The King’s Fund Annual Conference, 2023

The session’s dominant theme became clear early on, as each speaker highlighted the crucial link between inclusive cultures, workforce retention and safe care.

Integral to this was understanding and celebrating ethnic diversity, especially in culturally rich areas and because of increased international recruitment in recent years. Recognising multi-generational differences and the motivations of flexible Bank staff were also key, the audience heard.

Cheryl Samuels said inclusion was about ‘seeing the potential in everyone’ and there should be greater focus on aspirational career planning to increase opportunity for all.

She said: “Sometimes we look at what we see on the face of things. We need to create organisations that are fit for humans who are all different - look different, feel different, behave differently - but actually we're all aspiring to the same thing, which is world-class care.

“We need to recognise there is no one-size-fits-all, and that we need to really start to get to know our people and understand what motivates our staff. We have a multi-generational workforce, and the needs of all those people are very different. You mix that up with migration, and the fact that we keep recruiting our doctors and nurses from other countries - but yet we still haven't learnt how to treat those people well, how to induct them into our organisations, how to socialise them and support them to be in our organisations, and feel like they can start to begin to call this home.”

Martin Griffiths suggested there were challenges both in attracting younger people into healthcare and retaining experienced mid-career clinical staff, some of whom he felt were in a ‘flat cycle’ because they could not develop their skill sets beyond where they are.

He said: “We need to understand what that’s all about and that the careers we work in now are not fit for younger people or older people, and they have to change. Patients deserve better. Patients deserve multi-disciplinary care, delivered by calm teams that are well-led and managed, and for the clinicians within those teams to be respected for their skill sets, and to work in a co-ordinated fashion to deliver care. When we do that, we do our jobs better, our patients do better, and we live better lives.”

The Bank workforce reflected these demographic challenges and therefore needed more attention to ensure safe care in an NHS under severe pressure, the panel said.

The ethnic diversity of the NHS Professionals Bank was up to 10% higher than some internal Trust Banks and a further 10% higher than the substantive workforce, said Helen Ives, adding that the Bank was ‘the only option’ for some minority groups who were seeking psychological safety while delivering care.

She told the audience: “Diversity, inclusion and equality are really important when you come to understand your Bank workforce, because some of that is ‘I can only work here’ and ‘I only feel safe to work here.’ This is tough stuff for us to face into, and very much builds on what we're learning about the experiences of people in the substantive workforce.”

Cheryl Samuels agreed and said there should be a ‘deep dive’ into the Bank workforce to help shine a light on inclusion issues, and to identify what needs to be done at organisational and leadership level to retain more staff substantively.

She said: “It is no accident that the majority of the people that sit on the Bank, internally in our organisations, look like me. And that's where we need people to properly understand systemic and structural discrimination, because we don't have this issue when we look at other parts of the NHS – substantive staff in some cases are ‘escaping’ onto the Bank.

“We need to look at the behaviours of some of our leaders, we need to challenge the mindsets, we need them to start realising there's a proportion of staff who have escaped from the permanent workforce to work on the Bank because they get the flexibility, they get the control, they get to do things that are different, they build on their skill sets, and they can balance their home life with their work. It is about holding up the mirror and being honest and saying: we know there's a proportion of people on the Bank who are there because they've been treated badly in the substantive workforce. That's just not good enough, and it's not sustainable.”

Martin Griffiths added: “Why is it that the demographics in Bank workers are so skewed compared to substantive positions? What is it about the organisation that means that certain demographics don't feel comfortable staying in the organisation and would rather work on the Bank?”

Helen Ives argued that such a Bank ‘escape’ can be seen positively as a ‘retention opportunity’ because it can increase the ‘locus of control’ at different points in a healthcare professional’s life and career.

She said: “Someone switching to Bank needs to be seen as retention within the NHS. They have explored an opportunity that's available to them and said: ‘I want to continue giving patient care, but I’m switching to the Bank where I'm in control of where I work, when I work, I have less politics, less paperwork and I can focus on my patients’. Yes, maybe it's a threat, but also it's a huge opportunity to retain people in a different way of working. This can be a really positive strength.

“We need to face the fact that the world of work is changing. People want more choice, more control and more say over what they do and when. We have to grab it as a retention opportunity.”

Another striking theme emerged during the panel’s focus on inclusion: the need for more kindness in the workplace.

Martin Griffiths said the NHS workforce operated in an ‘attritional environment’ and therefore kindness was essential.

He said: “We've forgotten what we’re trying to do here, which is care for patients, and part of caring for patients is caring for each other and being kinder and more considerate.

“We need to remember that our organisations aren't just built on SOPs [standard operating procedures]. They are built on nodes of competence that sit within people. Institutional knowledge isn't in SOPs, it’s in people and the culture we present. And if that culture isn't preserved by individuals who understand and live it, we’re lost. So we need to make sure we explain ourselves to each other, we are kinder to each other, and we understand the views of everyone in the situation.”

Cheryl Samuels argued that leaders should role-model positive and caring behaviours, especially in the context of inclusion.

She said: “We know there isn't a level playing field. There are lots of disadvantages, and some sections of society come with lots of inequalities, thoughts, beliefs, views, opinions and behaviours. It’s about setting the bar of what's acceptable and what isn't acceptable, and holding people to account for that.

“I'd like to see more listening, more compassion, more caring and more thought. We need to be pragmatic about some of the things we can put in place for our workforce that mean they're going to have a better experience, and break down some of the barriers that exist in our organisations.”

Helen Ives said feedback data from the NHS Professionals Bank showed that ‘basic acts of human kindness’ can make a big difference for the flexible workforce, some of whom can join new organisations and teams on a regular basis.

