Research and analysis

Chapter 2: where the NHS is today

Published 17 December 2025

Applies to England

Summary of findings in this chapter

Both the public and staff say the NHS is in crisis. The challenges they face working, accessing and using the system are much more salient than things they feel are working well. When talking about the aspects they feel are working well, many caveat them as a positive despite the ongoing pressures.

For the public, the main challenge is access, particularly to primary care (GPs, dentists) but also to mental healthcare, A&E and routine secondary care. Almost 7 in 10 (68%) participants on the Change NHS website reported issues getting a GP appointment and over 3 in 5 (62%) have experienced delays accessing care in A&E. This drives a sense of frustration, stress and anxiety when approaching the health service. For some, this frustration is so great that their belief that the NHS is there for them as a safety net is being undermined.

Groups of the public with greater experience of using the NHS are also likely to report challenges with poor communication and co-ordination. As with access challenges, these create a sense of frustration. For some, it also calls into question the safety of the care they are receiving.

Staff report challenges with staffing levels, funding and poor technology, all of which create barriers to delivering safe and effective care. Among staff responding through the Change NHS website, 4 in 5 (80%) have experienced staff shortages and almost 3 in 5 (58%) reported high levels of staff turnover. The impact of this is clear: significant majorities report having an unmanageable workload, stressful work environment, low morale and poor mental health. Many also describe poor relationships with leadership and internal processes which get in the way of them creating positive change.

Despite this, both audiences are incredibly proud of the NHS. Staff and public are deeply committed to its founding principles of offering care free at the point of use to everyone who needs it. They want to ensure it is fit for the future. This is evidenced by the scale of participation across the engagement, as well as the spirit of discussions at the regional events and national summit.

2.1 What’s good about the NHS

Across the engagement, members of the public and staff working in health and care have shared what they feel is working well about the NHS and what the challenges are. Many of the themes and examples shared in this chapter are well established and consistent with wider research, including Lord Darzi’s independent investigation. Nevertheless, it was important to give space to hear these experiences to provide context for the engagement and to understand priorities for change.

2.1.1 Public perspective on what is working well with the NHS

There is a strong sense of pride in the NHS. Despite many experiencing challenges, public participants across the engagement were able to identify several areas where they felt the NHS is working well.

The NHS is universal and free at the point of care

This consideration underpinned all discussions about what is positive about the NHS. The fact that the NHS provides healthcare to everyone who needs it, free at the point of use, was perceived as one of its greatest strengths and a source of national pride.

Simple, efficient, free. Simple to access, efficient once you’re in the system, and stay free.

(Public deliberative event participant, Midlands)

Staff are dedicated, hard-working and compassionate

A recurring theme from the public was praise and admiration for staff. Firstly, the public praised staff’s expertise. The public felt staff - from doctors, to nurses, to allied health professionals - are experts in their field and deliver care to a high standard. As a result, the public often said they felt safe and appropriately cared for when they use NHS services.

Secondly, the public noted that most staff are warm and approach healthcare with compassion and dedication. The public felt this approach is particularly remarkable given the very challenging circumstances staff were perceived to be working in. This generated a sense that staff care deeply about their work, patients and the NHS as a whole.

The staff are the best thing [about the NHS]. Most of the interactions I’ve had, whether it’s my GP surgery or at the hospital, have been with caring staff. Even though time’s short and you can’t spend as long going through everything. But the staff have always, always listened. They’ve taken my concern, they’ve done something about it.

(Public deliberative event participant, North East and Yorkshire)

Care is often delivered to a high standard

Throughout the engagement, many members of the public have highlighted the quality of care they receive as an element of the NHS that is working well. Examples they shared to illustrate this were most commonly drawn from acute and emergency care and from ongoing specialist care. Public deliberative and community engagement participants often contrasted their positive experiences of high-quality care with times when things went wrong or with negative stories they had heard in the media. Many felt lucky and at times surprised to receive high-quality care in the context of a system in crisis.

When patients talked about instances of high-quality care across the engagement, 5 themes emerged.

