To ask how NHS managers get away with it...

[cakehoover123]

Have friend who works for an NHS service and is constantly asked to work beyond her hours, take on unmanageable caseloads so she ends up doing admin in the evenings, etc. This is because there aren't enough staff and they can't recruit.

She says she can't say no, because if she does the service will fall apart. She's permanently terrified that she'll make a mistake through exhaustion and get struck off.

But surely the managers should be held accountable for this. If a manager can't run and staff a team safely, within normal working hours, that's a massive management failure.

In my (private sector) job, if a manager asked me to work like that, I might do it for a week but any longer and I'd say no, and if they pushed, I'd be raising concerns about them with leadership. And if leadership didn't fix it, I'd leave.

How do NHS team managers get away with pushing their recruitment and retention failures onto exhausted frontline staff? Why aren't senior managers holding them accountable?

Is it because frontline staff don't want to fail patients, so they just keep working? But even then - having exhausted staff isn't actually good for patients - and surely managers should have the courage to point that out.

YABU - you don't understand the NHS / your friend is an exception
YANBU - it's nuts.

@TippledPink thanks for your answer. That sounds like a really difficult situation to be in, I hope things improve.

This thread has nothing to do with Lucy Letby case btw - didn't even occur to me anyone might think that!

I've worked alongside some very good managers and some idiots, but either way, they do often get the blame for things that are outside of their control.
I was the Clinical Director of an understaffed department for many years and yes, I asked colleagues to do unreasonable things sometimes (and did them myself ) to ensure the service was maintained. And it isn't that nobody was trying to recruit extra staff, but there are not enough in the country and various government policies over the years have made it much more difficult to recruit from overseas. Trusts are competing amongst themselves for doctors so a small Trust that is already short staffed and has less money is at a huge disadvantage and ends up basically held to ransom by ridiculously expensive locum agencies. There just isn't a limitless supply of funds and employing locums brings a plethora of it's own problems so there is no easy answer unfortunately.
It is easy to blame frontline managers, and yes, I have met some who I think were useless and a few I think were actually amoral - but I could say that about clinicians too. But actually plenty of them are decent people trying to do a decent job in nigh on impossible circumstances having to chase ridiculous targets and given accountability but not the authority to actually fix things. Pretty much everyone thinks they could run their department better than the current managers and that the solutions are obvious - until they try to do it. I was much the same until I became Clinical Director and I had to eat a lot of humble pie when I learned more. Many of the best people I have worked with have left the NHS because they know they've got an impossible job. The root of the problem lies with successive governments but of course it suits the politicians to blame incompetent staff, whether clinical or managerial.

I work in nhs community team. My line manager and team manager are the best I have ever worked with and shield their staff from much of the rubbish flung our way and the ‘perform miracles with less’ rhetoric. This has also been the case in previous teams I have worked in. Maybe I am lucky?

We cannot recruit health professionals for love nor money. Gaping holes in staffing within the team but the referrals keep on coming and so those of us left see our caseloads and risk rising to unmanageable proportions because otherwise what is the option - oh yes, the team is ‘breaching’ arbitrary timescales. So our service users by default get substandard care from those on the ground doing the their best but thwarted by the system we work in. Deeply unsatisfying for all involved!

Slightly off on a tangent there but the mess the system is in is squarely not on the shoulders of the band 7’s on the ground doing an absolutely thankless job! Maybe it is fault higher up the food chain…but we never see sight nor sound of those people in our day to day work…..

I work in the criminal justice sector where it's the same as your friend describes. We cannot recruit, it's not a management failing when your payscales are set by the government and no one in their right mind would come in on that salary now. It's also why we lost staff quicker than we can recruit, yet even very senior management have no influence over pay

It's not just the managers at CoC though. There have been cases all over the country of frontline staff being persecuted for blowing the whistle on unsafe hospitals. If/when the trust directors do get found out they just get promoted out of harm's way.

