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.
Domestic violence and abuse blights the lives thousands of NHS staff every year, and the problem has only got worse since the start of the pandemic. But work can be an important refuge and source of strength for people experiencing abuse, and good support from managers and employers can be a lifeline.
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?
Published by Managers in Partnership, October 2020. Picture: Cheryl Samuels
Cheryl Samuels, deputy director of workforce transformation at NHS England, talks about her experiences as a black manager in the NHS. Interview by Craig Ryan.
The first taste of injustice in my career came at the Ministry of Defence. The director agreed to fund my postgraduate studies, but my line manager was determined to discourage me and refused to authorise it. There were only three black women in our team and it was very clear they were not permitting us to proceed through the so-called ‘glass ceiling’ – which looked more like concrete.
That was my first experience of the disconnect between the strategic vision coming from senior management, who wanted to train and develop staff, and operational managers who don’t get the vision, feel insecure and use bullying techniques to keep people ‘in their place’. This brought the saying “we have to work three times as hard” much closer to home.
Working in the NHS has been a largely positive experience, but I’ve come up against the usual stereotyping and unconscious bias — like turning up to formal meetings and senior colleagues assuming I’m a note taker or asking me, “Can you make me a cup of tea?”, because they assume I’m an administrator. I remember as a deputy director going to meet staff with our white male recruitment manager, and staff ignoring me and only talking to him because they assumed he was the deputy director. As the social and cultural commentator Afua Hirsch has mentioned, in certain spaces assumptions and stereotypes prevail – in this case that a black woman couldn’t possibly be the deputy director.
As a black woman, there are lots of ‘micro-aggressions’ that manifest themselves in the workplace, especially when you critique, query or challenge the status quo. Managers can feedback that “Cheryl was a little bit aggressive”. You’ve got white people doing exactly the same thing but their critique is accepted as “challenging and authoritative”. Those micro-aggressions build up, leading you to become more constrained and controlled, which means adjusting your authentic self to fit in with everybody else, rather than being genuinely accepted and able to come to the table as you are.
I’m conscious that if I make a mistake, it’s not going to be tolerated in the same way as a white person’s mistakes — the threshold is much lower for people of colour. I think that’s because some people lack confidence in working with people who are different — it’s easier to be compassionate towards those who are similar to you. When you look at the statistics on how many black staff are disciplined, it’s obvious that some white managers feel more at ease hiding behind formal processes.
I’ve been fortunate to have some ‘good eggs’ — supportive directors who’ve encouraged me to build a profile and take on responsibilities outside my role. Now we need those white allies to step up to the plate, do their homework, understand systemic and behavioural injustices and actually start calling them out. It needs to become socially unacceptable — not just corporately inappropriate — to treat a group of people in this way because of the colour of their skin.
We also need to try to humanise the black experience, so other people understand what it’s like to have the security guard follow you around a shop all the time. Talking to my team recently, I found out that none of them has ever been stopped by the police — not one!
With Black Lives Matter, I do think things feel different – we will probably take some strides forward. But when I think of my grandmother’s experiences as a psychiatric nurse — she was one of the first black nurse tutors — and then look at some of the things that have happened to black staff during Covid, I’m not confident that the next generation will see systemic change towards a society that values them.
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:
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.
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.”
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.
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.