Firstly, responsive, clear and timely communication, including about appointments and follow-up care. For example, the public said that if they are on a waiting list, feeling clear about when they will be seen, understanding next steps and having someone in the NHS they can contact with any questions, all indicated high-quality care.

Secondly, smooth and efficient care pathways. For example, the public talked about instances where they have received a swift referral from their GP to diagnostic testing, secondary care or mental health care. In these examples, they felt the system was working as it should and they did not have to fight to access the care they needed. 

Thirdly, feeling heard by staff, including being taken seriously and not feeling they had to push or advocate to receive care. This was often contrasted with times when patients felt their symptoms were dismissed, leading to delays in diagnosis or misdiagnosis.

Fourthly, feeling able to make informed decisions about their care. This often included having a meaningful 2-way conversation with staff - for example, about whether a particular medication or treatment was right for them. By contrast, a feature of poor-quality care was described as feeling as if treatment options had been pushed onto patients.

Finally, skilled and compassionate staff, as described below.

But for me personally, my GP practice is absolutely amazing. I can phone up in the morning and get an appointment in the afternoon. If they get blood test results back from anywhere, they’ll phone me up and tell me what they are and what should be done. I just cannot fault them.

(Public deliberative event participant, London)

There are (some) good examples of innovation and technology

A minority of public participants on the Change NHS website highlighted efforts to focus on innovation and make better use of technology as examples of where the NHS is working well. These participants welcomed the NHS taking a more data-driven approach, having greater involvement in clinical research and exploring cutting-edge treatments. They were also often enthusiastic about the potential for more advanced technology unprompted.

By providing personalised videos, recorded by the patients’ surgeon, while the patient is still in post-procedure recovery, the HaPPi project has transformed patient communication. The average time taken for the surgeon to record the video is around 90 seconds. In addition to the personal videos, patients can access a video library of frequently asked questions.

(Public Change NHS website participant)

2.1.2 Staff perspective on what is working well

In the online events, staff were asked to share examples of what has made them proud at work, and what they value about their role. These themes were also reflected by staff participants in the in-person deliberative events.

Patient care and impact

For many staff, the feeling that their work makes a difference to patients’ lives was a significant source of personal satisfaction. It is also a key aspect of what staff felt is working well about their role, and the NHS more widely. Many described recent occasions where they had been able to help patients and their families, including supporting people to get healthy for surgery, helping patients to manage chronic pain or to maintain their independence, and providing compassionate care.

For some staff, working to address health inequalities and support more vulnerable patients and populations is a fundamental part of delivering excellent care. These staff described taking significant pride in developing targeted interventions for underserved communities and improving access to care for marginalised groups, including those with learning disabilities, mental health conditions and people with experience of homelessness.

Supporting and providing care for pregnant women especially from ethnic minority groups, making them feel safe just by seeing someone who looks like them.

(Staff online event participant)

Dedicated, compassionate and resilient staff

Across deliberative and online events and on the Change NHS website, staff highlighted the quality, dedication and compassion of their colleagues. There is a strong sense that staff consistently go ‘above and beyond’ to deliver care and support for patients, particularly in light of the challenges around staffing and increasing levels of demand. It was felt that this dedication sustains the NHS.

One commonly mentioned example of staff delivering compassionate and patient-centred care was end-of-life care. Staff reported feeling proud of the fact that they had supported patients to have dignified deaths in the place they wanted to be, with their wishes and preferences respected.

Providing high quality end of life care in the hospice and community was rewarding and a privilege.

(Staff Change NHS website participant)

Collaboration and teamwork

Staff also said they are proud of the way their teams work together and support each other. Many felt they work together well in a context which is challenging and continuously requires them to adapt, both within teams and across different parts of the health and care system.

For many staff, this was largely about a willingness to pull together under difficult circumstances, maintain morale, and support each other professionally and emotionally. However, staff also highlighted the positive impact of working collaboratively to improve services, sharing examples of best practice and creating effective multidisciplinary approaches to care, both across primary and secondary care and through joint efforts with voluntary and social care sectors.

