NHS staff still going the extra mile

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By Professor Mark Exworthy, Health Policy and Management
Health Services Management Centre, University of Birmingham.

Since March 2020, the commitment and hard work of NHS staff have been widely recognised as they respond to the covid pandemic – the regular 8pm `clap for carers’, impromptu street signs and banners across the UK, the  Queen’s birthday honours, as well as the recent announcement of the George Cross to the NHS.

Many NHS staff do indeed regularly ‘go the extra mile’ to undertake additional work beyond their contracted hours long before the pandemic.

`Going the extra mile’ has been termed donated labour or discretionary effort. It is a notable and persistent feature of the NHS workforce. Donated labour refers to labour supplied but not contracted for, unpaid overtime, circumstances where the worker contributes effort that is not fully compensated by wage payments, and willingness of workers to both fulfil and go beyond formal job requirements. It entails extra tasks undertaken during work alongside existing responsibilities and work outside normal hours. Donated labour includes (for example): volunteering for activities beyond the usual job role; putting in extra effort (e.g. forgoing breaks); working/staying in an organisation despite hardship (e.g. Impact of pension rules); helping patients/carers and co-workers with personal matters.

According to the NHS Staff Survey 2020, 54% of all staff work additional unpaid hours each week, with one in seven staff working 6 or more extra hours each week – unpaid! For example, the Tavistock and Portman NHS Foundation Trust and the South London & Maudsley NHS Foundation Trust both record 25% of staff working unpaid for 6 or more hours pw – the highest among NHS providers. (Milton Keynes CCG records a figure of 42% of staff).

For some time before the pandemic began, NHS staff had been feeling the strain of rising patient demand, increased co-morbidity and staff shortages. The Long Term Plan, Interim People Plan and Pay Review Body have emphasised the importance of NHS staff having `rewarding jobs’ and `support to manage the complex and often stressful nature of delivering healthcare.’ Positive work environments (with supportive HR practices and recognition procedures) are linked to staff wellbeing and productivity.

Yet, the majority of staff work additional unpaid hours each week which will reduce staff wellbeing, reduce quality of care and put patients at risk. Assigning extended hours and unexpected shift changes (forms of work intensification) might result in staff fatigue and disregard the personal/family needs of the workforce. Also, low staff morale has a negative impact on wellbeing, compounding difficulties in recruiting and retaining staff.

In some areas of the NHS, there is a deep-seated culture of long working hours that many staff find difficult to challenge and some staff do not recognise the need to care for their own health. Staff may become increasingly expected by employers or peers to work longer.

Donated labour stems from the commitment and ethos of staff and reflects the values, norms and customs of clinical staff about what is expected of them (such as working additional hours or roles) and what they offer in return. Much of this is rightly praised and valued by the public. However, if the NHS promotes or relies on donated labour, especially where it is part of a managerial culture, then it is in danger of exploiting professional ethos and commitment (e.g. via bullying or harassment). Donated labour might therefore increasingly compound further the effects of staff shortages – currently, over 100,000. An offer of a 1% pay rise is likely to do little to alleviate the situation. (This compares to France where nurses have been awarded an average increase of €183 per month). Potentially, donated labour could result in overworked, demotivated and under-valued staff, leading to unsafe practices, poor patient experience, toxic team cultures, staff sickness and poor staff retention.

Therefore, a better understanding of relationships is therefore important to inform workforce strategies and support staff well-being so that they can provide better patient care through the on-going effects of the covid pandemic. However, the various forms of recognition over this past 18 months are important symbols of the nation’s collective gratitude to NHS staff but such recognition needs to be reinforced by material measures, notably pay increases, staffing levels, better retention policies and work environments.

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