https://www.bbc.com/news/health-66051884

https://www.theguardian.com/uk-news/2016/feb/04/dismissed-nhs-whistleblower-who-exposed-safety-concerns-handed-122m

www.bbc.com/news/uk-england-cambridgeshire-65461463

We get the pressure to stay past hours from seniors (they are all trained and qualified to do the work themselves)
It is the seniors who say - I have to leave early today as my normal train has been cancelled so I need to get the earlier one (how about getting the later one).
Or phone at 5:35 to say can you do this for me.
Or can work from home.
Or in the morning say why wasn't this done last night (the request was made after normal hours).
Staff will do this because patients will otherwise suffer and partly because they are scared of the managers.
We do have one member of staff who will say do it yourself to a senior (that person is approaching retirement and has no worries about references etc) although that person will always stay and help

Lol at you thinking this is an NHS thing, (if you're genuine - my guess is this another 'woe is me, I work for the NHS' thread). The additional hours worked in the private sector is generally considerably more than the NHS.

Until recently I was a Clinical Director in the NHS. I worked alongside many clinical and non clinical managers and I've found that a lot of the issue is with clinicians who have been put into management positions without adequate training.

Whilst the non clinical staff tend to have training or experience in managing people and systems, often us clinicians are put into senior lead positions where we are expected to advise on pathways and strategy with no knowledge of what that means.

NHS managers are the scapegoat for the failure of the government to fund and resource the service properly. They are criticised by those on the frontline who don't understand the pressure of the job (see above) and, dare I say about my fellow clinicians, often have a martyr complex. They are criticised by patients and public because they don't speak out to defend themselves and because patients think they know more about how the NHS runs than they actually do, they also don't understand the job. And they are criticised by the right wing media because they are an easy target for covering up the real problems in the NHS which is lack of investment by central government.

Because most of the work that goes on in senior management is invisible to the front line staff and the public, they don't know how many hours senior managers and clinical leads actually have to work just to keep things going....not make the improvements we can see need to be done....but just to get that service, that hospital open and running each day.

A senior manager once said to me that their roles will only be understood if they all walked out one day. However, they won't. They don't even strike...yet continue to support the front line staff.

Whilst there are individual failings with some people in management in the NHS, and it would seem to be the case in this case, those failings will be investigated. However, we must also be aware that whatever failings elsewhere, that the actual blame for those deaths lies with one person and she must not be excused from her part in it by saying oh it's the managers faults. The murderer is always responsible for murders they commit.

I agree with what you say about Band 7’s.

Across the unit I used to work on there were six Band 7’s (the ward managers) and
they were amazing. They were so supportive and genuinely cared for the staff and they took on a lot of extra duties to try and relieve some of the pressures on their nurses.

They were incredibly burnt out too but you always felt they had your back and you could go to them about anything and they’d do their best to support you.

It’s the Band 8’s and above that were the problem. They may have had some infrequent occasions where they showed some care and compassion towards struggling nurses but it was all very superficial and come the next day they’d act like the same nurse and her problems never ever existed in the first place. Staff are lucky if they even get a hello out of the matrons even though they know much we’re struggling.

There is always an element of feathering your own nest when you get higher up the chain and the NHS is no different.

Management failings at that hospital illustrate how dangerous that is.

I work for the NHS. I think a problem is that no-one can or will admit that their team is unable to meet their objectives. In a previous job I felt that we were a failing team, but no one said this.

The problems are really systemic. And also in my experience not always a money problem.
I'm a nhs manager for a community mental health team

We have several vacancies in our team that we simply can't recruit to, we can put out the advert multiple times but people don't apply.

When teams get given a burst of new money, they fill that with staff from other services because everyone is fishing from the same tiny pool of applicants. Say the ward gets given a big boost of money for attractive roles, the staff that fill them will be coming from other teams in the local area leaving them shorter staffed thus less likely to provide the care to stop people going into hospital.

What happens is we are short of say nurses, that means the burden on the other nurses is high. Those nurses might then either leave to try and find a less stressful role, or they go off sick. When that happens the burden then increases on the other nurses. What this means is that often by the time I've managed to fill a vacancy, or get a staff member back of sick, the remaining nurses have had enough and one of them will then be off. And so the circle repeats.

When we have new staff, the current staff are often stressed so we don't give them the best induction or shelter them in the way we should thus they also leave.