The ongoing resilience and teamwork [when] faced with constant changes.

(Staff online event participant)

Professional growth

Staff felt proud of their professional development, as well as of their ability to support others to develop. This included completing qualifications, developing new skills, mentoring colleagues and taking on leadership responsibilities. Staff described feeling personal satisfaction from helping colleagues grow professionally but also highlighted the impact they felt this could make, however small, on recruitment and retention of staff in the NHS.

On the Change NHS website, training and development opportunities were also listed as factors driving job satisfaction. In addition, where they are in place, flexible working arrangements were felt to help facilitate learning, development and progress. 

[In the last month, the thing that has made me most proud is] delivering a menopause training session and participants thinking about how they were going to take this information forward and change practises for patients and colleagues.

(Staff online event participant)

Service development and innovation

Staff welcomed the opportunity to innovate in their roles and reported taking pride in developing innovative methods of delivering care. Where this had happened, staff felt they had the ability to implement organisational change and drive positive improvements to services.

Many of the examples shared by staff related to enhancing the efficiency of the NHS, from online portals for accessing health records to establishing digital champion groups to encourage staff to improve their digital skills. Staff also pointed to the development and implementation of new service models as examples of where the NHS can successfully innovate, including successfully piloting and launching new ways of delivering care, or designing services that are more accessible to patients.

Case study: experience from staff participant on the Change NHS website

Ksenija works for what she described as a very forward-thinking integrated care board (ICB). Her team is transforming the way that people living with cancer and other long-term conditions live well before, during and after their diagnosis. To do this, they are working with organisations across the integrated care system and with patients to co-design solutions to the challenges they face. Ksenija works in a rural and coastal county with poor transport, high levels of deprivation, a higher-than-average population age and stark health inequalities. This has meant she and her team have had to do things differently. They have taken a holistic, patient-centred, place-based, whole-system approach which has proved effective.

We have taken a place-based approach and thought about where people already go to get support and we’re developing projects around these places - hospital, pharmacy, primary care and localities, work, communities and at home.

Note: names have been changed to protect participant anonymity.

2.2 The challenges

2.2.1 Public perspective on the challenges within the NHS

Public participants on the Change NHS website and participants at the public deliberative and community engagement events shared some of the challenges they have personally experienced with the NHS. These are set out below, starting with the most commonly mentioned challenges.

Figure 1 shows the proportion of public participants from the Change NHS website and nationally representative survey who have experienced a range of challenges.

Figure 1: chart showing challenges participants on the Change NHS website have experienced, compared with a nationally representative sample

Shows percentage of Change NHS website participants selecting answers to the question: ‘Which, if any, of the following have you personally experienced?’

Challenge	Portal participants	Nationally representative survey participants
Difficulties getting a GP appointment	68%	55%
Poor co-ordination between different services	63%	26%
Long wait times in A&E	62%	42%
Delays in being referred for treatment	53%	35%
Poor communication with patients	53%	26%
Long wait times for a hospital procedure	49%	32%
Treatments or services not available on the NHS	35%	20%
Waiting to access community services	33%	14%
Poor-quality care	33%	16%
Waiting to access mental health services	28%	14%
Other	11%	3%

Base: all participants on the Change NHS website who answered this question in the ‘Start here’ survey (number equals 72,877). This survey was live between 21 October 2024 and 14 April 2025. All those who answered this question in the nationally representative ‘Start here’ survey (number equals 2,025). This survey was live between 12 and 17 December 2024.

In general, participants on the Change NHS website who are aged 18 to 34, are from an ethnic minority background, who have a disability or who have caring responsibilities were more likely to report experiencing challenges than all participants on the Change NHS website. Those aged 75 years and over were slightly less likely to report experiencing challenges overall.

Access to care

The most common challenge public participants experienced with the NHS is access to care. Difficulties getting a GP appointment was the most common challenge experienced by public participants on the Change NHS website: nearly 7 in 10 (68%) reported it as a challenge. This was followed by waiting times in A&E and for elective care. Participants from an ethnic minority background on the Change NHS website were more likely to report experiencing these challenges compared with all participants.

