Rebuilding the Psychological Contract in the NHS: Reflections on the Darzi Review

Introduction

The Darzi Review of the NHS offers a comprehensive and often sobering analysis of the current state of our health service. While it addresses crucial issues such as workforce and culture, the underlying causes of these challenges, in my view, are more nuanced and complex than presented. One of the most significant shifts observable across the NHS, pre- and post-pandemic, has been the change in the psychological contract between the NHS and its staff, particularly clinicians.

The Importance of Goodwill in Driving Change

Throughout my career, working to review, transform, and improve various aspects of the NHS, one element has always stood out: the goodwill of the workforce. This goodwill is the driving force behind positive change, motivating staff to go beyond their formal responsibilities and embrace new processes, even when success seems uncertain. I’ve seen this willingness in many forms—a suspension of disbelief where staff say, “I’m not sure this will work, but I’m willing to give it a go.”

Goodwill is not about structural excellence alone but about the dedication and commitment of staff. Across a wide range of NHS organisations, I’ve observed that success often hinges on how supported and valued staff feel. Leadership culture plays a vital role here—not just at the top, but throughout every layer of management. In many cases, it’s the junior managers, with their creativity and resilience, who turn organisational challenges into opportunities.

However, in recent years, I’ve noticed a shift in this dynamic, which I believe is largely due to the wider impact of the COVID-19 pandemic.

The Impact of COVID-19 on NHS Workforce Culture

The pandemic placed unprecedented strain on NHS staff, affecting them physically, mentally, and emotionally. The early shortage of PPE, which tragically resulted in the deaths of many healthcare professionals—including Dr Alfa Sa'adu—was a stark reminder of the vulnerability of frontline workers. For many, this moment changed their relationship with the NHS as an employer.

Before the pandemic, many clinical staff believed that the NHS would “look after its own.” This belief often led them to prioritise patient care above their own work-life balance or even their safety. However, the challenges of responding to COVID-19, compounded by stories of profiteering related to PPE provision, weakened this trust. The psychological contract between the NHS and its staff was strained, and the impact of this shift cannot be overstated.

The mental health toll on healthcare professionals during the pandemic was severe. Estimates suggest that the incidence of PTSD among NHS staff during this period was double that seen in veterans returning from conflict zones like Iraq and Afghanistan. This stark statistic underscores the emotional burden faced by healthcare workers, many of whom have since reassessed their priorities and approach to work.

This change does not mean that the commitment of NHS staff has diminished. They remain dedicated to their roles, but the willingness to self-sacrifice as they did before the pandemic has understandably diminished.

Rebuilding Trust and the Psychological Contract

During the pandemic, public support for the NHS was symbolised by gestures like clapping and banging pots. While heart-warming, these acts contributed to a narrative of heroism that, in many ways, obscured the very real needs and concerns of healthcare workers. Post-pandemic polls suggest that public support for the NHS has waned, and as Darzi’s review hints, rebuilding trust between NHS staff, the public, and the institution itself must now be a priority.

The first step in this process is re-establishing the psychological contract between the NHS and its workforce. This requires more than grand gestures or financial rewards; it calls for meaningful, thoughtful change. Non-financial recognition is just as important, reinforcing the value of staff in ways that truly make them feel respected, supported, and appreciated.

A Call to Action

Building on Darzi’s recommendations, we must focus on fostering trust within the health system. We need to ensure that NHS staff feel valued—not only as employees but as vital contributors to the future of healthcare in the UK. If we are to achieve a high-performing NHS, its workforce must feel secure, supported, and, above all, appreciated.

This is not a quick fix. It is a long-term commitment that must be embedded into the culture of every NHS organisation and supported by the government, irrespective of political affiliations. Only then can we begin to rebuild the goodwill that has been so essential to the NHS’s enduring success.