The Loneliest Profession in Healthcare

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Steven Shorrock CC BY-NC-SA 2.0 https://flic.kr/p/HoF2kK

Health and social care is one of the biggest employers in developed countries, and the National Health Service (NHS) in the United Kingdom is one of the largest employers in the world. By some calculations, the NHS is the fifth biggest organisation in the world in terms of number of staff, calculated at around 1.5 million, or 1.25 million full-time equivalent. That figure does not even include temporary staff, general practitioners, dentists, optometrists, and other staff in the independent sector or private hospitals.

It is an organisation facing enormous demand. Looking at just a few headline aspects, the NHS deals with over 1 million patients every 36 hours, with over 16 million hospital admissions in 2015/16, over 23 million attendances at Accident & Emergency departments in 2016/17, and over 89 million outpatient attendances in 2015/16. In terms of NHS net expenditure, meeting this demand cost over £120 billion in 2016/17, and is expected to rise to over £126bn in 2018/19.

Not surprisingly, it is also a bafflingly complex organisation, in terms of: the variable and unpredictable nature of demand; the huge variety of staff roles and competencies; the incalculable number of different types of equipment (which are very often not designed according to ergonomic standards) and medicines (which often look or sound alike); the tens of regulators, professional bodies, and associations; the thousands of laws, regulations, diktats, policies, procedures, guidelines, and good practice documents for clinical and non-clinical staff; the complicated record-keeping and communication channels; the links to government agencies, local authorities, police and fire services, suppliers, independent providers, universities; and the interactions between all of these that make it such a complex sociotechnical system of systems.

Added to this are the elements of the system that cannot easily be seen, let alone counted, but strongly affect human behaviour, including: shifting goals, incentives, punishments, subcultures, and pressures from the public, media, regulatory and professional bodies, politicians, and associations.

You’d expect, then, that Human Factors/Ergonomics would be very relevant to the NHS (the two terms are seen as equivalent within the discipline, though the terms are used in different contexts). After all, HF/E is:

“the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance” (International Ergonomics Association).

Healthcare organisations should naturally be interested in human well-being, of patients and staff. It is obviously important that the NHS, as a system of systems, performs effectively.

So you’d also expect that many HF/E practitioners would be embedded in the NHS, directly employed by the NHS and its Trusts, just like quality improvement specialists, performance management specialists, human resources specialists, and indeed even staff who work directly with patients, such as Dietitians. After all, the role of HF/E practitioners is directly relevant to the effective provision of health services, as per the ‘7 key principles that guide the NHS in all it does‘.

“Practitioners of ergonomics and ergonomists contribute to the design and evaluation of tasks, jobs, products, environments and systems in order to make them compatible with the needs, abilities and limitations of people.”  (International Ergonomics Association).

HF/E practitioners are well-embedded in a number of sectors, notably aviationraildefenceoil and gasnuclearmanufacturingregulationproduct designinclusive design, and UX.  NATS – a provider of air traffic services in the UK and international airports, airlines and governments – employs around 25 qualified Human Factors practitioners (comprising Human Factors/Ergonomics practitioners and Psychologists). The Rail Safety and Standards Board (RSSB), Network Rail, London Underground, BAe SystemsQinetiQ (formerly part of the Defence Evaluation and Research Agency [DERA]), and other large organisations and regulators such as the Health and Safety Executive, all have long-established teams of qualified HF/E practitioners, who help to optimise system performance and human well-being by contributing to the design and evaluation of tasks, jobs, products, environments and systems in order to make them compatible with the needs, abilities and limitations of people.

Compared to any of these organisations, the NHS is enormous. To make one comparison, NATS is an organisation of around 4,500 staff – a third of the staff in some of Britain’s biggest hospital trusts. The NHS is 333 times bigger than NATS in terms of staff. Even individual hospital Trusts are enormous, with staff counted in the thousands, and up to 15,000 – three times bigger than the whole of NATS.

Of the 1.5 million members of staff, professionally qualified staff make up over half (53.8 per cent) of the Hospital and Community Health Service (HCHS) workforce (based on FTE). Healthcare obviously requires professionally qualified and accredited staff in order to provide effective services.

So how many professionally qualified HF/E practitioners are there in the NHS? It is not straightforward to answer, because ‘human factors practitioner’ (or human factors specialist, etc) and ‘ergonomist’ are not protected titles. Anyone may describe themselves as such (much as anyone can call themselves a ‘psychologist’, which is not a specifically protected title). But the profession of Human Factors/Ergonomics is Chartered in the UK, like others such as Chartered Psychologist, Chartered Engineer and Chartered Accountant. Chartered status in HF/E is conferred by the Chartered Institute of Ergonomics and Human Factors to those members who fulfil certain criteria. This includes “having a high level of qualification and experience and being able to demonstrate continuing professional development”, and operating under a Code of Conduct.