Table 1: proportion of participants on the Change NHS website experiencing challenges related to accessing care, compared with the nationally representative sample

	All public Change NHS website participants	Nationally representative sample
Difficulties accessing a GP appointment	68%	55%
Long wait times in A&E	62%	42%
Delays in being referred for treatment	53%	35%
Long wait times for a hospital procedure	49%	32%
Long wait times for mental healthcare	28%	14%

Base: all participants on the Change NHS website who answered this question in the ‘Start here’ survey (number equals 72,877). This survey was live between 21 October 2024 and 14 April 2025. All those who answered this question in the nationally representative ‘Start here’ survey (number equals 2,025). This survey was live between 12 and 17 December 2024.

Participants in the public deliberative events often noted how access challenges are interconnected. For example, many felt that waiting times in A&E have increased in recent years due to challenges with getting a GP appointment. Similarly, a smaller number of participants felt that long waiting times for hospital procedures mean the pressure falls back on GP services.

Deliberative engagement with children and young people also highlighted that challenges with access can be compounded by a lack of support within schools. Very few children and young people who took part in the deliberative event reported having a nurse in place in their school, and their parents separately raised the issue of a lack of qualified school nurses. As a result, parents said that they felt completely reliant on their GP in the event their children are ill.

Public participants across the engagement felt deeply frustrated as a result of struggling to access care. Many stressed the negative impact on the patient and their quality of life as a result of waiting, particularly for hospital procedures and mental healthcare where many worried that delays will exacerbate the existing issue or cause others to develop.

As well as frustration, the consequence of this challenge is reduced confidence in the health service overall. Many described feeling that it is impossible to access care in a timely manner. For some, this has shaken their trust that the NHS will be there for them when they need it. In response to this challenge, we heard of members of the public taking alternative approaches such as using private healthcare, holistic medicines or simply avoiding seeking care until it is an emergency.

Case study: experience from public participant on the Change NHS website

In April 2023, Jane found a pelvic lump. After seeing her GP, she was referred to the hospital on a ‘fast track’ 2-week wait for suspected cancer. Jane had to wait 5 weeks before having an initial computed tomography (CT) scan at the hospital and a further 2 weeks to see a consultant about the results. She was told she would require surgery, and this was scheduled in 7 weeks later. During the 14-week wait for treatment, Jane said she could feel the tumour growing inside of her. She says she was ‘lucky’ as the tumour had not spread beyond her ovary and the medical team was able to remove all of it during surgery. She described the experience as extremely stressful, which has left an emotional and physical toll.

I’m now better and my prognosis is good, but my overall experiences battling through the NHS and threadbare or non-existent services has left a personal and physical toll.

Note: names have been changed to protect participant anonymity.

Poor co-ordination and poor communication between and from different health and care services

Poor co-ordination between different services was a challenge for over 3 in 5 (63%) participants on the Change NHS website and poor communication from services was a challenge for just over half (53%). Both of these challenges were more likely to be reported by participants on the Change NHS website with caring responsibilities, with a disability and from an ethnic minority background.

Table 2: proportion of participants on the Change NHS website experiencing poor co-ordination between services and poor communication from services, compared with the nationally representative sample

	All public participants on the Change NHS website	Nationally representative sample
Poor co-ordination between services	63%	26%
Poor communication from services	53%	26%

Base: all participants on the Change NHS website who answered this question in the ‘Start here’ survey (number equals 72,877). This survey was live between 21 October 2024 and 14 April 2025. All those who answered this question in the nationally representative ‘Start here’ survey (number equals 2,025). This survey was live between 12 and 17 December 2024.

