Passing the duvet test

Kevin Lewis voices his concerns with the latest NHS recruitment drive and why so many working in the industry aren’t going to sleep happy

At a CPD event the other day I bumped into someone I first met more than 40 years ago, when he attended a lecture I was giving. He reminded me I regularly used to refer to ‘the duvet test’, and proudly confirmed that since going part time, he passed it much more often than hitherto, and with flying colours, too.

I should explain that this test relates to what goes through your mind at the end of the day when you shut your eyes and disappear under the duvet. If you are smiling, happy and contended – perhaps because you have had a fulfilling day and/or are looking forward to a day or weekend off – you pass the duvet test.

If instead you have had a rotten day and/or experience a deep sense of dread whenever you are due to be doing dentistry the following morning, you fail the duvet test. I used to say it was perfectly OK to be smiling more broadly on Friday nights than on Sunday nights, but you still need to be able to force something of a smile when you are working the next day. A ‘yippee’ is not mandatory.

I am not sure how many dentists would pass the duvet test today. The evidence – from the BDA’s surveys and from the latest published versions of the government’s own annual statistical report on Dental Working Hours, Working Patterns, Motivation and Morale – makes for depressing reading.

A staggering proportion of dentists report low or very low morale, high or very high levels of stress, and the responses of a high number of them indicate they are thinking of leaving the profession within the next five years.

Recruitment drive

It is against this background I have been reading with incredulity about the NHS’s latest global recruitment drive. And, before you say a word; yes, it is uncannily like the last recruitment drive (the one that didn’t work) and the one before that. The key difference is the gap they are trying to plug is so much bigger, that the numbers of new people required are bigger, too.

NHS Improvement, tasked with the creation of a sustainable workforce strategy, plans to more-than-treble the number of ‘foreign’ (sic) nurses coming into the UK to work in the NHS, and to maintain this new level for each of the next five years. Good luck with that one.

They are planning to plunder the same impoverished countries as usual, creaming off the best of their healthcare workforce, but this time they will be offered a free movie on medical ethics to watch on the plane.

You know the bit in the flight safety briefing, about fitting your own oxygen mask before helping other family members? Basically, look after number one first – which is precisely what the NHS seems to be doing. 

There is also the tiny problem that has beset every previous stab at workforce planning. In fact, three tiny problems, which together add up to another whopping great problem.

Firstly, there is no point dragging people – even vast hordes of people, assuming you can find them – in through the front door if you are still losing shedloads of people out the back door. You have invested heavily in training all these people, so why not start by investing in retaining a greater proportion of them?

Secondly, the demand itself gets bigger while you are busy trying to meet the demand you started with. And thirdly, any resulting shortfall between supply and demand is compounded year on year, so you accumulate an ever-increasing backlog that will take many years to reduce, which then becomes a casualty of short-term budgetary constraints.

The view of the chief executive of the Royal College of Nursing is: ‘Ministers have abused the goodwill of nurses for too long and that dam is starting to burst. The modest increases (in planned extra headcount) are not of the scale or kind to meet demand and the workforce crisis isn’t abating.’

Applications for training places in nursing have fallen by a third since 2016, so she appears to have a point.

Meanwhile, the medical GP shortages in England alone will have tripled by 2023-24, if a recent report from the Health Foundation, King’s Fund and Nuffield Trust is to be believed. A worse GP crisis in Wales has also been highlighted.

Unnatural wastage

The erosion of any skilled workforce is always tragic, but when it’s designed into the system and how it operates, it brings a whole new meaning to the understated term ‘wastage’, which is so beloved of workforce planners. Wastage it most certainly is.

But when you desperately need precious skills known to be in short supply – and cannot easily replace them, substitute them or approximate to them – it is beyond wastage. It would require a septic tank of industrial proportions to contain the management incompetence that allows it to happen.

On the subject of which, the NHS people plan itself refers to the infamous ‘revolving door’ history of failed and discredited NHS managers collecting their exit payments, and resurfacing in another equally senior role somewhere else in the NHS.

It concludes: ‘It cannot be right there are no agreed competencies for holding senior positions in the NHS, or we hold so little information about the skills, qualifications or career history of our leaders.’

The NHS is apparently ‘committed’ to creating a set of core skills, values and behaviours for managers in various roles. Stuff such as respect, honesty, decency, fairness, compassion, a sense of accountability and having the competence required to do the job, presumably.

But creating? You cannot be serious. This is the UK’s largest employer by a country mile and we are still thinking about making a start on basic stuff like this? It explains a lot.

All this prompts me to think again about that duvet. There may be a simple explanation for why so many people in NHS healthcare, and public services more widely, seem to be failing the duvet test so comprehensively and consistently. The bed (aka the true cost of providing the service the public expects and is being promised) is clearly a super king, but the duvet (the money on the table) is only designed for a double at best or, more likely, a single.

The duvet is never going to be big enough to keep the whole bed warm and cosy at the same time. Someone has to lose out – and no prizes for guessing who that might be. In fact, the patients are losing out too, because, as the BDA has been pointing out so effectively, the government cannot say much about access problems in dentistry, when the funding is only sufficient to commission services for half the UK population, and when they keep nicking dental money to pay for other NHS services.

Studied inactivity

Dentistry – and notably the BDA – has been warning the government that they have sown the seeds of a similar crisis in primary care dentistry, and the fact that 13 long and painful years have passed since the creation of the UDA system is evidence enough that the government is not remotely concerned because after many decades of trying it has at last stumbled upon a way of controlling and containing its expenditure on the general dental services.

It has turned hand-sitting into one of those new competencies for NHS managers and commissioners, if not into an actual artform. It has certainly provided an extended masterclass in studied inactivity.

I am all for having a plan when faced with a problem. But the ability simply to write one – especially based on cutting and pasting from previous failed plans, and plucking yet more hopelessly unachievable numbers out of thin air – doesn’t cut it any more.

Platitudes such as ‘it’s not just a question of money’ don’t help either, especially not when even the existing money is disappearing faster than you can say ‘clawback’. Nor does tinkering with the definitions so that ‘doctor’ doesn’t necessarily mean a ‘real doctor’, but someone whose job title is designed to sound a little bit like a real doctor.

We need more than smoke and mirrors, and a lot more than a plan.

Wherever one looks in the NHS, and I include dentistry in this, the morale crisis and the levels of disillusionment, chronically high workload and stress levels and evidence of burnout are all around us.

Where is the sense in recruiting more people into a system with such fundamental and intractable endemic problems, yet to be resolved?

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