We can therefore count the number of ‘Chartered Ergonomists and Human Factors Specialists’ (CErgHF) employed by NHS Trusts, since a list of CErgHFs is published here. At the time of writing, there are 429 CErgHFs on the register. While there are others with various qualifications, and those who may have ‘human factors’ in their job title, the CIEHF is the only arbiter that provides a countable, unarguable category (as is the case for a Surveyor or Accountant) for the purposes of determining how many work in NHS Trusts.

From my own research, I have determined the number of NHS Trusts that directly employ a Chartered Ergonomics and Human Factors Specialist, and the number CErgHFs in the 233 NHS Trusts.

That number is 1.

Whichever way you look at it, the number is one.

To my knowledge, after researching the network of CErgHFs, one Trust employs a CErgHF as a Human Factors/Ergonomics specialist, and that one Trust employs – at present – one CErgHF.

Let that sink in for a moment.

An organisation of 1,500,000 staff and £120 billion expenditure.

If the number of HF/E specialists in NATS (which works in an ultrasafe sector – commercial aviation) were scaled up to the number of staff in the NHS, there would be over 8,000 HF/E specialists. Obviously, that is neither feasible nor necessary. But even if there were just one CErgHF per Trust, then there would be 233 CErgHFs in Trusts, plus those who should certainly be in other central bodies, such as NHS Education (NHS Education Scotland has a CErgHF working in an HF/E role), NHS Improvement, NHS Digital, etc.

Even one CErgHF for a Trust of up to 15,000 staff is, however, inadequate, especially given the thousands of so-called ‘excess deaths’ every year, and the apparent focus on ‘Human Factors’ in bodies such as:

The tens of thousands of so-called ‘excess deaths‘ should lead us to question why the NHS Trusts have only one Chartered Ergonomist and Human Factors Specialist. Even if HF/E could help prevent just a relatively small number of deaths and injuries, then we must ask why it is not being integrated professionally. HF/E focuses on many aspects of healthcare that must be designed properly in order to deliver safe, effective, and cost-efficient services, and relates directly to the work of the NHS, especially (NHS England):

In other industries, HF/E contributes to to the design and evaluation of tasks, jobs, products, environments and systems, for improved system performance and human well-being, in terms of:

  • the design and evaluation of equipment
  • the design of tasks and jobs
  • the design of physical and ambient environments
  • the design of policies, procedures, checklists, guidelines and job aids
  • human factors integration into management systems
  • human performance assessment and support
  • safety assessment (and risk assessment generally)
  • incident and accident investigation and analysis
  • staffing and manpower planning
  • shift design and fatigue risk assessment and management
  • stress management
  • communication design
  • safety culture and organisational culture evaluation
  • non-technical skills, team resource management, and (simulation) training.

Of these functions, the main focus of human factors integration in the NHS has been the latter. Many clinicians and educators have embraced human factors and integrated it into their non-technical skills, team resource management, and simulation training. It’s perhaps an obvious place to start, it’s vitally important, and it’s very well done (in fact, simulation training in some Trusts could teach aviation a thing or two – and has here and here). There are also a few individuals in the NHS with HF/E qualifications and experience, but who are not Chartered. Aside from a small number (mostly in Scotland), these do not work as HF/E specialists per se and/or are not performing the activities above for Trusts.

And there are Chartered HF/E specialists in medical device design companies outside of the NHS, and of course in consultancies and universities, who consult or conduct research in healthcare organisations.

More generally, there is significant interest in HF/E from clinicians; so much so that one would expect that it was actually integrated into the NHS. The term ‘human factors’ regularly crops up on social media and in conferences (though it could mean anything).

But none of this embeds a systematic consideration of designing for humans in healthcare, which is part of normal business in many high-risk industries. This can only really be done with trained and qualified practitioners, just as is the case with Physiotherapists, Dietitians, and Counselling Psychologists. In the absence of the HF/E equivalent in the NHS, front-line staff are having to do what they can, with the time they have, and otherwise work around and patch up problems in resources, constraints and environments that are:

  • not understood at the blunt end
  • always changing
  • not implemented or functioning as originally designed or imagined
  • often not ‘designed’ at all, and
  • degraded and stretched beyond design intent.

When things go wrong, it is patients, families, and clinicians who suffer the consequences.

And yet, of the 233 NHS Trusts, only one Trust employs a Chartered Ergonomist and Human Factors Specialist in an HF/E role, and that Trust employs – at present – one CErgHF.

It’s incredible. But it’s true.

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About stevenshorrock

I am a systems ergonomist/human factors specialist and work psychologist with a background in practice and research in safety-critical industries. My main interest is human and system behaviour in the context of safety-related organisations. I seek to enable improvement via a combination of systems thinking, design thinking and humanistic thinking. I am a Chartered Ergonomist and Human Factors Specialist with the CIEHF and a Chartered Psychologist with the British Psychological Society. I currently work as a human factors and safety specialist in air traffic control in Europe. I am also Adjunct Associate Professor at University of the Sunshine Coast, Centre for Human Factors & Sociotechnical Systems. I blog in a personal capacity. Views expressed here are mine and not those of any affiliated organisation, unless stated otherwise. You can find me on twitter at @stevenshorrock
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