Participants on the Change NHS website were significantly more likely to cite experiencing poor co-ordination and communication than the nationally representative sample. This is probably driven by the self-selecting nature of participants on the Change NHS website and the fact that these participants were engaging with different NHS services more frequently compared with the nationally representative sample. For example, in the last 12 months:

• more than 9 in 10 (93%) participants on the Change NHS website said they had seen their GP, compared with three-quarters (73%) of the public
• almost three-quarters (74%) of participants on the Change NHS website said they had been to a hospital, compared with over 4 in 10 (44%) members of the public
• 1 in 6 (16%) participants on the Change NHS website said they had accessed mental health services, compared with 1 in 14 (7%) members of the public

The challenge of poor co-ordination between services was highlighted in public deliberative events across all locations. Many participants had examples of being referred between services (for example, a GP making a referral for diagnostic tests or to see a specialist consultant) and important information not being communicated. This meant patients had to repeat themselves to multiple different healthcare professionals. This not only caused frustration but also reduced their confidence that healthcare professionals had received all the information they needed to provide a comprehensive and safe service.

I had a double mastectomy. I’m 28, so it’s maybe quite an uncommon age. And one of the things I found when I had my daughter was that from the midwife through to hospitals through to health visitor, they always asked me how breastfeeding was going. Now, obviously that’s not an option for me, but the message never seemed to get through from one person talking to another or from reading notes.

(Public deliberative event participant, East of England)

The challenge of services feeling fragmented and hard to navigate was raised in the community engagement by a number of seldom heard audiences as a particular concern. This included those with alcohol and drug dependencies, veterans, people with experience of homelessness and those with learning disabilities and neurodivergent conditions. All of these audiences described feeling ‘lost’ in the health and care system on multiple occasions. They also described having to tell their story multiple times when moving between services, leading to distress and disengagement. Within this, participants described 2 specific challenges.

Firstly, that it feels very difficult accessing care for more than one diagnosis at the same time, leading to concerns about gaps in care. Many highlighted the challenge of accessing overlapping support for physical and mental health conditions, reporting a sense that their conditions are treated in isolation rather than staff taking a holistic view of their overall needs. This was described as a particular challenge by those in the LGBTQIA+ community, people with drug and alcohol dependencies and those with neurodivergent conditions.

Secondly, that there is a lack of cross-sector collaboration beyond health and care. For example, those with experience of homelessness wanted to see greater evidence of the NHS, voluntary organisations and police and probation services working together effectively to make sure that people are not only able to access healthcare when they need it but are also signposted to tailored support.

Many individuals feel lost navigating fragmented systems, being passed from service to service without resolution or compassion.

(Community engagement, people experiencing drug and alcohol dependence)

The issue of poor communication was closely tied to poor co-ordination between services. The main issue public participants in the deliberative events reported with communication related to its unco-ordinated nature. For example, participants were frustrated by:

• appointments being cancelled without anyone telling them
• receiving several letters for an appointment, each with a different date
• turning up to appointments and the service having no record of them

Others were frustrated that they had not received copies of their notes and letters - for example, that the hospital shared with their GP.

A smaller number of public participants described poor communication from healthcare staff. This was most notably communication lacking in empathy and feeling rushed. For example, a minority of participants felt that their concerns were dismissed, or that staff in GP surgeries were not kind when they explained that they could only discuss one issue per appointment.

Case study: experience from public and staff participant on the Change NHS website

James is a retiring consultant who has been working in the NHS for 38 years. A close relative of his has stage 4 cancer. In August last year, in a surgical outpatient clinic, they were told she was being referred to a different, more specialist hospital for surgery. They had another appointment 2 weeks after this, where James followed up on the referral. The nurse had to check the status of the referral and let James know the next day that it was emailed to the specialist hospital 12 days after the initial appointment.

James questioned why an extremely urgent referral letter had taken 12 days to be typed up and sent. The nurse was candid in their reply and said it had probably sat in a pile with other letters (both urgent and non-urgent) and they did not have sufficient resource to manage the process. James felt that a more integrated communication system could have resulted in a referral within 24 hours, but also that priorities are incorrect regarding communication.

