The Times Health Commission: Work and health
I was one of over 600 witnesses that gave evidence to the Times Health Commission, set up over one year ago. The Commission’s report was published earlier this week and interrogates the challenges faced across health and social care, with a view to recommending a way forward. Here are the work and health highlights.
The poor health of the nation is affecting productivity
Higher than ever numbers of people of working age are falling into economic inactivity due to ill health. Mental ill health and obesity are significant contributors. The shortfall of the health service resulting in delays in accessing healthcare is perpetuating this.
There is a proven connection between health inequality and economic inactivity, which is why addressing social determinants of health is so important.
Addressing social care provision will enable a large number of unpaid carers to go back into employment with positive consequences for the economy.
Statutory sick pay reform should be considered to broaden eligibility for sick pay and allow payment from day one rather than day four. This will help contain presenteeism which has a negative effect on productivity, as well as reduce the spread of infectious diseases through work. Implementing this would be of overall economic benefit.
Radical change is required for the NHS to be sustainable
Organisational memory is very short, and recent decades have seen reshuffles across health service infrastructure without significant benefit to patients. Reshuffles are costly and organisational change is an additional stressor, challenging for staff to navigate.
The Commission concluded that changing the NHS funding model may cause significant disruption to the NHS, with no guarantee that the situation would improve as a consequence. Instead, looking to technology, analytics and decentralising control as routes to increasing efficiency within the health service were recommended. Research and clinical teams need to achieve better integration and we should be working towards a unified patient record.
The other critical route to leverage, which would take considerable investment to achieve, is a pivot to prevention rather than a reactive approach to healthcare. Difficult to reach working age populations could be targeted by mobile screening services coming to the workplace. Helping people age well should be part of the prevention agenda.
Changing how we work
New ways of working are emerging that streamline service delivery. Successful initiatives include high intensity theatre lists and surgical hubs, and distilling acute and planned care into entirely separate workstreams. There are examples of GP practices being absorbed by integrated care systems, in a model that is working well in some parts of the country. Some integrated care systems are looking to take over local social care provision to enable further join up.
Opening up lines of communication between community and hospital teams via weekly meetings to discuss high priority patients can reduce the admin burden on clinicians. Asynchronous communication between patients and clinical teams can help appropriately triage non-urgent health issues, such as the use of online consultations in general practice.
Recognising the wider determinants of health will involve integrating healthcare with support for wider social needs, including housing and employment support. Deploying non-clinical staff to community care settings could help achieve this.
Smarter ways of working will include investing in and integrating technology to expand service provision and relieve workforce pressures, as well as supporting the prevention agenda. Use cases include deploying AI in diagnostics, logistics and giving wearables to patients to incentivise healthier behaviours.
Bolstering the workforce
Current workforce plans are inadequate and do not address the pervasive issues with retention. At the same time, the NHS is already the biggest employer in Europe. The IFS forecasts that by 2036 the NHS will be employing one in 11 of the entire workforce in England. It is unsustainable to think that continuing to expand the workforce is the solution to bolstering service delivery. Instead, change in how the NHS operates is necessary, as outlined above.
This said, unacceptable pay and working conditions must be addressed to achieve retention of existing staff. Market forces operating through agency recruitment indicate how significant underpayment can be- with some rates being escalated to thousands of pounds per day before staff are willing to undertake them. Incentives must be improved for permanent staff to be retained. Nurses are quitting their NHS roles and moving to work in supermarkets where pay and working conditions are better. More staff are leaving the NHS because of poor work life balance than reaching retirement age- people are no longer able to shoulder the personal cost of working for the NHS.
The NHS workforce is 80% female, and 25% of staff come from black and ethnic minority backgrounds, yet there are still issues with the gender pay gap and toxic culture in workplaces including bullying, sexual harassment and racism. There remain issues with freedom to speak up when they witness poor care towards patients or staff.
The Commission recommended the foundation of the National Care Service to run in parallel to the NHS, with funding for social care to continue to be means tested with a higher asset threshold than currently in place. The recommended cap on social care costs- that nobody should pay more than £86 000 towards their social care in their lifetime, pledged to come in in October 2023 but still pending must be implemented. The National Care Service should hold independent providers to national standards and have its own workforce plan. Social care workers should receive parity to their NHS equivalents in terms of pay and working conditions.
The NHS workforce plan should include non clinicians in its strategy- from software engineers to health coaches. Doctors should be given more control over where they work during postgraduate training and healthcare professionals who stay in the NHS should be supported with their student debt through loan forgiveness schemes. The private sector could also contribute to medical training.
Report highlights
If nothing else, I recommend reading the ‘On The Front Line’ and ‘Patient View’ sections of the report, which go some way to illustrate the human aspect of what is happening in health and social care today.