Your team then gets a reputation for being stressful thus no one then applies for a job. Thus your short staffed and it becomes more stressful.

When your short staffed, there's more chance that people miss vital bits of paper work etc so have trickier relationships with management= thus more stressed and less likely to stay

We have a slight excess in our budget, but what we have done is convert the funding for harder to fill qualified roles eg Dr's, RMNs into more diverse roles that re can recruit to. For example admin to take some of the administrative burden off the Rmns, or less qualified staff. However there are some roles and responsibilities that simply must be taken by certain staff and that staff group is ever decreasing.

Even things like admin roles are becoming harder to recruit to.

They are focusing on recruiting things like b5 mental health wellbeing practitioner posts because they now they can't get nurses but those posts can't do everything a nurse can. Thus all the easier cases, the ones where people are progressing well goes to them, while the nurses are left with a caseload of the same numbers as before but much more acute then before. The case loads become unbalanced with difficult cases, volitile cases more time intensive cases because only they can deal with the level of risk = more stressful/ less likely to stay

There has also been times where we have had to decline things like students, lower band staff, junior Dr's because we simply don't have the ability to supervise them properly = less staff

We aren't able to be fussy, often jobs only have one candidate (if any) thus underperforming staff members is common = more stress for everyone else.

it's hard to get people out of the nhs, but also people now tend to have a pick of jobs. It was really common for people to spend a few years as a b5 nurse as a junior, I'm now seeing people leaving university and being offered deputy ward manager posts, senior staffing posts. Some of the management haven't been qualified that long as the vaccum means people get pulled up quickly

People get a level of care that they aren't satisfied with , thus shout at staff, become more difficult. They then moan on social media about the profession = people don't want to stay

People here that professions are getting stressful during to short staffed= people decide not to qualify= job short staffed

You could give me a fair amount of money at this time but it wouldn't change much for my team. I can do things to support wellbeing like give fruit, give good incentives etc but I can't give them what they need the most which is more staff

This article shows some midwife stats that NHS loses 29 midwives for every 30 that it trains. So the numbers are leaving quicker than we can bring people in.

https://www.telegraph.co.uk/news/2018/09/12/nhs-loses-29-midwives-every-30-trains

Putting patient care to one side (I know unreasonalistic) what would happen if the team just said no, I'm not doing over time and I'm just doing my designated hours and they went home. What happens to the team or individual. Would they get fired for just doing their job in the time originally allocated.

Yes this is definitely an issue for many employees. I think the difference is that its potentially 'easier' to move employers in the private sector if you aren't happy - depending on how niche your job is of course.

In the NHS, you can become trapped as you're only trained for that role and it's hard to get comparable pay outside of the NHS because you aren't trained or qualified for anything else.

Plus you are motivated by your duty of care, whereas (for example) my husband has no motivation to work unpaid (he's not motivated to make his company owners richer funnily enough).

But I don't doubt that the same issues exist outside of the NHS. Though they don't face the same scrutiny and negativity from the public.

I guess it depends on the acuity of the work. For example if you just went home after your shift with no midwife to hand your labouring woman over to and so left her unattended - I would expect serious repercussions for that midwife.

Whereas if community physios refused to work overtime, lengthening their waiting lists, I wouldn't expect there to be repercussions.

Ultimately we have professional registrations that mean we are legally obligated to keep people safe. In my profession, we legally aren't allowed to just walk away from caring for someone, so if there's no one to take over from me, what other choice do I have but to stay?

Depends on what that means.
You for example wouldn't be able to leave a ward with no qualified staff on it, or you wouldn't be able to leave patients in dangerous situations. Every qualified member of staff has a professional conduct committee so you couldn't say I wad done with my working hours so I left that patient unattended, didn't sort out emergency care etc.

There are also some things like you would need to complete the relevant paperwork otherwise your putting people in danger, and would potentially be put up to competancy reviews if you hadn't done the minimum expecting of you. You might find that your time management, and prioritising gets scrutinised

Some things though aren't essential and it would be okay to time out.

I agree with a previous poster, some staff fall into a trap of thinking the whole nhs rests on their shoulders, thus don't step back when it would be OK to step back. Lots of things (depending on your role) can be passed on

People are often motivated to go above and beyond which is lovely but you might find yourself under scrutiny if you are spending time doing things that aren't a 100% essential, if you aren't also completing the essential tasks.