This was a letter which was urgent and where the result was the commencement of cancer surgery (or should I say access to a different waiting list for cancer surgery). No-one owned the quality of the process, to work out that there are urgent letters and non-urgent ones and they don’t all just sit in a pile together waiting for attention. Is this because the staff are defeated and don’t care any longer or is it because there is no-one sharp enough in NHS middle management to look at the processes critically and say, “this is not okay, under any circumstances”? […] We have an A&E waiting time target of 6 hours. Yet nothing for urgent letters.

Note: names have been changed to protect participant anonymity.

Instances of poor-quality care

Instances of poor-quality care were less common. A third (33%) of participants on the Change NHS website and 16% of participants in the nationally representative survey reported experiencing poor-quality care. On the Change NHS website, these were more likely to be participants from an ethnic minority background, with a disability or with caring responsibilities.

Although the issue was raised less frequently than other challenges, the impact was significant. Among the minority of participants who did report poor-quality care, examples were usually characterised by the opposite experiences to those which define high-quality care. For example, these participants described poor communication and co-ordination, rushed and uncompassionate staff, and errors. Examples not only included medical care, such as treatments and diagnosis, but also how they were cared for while in hospital, such as when being given food and water. Many of those who had experienced poor-quality care said that their experiences made them feel unsafe and worried about needing care again in the future.

Instances of poor-quality care were more commonly mentioned by seldom heard audiences in the community engagement, with 2 features being regularly mentioned.

Firstly, not feeling listened to or taken seriously, or having their concerns minimised by healthcare professionals. This was highlighted as a particular concern by asylum seekers, refugees and new migrants, Gypsy, Roma and Traveller communities, people experiencing drug and alcohol dependence and those with experience of homelessness. Sex workers also reported feeling a stigma or having their concerns minimised by staff because of their occupation.

Secondly, staff not fully understanding the situation or context, or displaying a lack of cultural sensitivity. This included audiences referenced above being reduced to a single characteristic in the way they were viewed and treated, such as their race or disability, rather than staff recognising their intersectionality.

Taken together, care of this kind leads to a lack of trust in both staff and the NHS overall. These audiences did not feel that care can truly reflect and meet their needs, nor that they have received the right information to make more informed and better quality decisions about their care. 

As soon as I told a therapist about my work, everything else I mentioned even from when I was a child, became a result of sex work to them. So I wasn’t able to properly access support I needed.

(Community engagement, sex worker)

Unlike examples of high-quality care, examples of poor-quality care aligned with participants’ wider perceptions of the NHS and the challenges it is facing. Members of the public therefore did not feel that examples of poor-quality care were surprising. Instead, they tended to confirm their perception that the NHS is not delivering for patients.   

A minority of participants reported making an official complaint about the quality of care they received, and some of those expressed frustration with how this was handled. These participants felt that the NHS had not been open and apologetic about what had happened to them.

Case study: experience from participant on the Change NHS website (public)

Isabel is a senior nurse. In 2022 her mother was admitted to hospital following a hip fracture. She was so appalled by the care her mother received that she stayed with her day and night. Several errors were made including wrong doses of medication, which caused her mother to fall into a comatose state for 2 days.

Isabel said the basic standard of care was poor, with minimal infection control and poor hygiene. She believes that this was how her mother contracted COVID-19, from which she died. Isabel felt the nurse assistants were rude, did not care and did not respect the elderly patient group for whom they were caring. Isabel felt her mother’s nursing care plan was ignored and neither she nor her mother were listened to. Isabel submitted a formal complaint, supported by her mother’s consultant.

I was and still am very close to walking away from my job and the NHS as I was and am so disgusted with the care.

Note: names have been changed to protect participant anonymity.

2.2.2 Staff perspective on what makes their role more challenging

Staff shared experiences and examples of the challenges they face in their roles through the online and face-to-face events, as well as on the Change NHS website. The themes discussed below appeared consistently across these strands of engagement. 

Figure 2 shows the proportion of staff responding through the Change NHS website who have experienced each of the challenges asked about. 

Figure 2: chart showing challenges experienced by workforce participants on the Change NHS website

Shows percentage of workforce participants on the Change NHS website selecting answers to the question: ‘Which, if any, of the following have you personally experienced working in the health and care system?’

