What’s missing from the NHS Long Term Workforce Plan

Back in the days of Health Commission Annual Health Check, policies and procedures were critical to quality. I certainly felt that way when the mental health clinical governance team I was on spent hours ensuring the practice followed policy. I also learned the value of staff involvement in policy and its impact on retention. So when I discovered the inclusion of this often overlooked aspect of retention in an evidence synthesis, I wanted to read on.

As part of the Health Foundation funded Efficiency Research Programresearchers from the University of Sheffield literature reviewed from 2004-2020 (Long, et al, 2023) to explore staff retention in mental health services. By chance I read this synthesis the same week as the NHS long-term workforce plan (NHSE, 2023). I wondered if the authors of the Plan had read this review and concluded that they had not. The synthesis highlighted what was missing from the Plan.

I was wondering if the authors of the NHS Long Term Workforce Plan had read this synthesis on retention.  I decided not to.

I was wondering if the authors of the NHS Long Term Workforce Plan had read this synthesis on retention. I decided not to.

Methods

The researchers carried out a realistic synthesis. A method that aims to develop theories that explain why interventions work (or not), how they work and in what contexts. The researchers carried out the review in 3′hybrid‘ (Rycroft-Malone, et al 2012), which combine traditional review methods with people’s opinions, including:

  1. Exploratory scoping of the literature along with workshops, from which they developed preliminary theories;
  2. Searches and data extraction;
  3. Data analysis, theory refinement and development of a logical model.

Three key elements of richness, relevance and rigor were considered. Various stakeholders, including staff and service users, helped test and refine the theories.

Results

The first phase of the review generated six preliminary theories of effective retention for further exploration. The formal search in the second phase generated data that was used to identify key factors and issues against each theory. Analysis of the data showed that the themes of the six theories were interconnected and overlapping. As a result, in phase three, the team integrated and refined the 6 theories into 3 key drivers, which represented a whole systems perspective on effective retention, starting with organizational culture and consisting of:

  • Workload and quality of care.
    • If staff experience a heavy workload,
    • then they will feel that they have to provide lower quality care to manage time demands;
  • Investment in personnel
    • If organizations invest in training, development and supervision,
    • then staff will feel more confident in providing higher quality care;
  • Staff contributions
    • If staff shape the development of policies and practices,
    • Then they will feel valued and supported to work autonomously.

The analysis indicated that all of these factors impact well-being, a sense of connection to an organization, and ultimately job satisfaction. To show the relationships between these theories, the team created a general logic model.

Figure 1 The logic model of factors affecting mental health staff retention.

Figure 1 The logic model of factors affecting mental health staff retention. See figure in full size.

What is valuable about this review is not only that it improves our understanding of retention, but that it generates a whole systems perspective. A perspective that is sadly missing from the Long Term Workforce Plan.

The three key factors for effective staff retention – workload and quality of care, investment and engagement – ​​arise from organizational culture and require a whole systems perspective.

The three key factors for effective staff retention – workload and quality of care, investment and engagement – ​​arise from organizational culture and require a whole systems perspective.

Conclusions

The Workforce Plan includes some of the factors identified by the review, for example training. However, the focus is on an increasing number of staff. The importance of investing in people highlighted in the review is less evident. The Plan recognizes the significant workload issues in mental health settings, but does not recognize the interconnection with quality of care. The third factor for successful retention – staff input into policy development – ​​is not even mentioned. The closest the Plan comes is a section titled “we have a voice that matters.”

The authors of the Plan appear to have overlooked the key point that this revision underlines: Simply hiring more staff is unlikely to solve the problems. We need to keep them. This central point is best summarized in realistic terms:

  • If workforce planning allowed for a comprehensive systemic approach to addressing retention,
  • Then the quality of care would increase and staff job satisfaction would improve.
  • Leading to… more staff stay.
Simply hiring more staff is unlikely to solve the problems.  We need to conserve them.