You also might find your team resents you if you are always passing a lot of work on to others that they feel you could have completed.

Local authority senior managers ditto. Regularly worked 50 hours weeks as a junior manager.

DH works in the private sector and there are times when he has to work late - completing a project, submitting quarterly reports etc but it is not every day and every week and the team does get an acknowledgement for the extra effort.
If we say no - patient may have to remain in hospital for another day, clinic waits are longer and tomorrow's in tray gets bigger.
Our seniors do not have manager training.
A lot of the non direct patient related work gets left or given to placement students to do or to those staff doing post graduate qualifications to do as their assignments

I don’t think what you described is exclusive to the NHS

The additional hours worked in the private sector is generally considerably more than the NHS.

The difference being you usually have more mobility in the private sector, if one employee is difficult the chances are you can move to a better employer, or use your transferable skills elsewhere.

Public sector jobs are different. You usually have invested time and money into a vocational skill (nursing, social work, teaching) and if you want to continue in that profession the chances are your employer is going to be in the public sector, with nationally set salary scales. There’s limited scope to progress outside your chosen profession and once you’ve been in post for a while you get stuck due to pension arrangements and annual leave (which tend to be the payback for lower salaries). You have a professional registration to maintain that will have expectations that you work safely, don’t compromise safeguarding etc which mean you can’t just stop when your shift finishes, and you don’t get paid overtime to compensate and TOIL means you’re robbing Peter to pay Paul all the time.

I worked long hours in the private sector but could negotiate my salary, change employers easily and my salary was higher. Moving to the public sector I still worked long hours, the work was emotionally demanding and carried a high level of risk, but everywhere was the same so moving wouldn’t help much.

How many folk here would be happy to think the social worker in some of the recent child deaths had decided to finish at 5.00 rather than complete their assessment report because “sometimes you need to let things fail”. The public sector do jobs considered necessary for public health and well-being, and I don’t know any part of the public sector that isn’t in crisis.

I work as a PA in the NHS supporting three band 8s and I can categorically say that all of them work those same stupid hours, and on call on top. Two of the people I work for also work clinically to fill gaps and have maintained their registration. Don't blame NHS managers. Blame the government.

This.

Medics are part of the problem too - the consultants are the lead professionals and yet many refuse to shoulder their part of the management burden. I have colleagues who refuse to turn up to “admin” meetings, yet complain endlessly about poor management. Non clinicians aren’t mind readers, and as long as some clinicians think that management is wasted time pushing paper then we’ll never win. I think the NHS spends far less on management and back office functions (IT anyone?) than comparable systems in Europe.

Agenda for Change is a real problem, too. Good staff can’t be paid more, and it leads to bizarre situations where our pathology service has loads of band 4 posts it can’t fill, budget underspend because of that but isn’t allowed to recruit band 5 or 6 staff. We’d be better off with fewer higher paid staff which we might stand a chance of recruiting, rather than endless band 4 vacancies.

This:

And the managers already know what the staffing levels vs workload are. It's not like they're going to receive an email giving them information they're not aware of.

I have colleagues who refuse to turn up to “admin” meetings, yet complain endlessly about poor management. Non clinicians aren’t mind readers, and as long as some clinicians think that management is wasted time pushing paper then we’ll never win. I think the NHS spends far less on management and back office functions (IT anyone?) than comparable systems in Europe.

I've had clinical colleagues do the same. They don't bother to turn up and leave the non clinicians to make the urgent decisions, then bitch about those decisions and generally make life awkward for everyone.

I'm a doctor, but I really admire the vast majority of non clinical managers I've worked with. They are shown a complete lack of respect by some clinicians even though their jobs are tough as well...just in a different way.

I'm currently on secondment in the civil service and working with some amazing people who have no clinical background at all but who instinctively understand patient pathways much more than a band 6 nurse on a ward who only has to think about that set of patients in that ward at that stage of the pathway. I have learned so much from them and genuinely looking forward to going back to my Trust with ideas for training my colleagues.