	Percentage
Staff shortages	80%
Inefficiencies in connected services	79%
Unmanageable workload or demand	74%
Complex administrative processes	73%
Stressful working environment	71%
Growing complexity of patient needs	66%
Low levels of job satisfaction or morale	63%
Poor mental health or burnout	62%
High levels of staff turnover	58%
Poor equipment	53%
Problems with workplace culture	42%
Other	17%

Base: all those who answered this question in the ‘Your experiences - workforce’ survey (number equals 3,620). The survey was live between 21 October 2024 and 14 April 2025.

Workforce and staffing challenges

Among staff responding through the Change NHS website, 4 in 5 (80%) have experienced staff shortages and almost 3 in 5 (58%) reported high levels of staff turnover. The impact of this was clear: significant majorities reported having an unmanageable workload (74%), stressful work environment (71%), low levels of job satisfaction and morale (63%) and poor mental health or burnout (62%). All of these challenges were felt more acutely by younger members of staff, particularly those aged 25 to 34, and those who have been working in the NHS for 3 or more years.   

In the deliberative events, staff described how being understaffed forces them to work beyond capacity. As a result, many reported poor work-life balance, low morale, high levels of stress and burnout. Staff also felt that understaffing is a barrier to accessing the professional development opportunities required to maintain and enhance their skills. There was low confidence that this will be resolved by hiring more staff. On the Change NHS website, staff described recruitment processes as slow and bureaucratic. 

While many reported staff pulling together to support and champion each other in the face of staffing pressures, this was not universal. Some non-clinical staff indicated they feel less supported, valued or readily acknowledged than their clinical counterparts, which they said is starting to have an impact on their morale and resilience.

Case study: experience from staff participant on the Change NHS website

Debbie is a midwife working in a busy acute unit. She feels that the main issue her team faces is understaffing. She has been told that her team is fully staffed, but Debbie does not feel there are enough staff to safely cover their workload. This means staff do not get breaks: there are not enough staff to cover breaks and look after patients at the same time. Debbie and her team regularly work for at least an hour past the time their shifts are supposed to end. They do not get this time back. Debbie feels the workload is too high for the staffing levels they have, even if on paper they are fully staffed.

Apparently, we are fully staffed. However, there is not enough staff to safely cover the workload [we have].

Note: names have been changed to protect participant anonymity.

Unsustainable workload

Closely tied to workforce and staffing challenges, three-quarters (74%) of staff on the Change NHS website reported experiencing an unmanageable workload. They indicated that growing service demand and limited resources are affecting their ability to maintain professional standards as well as creating systemic risks. Staff said that staff losses add to pressure on the remaining staff, leading to significant concerns about safety.

This view was shared in the staff deliberative events, where many highlighted how resourcing pressures have created a constant state of ‘firefighting’ that prevents focused, high-quality work.

On the Change NHS website, two-thirds (66%) of staff described the growing complexity of patient needs as an additional related challenge. When sharing their personal experiences of delivering care, staff also highlighted a sense that it is increasingly difficult for them to manage patient expectations about care or treatment.

I have been working in the health service as a registered nurse for a community trust since 2018. At the start of my career, I remember the workload [was] hard but manageable. However, this seemed to deteriorate following Brexit and then [the] COVID-19 pandemic. Since then, I have noticed higher demands placed on community services but with considerably less staff. There are often times where I feel unable to provide the level of care that I would like to dedicate to patients.

(Staff Change NHS website participant)

System and organisational challenges

Staff across the engagement described excessive administrative procedures, poor co-ordination between services and poor leadership decisions creating unnecessary obstacles to efficiently delivering patient care. This was a widely cited challenge: for example, almost 3 in 4 (73%) staff on the Change NHS website said that complex administrative processes are a challenge in their role.

Excessive administrative requirements, complex approval processes and rigid reporting structures were felt to divert time and energy from frontline care and innovation. In addition, many reported ‘red tape’ slowing down the implementation of changes. This caused frustration for staff trying to improve services or introduce new ones. More broadly, staff expressed the view that bureaucratic hurdles create a feeling of inertia, meaning change feels very slow to materialise, despite widespread agreement of the need for that change.