Simply hiring more staff is unlikely to solve the problems. We need to conserve them.

Strengths and limitations

The real strength of this review is not simply what it tells us about retention in mental health services, but what it offers us as a case study for other UK health settings. He We may not “prove” something, but we can learn something. (Flyvbjerg, 2006). As the NHS Workforce Plan recognises, mental health services have higher turnover and more vacancies than other staff groups. Staff face particular issues related to the nature of care, such as suicide risk monitoring and experience. Reportedly greater emotional exhaustion than colleagues in emergency settings. (O’Connor, et al, 2018). Furthermore, although the majority of the studies reviewed were from inpatient settings, the involvement of diverse staff and service users in the development of the theories helps to ensure that the findings have wider applicability.

One of the main limitations recognized by researchers is their focus on “interpretation rather than ensuring the most complete identification of information” (Long et al, 2023). This means that the review may not have detected all potential sources. The emphasis on the need to interpret may also have contributed to an apparent lack of emphasis on evaluation, at least in the article. The researchers claim that “Judgments about the quality of the studies were deferred until later stages of the analysis”. Unfortunately, the article does not provide further details on how the quality of the study was judged and the reader is left wondering what impact the postponement had on the conclusions reached.

The real strength of this review is not simply what it tells us about retention in mental health services, but what it offers us as a case study that may not

The real strength of this review is not simply what it tells us about retention in mental health services, but what it offers us as a case study that may not “prove” something, but where we can learn something.

Implications for Practice

This synthesis generates implications for several groups. First, for policy makers, highlight the need to retain, not simply hire, staff. Additionally, to address retention using a system-wide perspective that addresses interconnected issues. The interconnectedness of factors affecting retention is equally important for service providers. The review highlights the need to start with organizational culture and employ strategies that recognize:

  • The interconnection of Workload and attention quality
  • The need to invest in training and development
  • The importance of staff autonomy through participation in how quality care is articulated and practiced (often forgotten).

Finally, this review offers an implication for funders of health and social care research, especially those operating in the landscape of complex interventions. If we are to play a role in improve the evidence base, reduce uncertainties and improve care (HRA, 2023), then we must support syntheses of evidence that help us understand not only it worksbut also as.

The implications are not just for service providers or policymakers, but also for research funders who should support syntheses that help us understand what works and how.

The implications are not just for service providers or policymakers, but also for research funders who should support syntheses that help us understand what works and how.

Declaration of interests

Justine Karpusheff is deputy director of research at The Health Foundation. The Health Foundation funded this study as part of the Efficiency Research Program.

Links

primary job

Long J, Ohlsen S, Senek M, Booth A, Which S, Wood E. (2023) Realistic synthesis of factors affecting staff retention in UK adult mental health services. BMJ Open, 13(5) 2023. Available in: https://bmjopen.bmj.com/content/13/5/e070953#DC1

other references

NHSE (2023) NHS Long Term Workforce Plan. June 2023. Available in: https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.2.pdf

Rycroft-Malone J, McCormack B, Hutchinson A M. et al (2012) Realist synthesis: illustrating the method for implementation research. Implementation Science, 7(33) 2012. Available at: https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-7-33

Flyvbjerg B. (2006) Five misunderstandings about case study research. Qualitative research, 12(2) 2006. [abstract]

O’Connor K, Muller Neff D, Pitman S. (2018) Burnout in mental health professionals: a systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53. Available in: https://www.cambridge.org/core/journals/european-psychiatry/article/burnout-in-mental-health-professionals-a-systematic-review-and-metaanalysis-of-prevalence-and-determinants/8DE6B29F7AD65E2442726CA8D1F7F876

Health Research Authority (2023) UK policy framework for health and social care. Available in: https://www.hra.nhs.uk/planning-and-improving-research/policies-standards-legislation/uk-policy-framework-health-social-care-research/uk-policy-framework-health-and- research-social-assistance/

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