knows, it might all change tomorrow!”

Despite the political rhetoric, Jenkins believes some ministers – David Davis, in particular – now “get it”, and realise there’s no chance of securing a long-term trade deal by Brexit Day. This means they will have to ruthlessly prioritise what they do with the 21 months that remain.

In negotiating terms, that probably means agreeing the basic package on withdrawal terms – the “divorce settlement” – and a transitional agreement, lasting perhaps two to five years, while Britain’s future relationship with the EU is worked out in detail. “The transitional deal won’t be the status quo or a long-terms settlement; it will be something different. In what way, we don’t really know,” says Jenkins.

Running in parallel with the negotiations, but interacting with them in a wickedly complex way, will be process of legislating for Brexit – transferring the huge ‘acquis’ of EU and EU-derived legislation into UK law and making sure everything will work in the post-Brexit environment. 

That means replacing every law made under the powers of the 1972 European Communities Act, and trawling through other UK legislation which has an EU dimension or refers to EU standards or institutions, including thousands of EU directives. EU regulations, which apply directly in the UK law, will all have to be carried across to British law. Perhaps the trickiest job will be identifying and replacing the large volume of judge-made law – much of EU tax legislation, for example, exists only in European Court rulings.

The white paper published by the Department for Exiting the European Union (DExEU) before the general election won praise from some experts for not trying to do too much. “The white paper was not as ambitious as I thought it might be, and others feared it might be,” says Sir Stephen Laws, who as First Parliamentary Counsel, was Westminster’s chief drafter of laws from 2006 to 2012. “It confines itself to two issues: what do you need to do to preserve continuity after Brexit, and what do you need to implement the deal.”

As ever, the devil will be in the detail. One big problem the white paper doesn’t address is what exactly constitutes “EU-derived” legislation. Laws cites the example of the 1985 Consumer Credit Act, which was supposed to implement the UK’s obligations on product liability. “The European Court of Justice ruled that, whatever it actually says, it’s got to be construed as if it’s consistent with the European obligations. What you do about that, I just don’t know,” he says.

Despite the slimmed-down Queen’s Speech, the legislative workload for Brexit still looks formidable. Emma Norris, programme director at the Institute for Government (IfG), reckons Brexit will requite at least 15 new bills, plus the so-called ‘great repeal bill’. “On top of all that, you’ve got everything that’s in the Queen’s Speech and there’s lots of legislation left over from the last session that didn’t get through in time. This is a parliament under strain,” she warns.

The IfG’s recent report, Legislating Brexit, said the government and MPs need to strike a balance between proper scrutiny of potentially controversial legislation and the need to move at speed to meet the Brexit deadline. 

“I see parliament as a political filter for proposals coming from the government,” says Laws. “It’s really up to parliament to set its priorities for what it thinks it needs to scrutinise, and if it’s a question of how rather than what, fairly often parliament can adopt a looser approach to scrutiny, as they already do with legislation coming from Europe.”

Laws, who was more optimistic than many commentators before the election, says the inconclusive poll will make things much tougher. “The government is more vulnerable in the Commons to people trying to extract a price, more vulnerable in Lords because it has no mandate, more vulnerable in committee because may not have majority,” he warns.

“We have all the same problems as before, but now it’s politically difficult as well as technically difficult,” he adds. “They can’t use broad brush solutions because people have the power to unpick them – and that makes it technically more difficult too.” 

What makes the Brexit process so fiendishly complicated is that policymakers are aiming for a moving target. No one knows what the final settlement will be, or if there will be one at all.

To deal with this, the repeal bill will give the government similar powers those granted under 1972 Act it will be repealing. “It will be a power to implement whatever rules we come up with in negotiations with the other European countries,” Laws explains.

But the “nightmare scenario”, says Sir Paul Jenkins, is no deal at all. “The legal consequences of no deal are much greater. If we just run out of time and there’s no extension – all the treaties would cease to apply overnight, so there’s nothing.”

While much EU law could be copied across to the UK statute book, treaties involving third parties would not operate. As an example, Jenkins cites the EU-US open skies treaty, without which there will be no legal basis for planes flying from the UK to America. 

“What I would like to ask David Davis is, ‘at what point in the next two years are you going to begin bilateral negotiations with the US government for a contingent treaty so the planes can keep flying the day after we fall out of the EU?’” says Jenkins. He warns against leaving such contingency planning too late, because the entire Brexit deal could fall apart at the last minute over a single issue, even when the rest of it has been agreed.

There’s also a big risk that Brexit will become all-consuming, devouring ministerial attention and leaving departments unable to cope with anything else. Norris reels off a list of initiatives which were already going nowhere fast before the election: Heathrow expansion, the national funding formula for schools, grammar schools expansion and English devolution – not to mention Theresa May’s vague personal commitments to social mobility and industrial strategy. 

“There’s definitely a strain on ministerial attention. It’s absolutely critical that ministers are absolutely clear about what the priorities are, so that ministerial intention will guide the system,” she says. 

She adds: “This is not just about the Brexit departments – it’s about departments like DEFRA, the Ministry of Justice, Revenue and Customs – they’re going to be taking on roles they simply haven’t played for decades. It’s enormously increasing their workload and they’ve got to carry on with business as usual as well.

There are already signs that government is short of skills it needs to negotiate and implement Brexit. In mid-May, it emerged that the five departments most affected by Brexit – DExEU, DIT, DEFRA, BEIS and the Home Office – were urgently trawling other departments for policy staff, mainly at EO to Grade 6 level – with candidates expected to move with just two weeks notice.

“I’m not sure the government has a proper understanding of the capacity and capability it needs to deliver Brexit, and what the implications are for departments,” says Norris. “I think this one of the key planning questions the new government will need to get a grip on.” 

But Jenkins insists press reports about Remain-supporting civil servants dodging Brexit-related jobs are wide of the mark. “Everything I pick up suggests that’s rubbish. What I love and admire about the bright kids that I had working with me is that so many of them, whatever their personal views, have done what the British civil service does and gone rushing into to those departments because that’s were the action is.” 

Despite the intense pressure, Jenkins says Whitehall can still pull it off. “I wind all sorts of people up by saying I was a proud bureaucrat for 35 years and I’m still proud of it. If something can be sorted out, the great British civil service is capable of sorting it out.”