Inefficiencies in connecting services were only felt to add to this: 4 in 5 (79%) staff on the Change NHS website described this as a challenge. Staff across the engagement reported fragmented and poorly integrated services resulting in a jarring patient experience and inefficient service delivery. Despite praising teamwork within teams, many described a perception that different teams work in silos which leads to a ‘them and us’ culture, acting as a barrier to teamwork and collaboration. This is particularly challenging when it comes to integrating health and social care services. Staff readily acknowledged the interdependence of health and social care and wanted to see a seamless journey for patients. However, different funding systems, governance structures, professional cultures and information systems across health and social care are felt to perpetuate a sense of division.

Staff sharing their personal experiences on the Change NHS website described management as poor, with leadership feeling disconnected from day-to-day delivery of care, and driven more by targets and financial pressures than patient outcomes. Many also reported that both regional and national leadership seem resistant to change, a theme echoed in the staff deliberative events. This contributed to frontline staff feeling disempowered and unsupported by management structures. Staff readily accepted that, for the 10 Year Health Plan to be a success, staff at all levels will need to step out of their comfort zone to accept and adapt to new ways of doing things. As part of this, staff wanted to see a shift from the current management model, which feels more traditional, top-down and hierarchical, towards a more collaborative, innovative and patient-centred approach.

The complexity of patient needs and public expectations has developed at a quicker rate than services have modernised and systems leadership isn’t working well. The NHS command and control culture isn’t supporting decisions being made by the right people in the right place at the right time.

(Staff Change NHS website participant)

Infrastructure and technology challenges

Staff noted that outdated and poorly integrated IT systems cause delays, duplicate work and prevent timely communication and efficient resource allocation. Staff in deliberative events also felt that insufficient clinical space and inadequate facilities prevent them from providing appropriate care. This challenge was widely felt - just over half (53%) of staff on the Change NHS website described having poor-quality or insufficient equipment. Staff highlighted how these infrastructure limitations directly affect their ability to deliver services efficiently day-to-day.

Case study: experience from staff participant on the Change NHS website

Tina has worked as a doctor since 2013, both in hospitals and as a GP. She has worked in 6 hospitals and all of their computer systems have been “awful”. She feels the computer systems in general practice are much better but still has issues on a daily basis. She finds it frustrating that every hospital, GP practice and department seem to have different software, most of which is not intuitive and does not link up with other parts of the system. While Tina feels that the use of technology has improved over the last 12 years, it still feels slow. She has concerns about whether clinicians and people working with the software are being consulted about use of technology, and how it is implemented and managed.

Every day I think how much better the technology could be to save us time and make our practice safer.

Note: names have been changed to protect participant anonymity.

Challenges with workplace culture, bullying, harassment and sexism

Some staff raised significant concerns about workplace culture in the NHS, or reported working in environments which they felt were characterised by blame, fear and hierarchical divisions that mean they are unable to speak openly. They said that this has an impact not only on individual wellbeing, but also on organisational effectiveness: staff emphasised how an unhealthy culture contributes to high stress, burnout and high levels of staff turnover.

Within this, staff expressed profound concern about examples of racism, bullying and sexism they had witnessed within the healthcare system, ranging from microaggressions to overt discrimination, with particular impact on minority ethnic groups. These themes were raised across the engagement and particularly in a focused online session held with over 100 staff from ethnic minority backgrounds. On the Change NHS website, over 4 in 10 (42%) staff reported experiencing problems with workplace culture, including bullying, racism, sexism or harassment. Notably, two-thirds (67%) of those from Black, African, Caribbean and Black British backgrounds reported experiencing these challenges. Suggestions for prioritising and addressing these challenges are explored in section 3.5 of chapter 3.

I really hope things change. I have worked in the NHS for 20 years. This year the racism, bullying and harassment have gotten worse. It’s absolutely broken me.

(Staff online event participant)

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