The Times: What I learnt … about flexible working in the NHS

As featured in The Times

Dr Anas Nader, 37, co-founded Patchwork Health in 2017 to help hospitals reduce reliance on agencies for locums and to improve flexible working options for clinicians. Piloted with Chelsea and Westminster hospital trust, the firm’s software has since been adopted by 70 health organisations across 250 sites. In 2021 it recorded £4 million revenue having raised £9 million in venture capital, including from the British Medical Journal, the media arm of the British Medical Association. It has more than 100 staff.

Being a doctor or a nurse is a calling — but it is also still a job, and we don’t want to be martyrs to a system

I graduated from Imperial College healthcare trust and started working in the NHS as a foundation doctor and then in A&E. I enjoyed it, but I saw myself as someone who would both have a role with my stethoscope and also explore my other interests, such as technology.

My biggest frustration, which is where I felt psychologically burnt out, was not the physical strain of working in A&E — I knew what I was signing up to. It was the lack of flexibility to achieve what excites me in a career in medicine, and being boxed in as a number in the system, just part of a conveyor belt of moving patients down a process. The creative, problem-solving part of medicine was a very small part of the job. It created a lot of frustration and resentment.

I found that I was a member of a generation of doctors and nurses who see a world where we are not necessarily defined by our careers. We want to do a good job and enjoy it, but also do everything else we perceive is needed to lead a fulfilling life. Many of us wanted flexibility, but healthcare employers just didn’t provide that. I realised this was a complex HR, employment, compliance, system-wide problem.

Where would we even start?

For my sabbatical year at Chelsea and Westminster hospital trust I took on an innovation role as part of a team of doctors reporting to the management team to solve problems. One of the three problems assigned to me was to help reduce medical agency spend [on temporary staff], as agencies were costing us tens of millions of pounds every year.

In theory, all hospitals operate a bank — a black book of names of doctors and nurses, both your own permanent clinicians doing some overtime and also career locums. But that bank tends to be difficult to manage. It is often stored on Excel sheets, with mailing lists and WhatsApp groups used to broadcast shifts. That is inefficient and clunky.

There is also the financial challenge of managing rates. We found that clinicians’ hourly rates were all over the place. They were often locally negotiated on a case-by-case basis.

What happens is that the resourcing problem is often sent to an agency, and its solves it for you at a premium price. To fix that, we had to understand what these clinicians were looking for, so that we would be their employer of choice instead of an agency.

We divided our clinicians into cohorts

For junior doctors, a big part of [joining the bank] is supplementing your income, as your pay may not be as good as it could be. Another advantage is to gain exposure to other specialties.

For mid-level clinicians, it tends to be for more personal reasons: taking a step back from full-time work for parenting, perhaps, or looking after an elderly parent. An example would be only doing weekend shifts.

The third group tends to be before or just after retirement age. A lot of consultants or senior nurses would love to taper down their hours as they reach that stage. Often they want to pick and choose their hours and days to work around their schedule.

What all three cohorts want is empowerment, direct access to shifts, simplicity in the process and reliability in payments.

Looking at the back office functions within healthcare was eye-opening

It gave me a huge appreciation for the thankless job that NHS managers have in dealing with some chronic, complex problems. They are sadly equipped, with very few good tools to help them.

I presented the idea of a platform that manages temporary staffing from recruitment, on-boarding, compliance, risk management, shift management and shift broadcasting. I was allowed to continue working with every department team involved in workforce management to co-develop those capabilities. The trust would also be the first test site to validate the product.

That allowed me and my co-founder, Dr Jing Ouyang, to build a business plan and seek angel investment. We launched the pilot in the summer of 2017 and saw results quickly. From a baseline of 25 per cent of shifts from the bank and 75 per cent to agencies, it moved to 70 per cent on the bank and 30 per cent agencies. At the 12-month mark, we were hitting 80 to 85 per cent bank, and have plateaued since then.

The spend with agencies is about £5 billion across the NHS annually, with the fees to agencies being about £1 billion of that. We saved Chelsea and Westminster about £1.2 million a year on doctors alone. Over the last four years, we tallied up around £39 million saved across all the organisations we work with.

There are also qualitative improvements. From an administrators’ view, the technology reduced the admin work and gave them real-time visibility over the data; from a clinician’s, it is app or desktop-based with easy access to select the shifts you want, see the rate you will get paid and track your payments.

Agencies shouldn’t be demonised

I liken them to opiates. They are the kind of thing you don’t want your patients hooked on, or overly dependent on, but also the thing you are glad you have when the pain is there. It should be a short-term treatment for a short-term problem, not a chronic dependency for your long-term staffing.

We are now entering rostering

The next phase is to take that flexible working and tackling of the admin burden for locum work into permanent staffing. Imperial College healthcare trust is our innovation partner here.

One problem with rostering is that for most of the 20th century we had the role of the doctor and the role of the nurse, each defined by their professional designation. More modern ways of clinical work can allow clinicians — whether you are a physician associate, doctor, nurse, or emergency nurse practitioner, as well as other types of clinicians — to be deployed not by professional designation but based on a skill-set.

Certain tasks can be done by anyone who has a specific skill-set. Hospitals that are able to design work patterns based on skills have more flexibility to create hybrid rotas. That allows them to meet the modern working expectations of their clinicians.

We are now also looking at clinicians in some departments that are shift-based, such as A&E, being able to self-roster. It will finally bring flexibility to permanent staffing.