Leadership is critical to help address the UK's NHS retention crisis, researchers say

Frontline health care workers in busy hospitals feel that they are "just rearranging the deckchairs on the Titanic" according to new research into the impact of under-resourced and high-pressure emergency hospital departments in the UK.

A study from the Royal College of Emergency Medicine and University of Bath, led by clinical psychologist Dr. Jo Daniels in collaboration with colleagues at UWE Bristol and the University of Bristol, argues that hospitals need better leadership to help change cultures and support people's basic needs. The work is published in the Emergency Medicine Journal.

In addition to reflections from current frontline doctors, nurses and advanced clinical practitioners, the research also features exclusive interviews with household names in the UK: former doctors turned comedians. Adam Kay, Harry Hill and Phil Hammond all offer reflections on why they left, and how they hope the NHS can be better managed in the future to avoid others from doing likewise.

In February 2023 a University of Bath IPR report concluded that as many as one in seven health care workers were actively trying to leave the NHS. According to the Royal College of Nursing, almost 27,000 people left the register in the past year, with more than half leaving earlier than planned citing burnout, workload, and concerns over care quality.

The new study investigated perceived barriers to implementing better working practices and conditions for emergency medicine clinicians in the UK.

Building on previous work from the team looking at the toll of COVID for health care workers, its analysis highlights multiple issues associated with poor retention. These include a culture of blame and negativity in hospitals, untenable working environments, compromised leadership, as well as a perceived general lack of support leading to burnout and low morale.

Across the board, participants reported feeling undervalued due to their basic demands being unmet. These ranged from "sharing toilets with patients" to poorly functioning IT systems, or the absence of rest spaces and staff rooms. A lack of private space within hospitals meant many also found it hard to decompress.

In an accompanying video to the research, comedian and former doctor Adam Kay described a toxic culture where "it was a a badge of honor to work as hard as possible," where staff felt blamed, disempowered to seek support as they should be "unbreakable," and where expectations set were unrealistic.

A lack of formal training for consultants in charge of busy wards was also highlighted by a number of participants, as was the need for more "visible, compassionate leadership." Reflections from people interviewed suggested that leadership training should be embedded as part of medical training.

"We need to say to doctors, one really interesting career pathway for you is to get involved in NHS management and clinical leadership. And not in a way that says 'we have gone over to the dark side,'" said Phil Hammond.

When considering how staff continue to work in such difficult conditions for so many years, Harry Hill emphasized the "force for good" that has traditionally motivated NHS staff. Yet he suggested, after repeated reorganizations and a lack of support, this was wearing thin:

"When I was a doctor, doctors…were held in some esteem by society. That's gone to a large extent," said Hill.

Lead author Dr. Jo Daniels of the University of Bath explained, "At a time of national crisis in the NHS, with overstretched resources leading to long waiting times for patients and burnout for staff, our study asked what more could be done to improve the current challenges of staff retention.

"A common thread that emerged across our interviews was the critical importance of leadership in hospitals. Those in leadership positions are powerful agents of change, and have pivotal influence over team functioning, staff well-being and patient outcomes. However, lines of accountability and communication with executive management need to be clarified, opened up and improved.

"A new focus on leadership training and ongoing support for those in leadership roles will be critical to this. Given its central importance and the scope for leadership improving well-being at work, we have a prime opportunity now to address the problems which force staff to leave the workforce. Harnessing the potential in our leaders is where our focus should now lie."

Dr. Adrian Boyle, President of the Royal College of Emergency Medicine, said, "Working in emergency medicine can, by its very nature, be a high-pressure and stressful job. Our members, and their colleagues, who go above and beyond for their patients day in day out, should not also have to battle a system which is meant to be there to nurture and support them. We thank Dr. Daniels, her team, and all the clinicians who gave their time to take part in this important piece of research.

"What it reinforces is that the NHS must get better at caring for its workforce—its people are its greatest asset, and everything must be done to ensure their welfare. This research will now be shared with policymakers and will form part of the College's advocacy work to help inform and bring about the cultural shift that is so needed in our A&Es."

Moving ahead, the team involved in the study will also work with the professional bodies to help improve training and policies.

Dr. Daniels added, "We have outlined specific steps that can be taken by NHS trusts, but we need to start with recognition of how important this role is, and how vital it is that those in leadership positions are supported to lead. Without strong leadership, we can expect poor outcomes for all."