She said: “It is basic acts of humanity like: ‘Welcome to the team, this is the handover and please join us, there's the break room, let me show you how we do the meds rounds’. It's also things like: ‘I know how to speak up in this Trust, I know how to access training and professional supervision and some level of appraisal’.

“These are things we can take for granted but we now need to  develop and strengthen in our flexible workforce, if we are to make the most of the opportunity to use them strategically.”

While panel members spoke candidly about retention challenges in the NHS, they also highlighted opportunities to innovate and improve the workforce system.

For Martin Griffiths, the sense of unhappiness and ‘existential threat’ felt by many in the healthcare workforce at this time presented ‘a real opportunity to disrupt the traditional narratives around what employment and experience look and feel like, and to change the system for the better’.

Clinical apprenticeships and a fresh look at medical training were two constructive ways to achieve this, he argued.

“What's the problem of apprenticeships? Why are we so scared of them? What's wrong with allowing individuals to enter into a career in clinical work from where they are now? Why do we have to be hot-housed into GCSEs and A-Levels, and pick that tiny proportion of people who meet that target, and then hot-house them into a career and say you have to do this for the rest of your life? What's wrong with starting older, or starting in a different space? What's wrong with getting paid to learn?

“Apprenticeships are the key to attracting and developing a workforce who want to do the work and who have been barriered by the way we select our staff. I think the only way we're going to encourage people who want to have autonomy and choice in their clinical career is to allow them to enter it in a way that's much more equitable. I understand the scare stories about not having appropriate skills. But to me, I'm an apprentice myself. For me, working and learning on the job with experienced people, acquiring institutional knowledge, acquiring the culture and behaviours, being treated as equal as you learn, getting paid and being good on day one - it's an ideal solution, is it not?”

Cheryl Samuels agreed and said apprenticeships were an opportunity to expand the medical workforce so it is more inclusive and better for patients.

She said: “If you want to go to medical school, you've got to have the support, the backing and the finances. There are lots of things you need to have in place to go and do that, as opposed to, for example, choosing to be a bus driver. There is something about how we disrupt the patterns of inequality, and embrace the opportunity to get people in from various parts of society who, once they are in that workforce, will mean that we get greater representation, we get people who our patients will be able to relate to and who will equally be able to relate to their patients.

“There's a real opportunity for us to close the gap around how we communicate with our patients, how we train our staff, and recruit from backgrounds that are representative of the communities in which they serve. I don't think we've cracked that at all levels across all the professions.”

Cheryl continued by saying there should be a stronger emphasis on values and behaviours in recruitment, adding:

“We haven't got all our leaders and recruiters used to really looking for the values that people espouse and recruiting for that. I've sat on many disciplinary panels and appeals in my time and when you look at the sort of conduct issues involved, they could have been resolved had people just had a different attitude, different behaviour, different communication style and a different way of handling conflict.

“If we were tested for some of these things, it would mean we were recruiting values-driven people, we would have the compassion in our organisations, we would have people who are caring, respectful and thoughtful. Instead, sometimes we are testing for technical skills, which are not really needed for some roles at a senior level.”

Martin Griffiths, who works closely with medical undergraduate programmes, said: “Nobody cares what I look like at 3am if I’m competent, do they? We need to work around competence rather than qualifications.

“Competence-based practice is important; how you get to that line isn't really important. I don't think we can all come from the same lineage and say that's right. It doesn't make any sense. Our patients aren't that way, our staff aren’t that way. We need to get the benefit from having a diverse workforce, not just in demographics, but in experience and journeys [into medicine], because that gives us a much more powerful ability to support our communities, patients and organisations.

Responding to panel chair Anne-Marie Archard’s question ‘Where is the hope?’, Helen Ives highlighted positive examples of working differently to solve recruitment challenges at scale.

Helen said: “When we've put things in place with our partner Trusts, such as net-new programmes for healthcare support worker development, we've found that we do that at scale really well in the NHS. I was privileged recently to judge the Nursing Times Workforce Awards, and I heard real bright spots of working differently at scale and bringing new people into organisations from new demographics. The spirit of that was also captured in the Long Term Workforce Plan.

“Having said that, we've got to break some stuff down. As the largest employer in the UK, we need to have a strong voice about how apprenticeships run, what flexibility they have and how we can access the Apprenticeship Levy, for example. If you're a Bank worker and not an employee, you can't access the levy, which is a real own goal because we have so many people working on the Bank who are exploring possible career options in the future, or maybe working at a particular practice level and who are really keen to top up.

“We need to explore innovations like flexi-job apprenticeships, where we can think differently about how we deploy healthcare staff and how we use that 20% off-the-job time – perhaps working flexibly in another team, for example.” 

Cheryl Samuels said it was important for training programmes to ‘positively disrupt people’s thought patterns’.

She said: “It’s about starting with self, and starting to challenge your own perceptions, beliefs and biases, whether they are about flexible working, understanding how teams work, or inclusion and belonging. It means having trainers who are giving you perspectives and thoughts around things that ordinarily you might not have been exposed to, depending on your background.”

For Martin Griffiths, supportive coaching was ‘integral’ to the development of effective clinical skills and practice. ‘Professionalising’ this support, so it was a core part of clinical practice and there for everybody at all points in their careers – especially new starters and those from different backgrounds – was another important opportunity to be more inclusive and improve NHS care.

He said: “We shouldn't just coach people ad hoc or because we like them; we should do it as part of our practice to make sure everybody in the system has somebody to support them. It's very hard being the first one in a space, or the odd person out. We attract people from diverse backgrounds, but they're not supported and you have to have somebody to help you navigate the system. I think when we do that bit right, we will see our service flourish.”