A staff-led NHS? Improving patient care by engaging staff and devolving decision-making

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Last autumn I was asked by Norman Lamb and Francis Maude to lead a review of staff engagement and empowerment in the NHS. I was assisted by an expert panel drawn from the NHS and other sectors and visited a number of NHS providers and public service mutuals in different parts of England. Our report published today contains three central recommendations.

First, we argue that NHS organisations need to redouble their efforts to engage staff in the light of compelling evidence on the relationship between staff engagement and organisational performance. The pioneering research of Michael West and others has shown that organisations in which staff report that they are engaged deliver better outcomes for patients and benefit from lower absenteeism and staff turnover. The corollary is that organisations with low levels of engagement – like Mid Staffordshire NHS Foundation Trust – are more likely to deliver care of an unacceptable standard.

The link between staff engagement and organisational performance has been known for some time and the good news is that levels of engagement across the NHS in England are increasing. The not-so-good news is that there are wide variations within the NHS with examples of excellent practice and rapid improvement in some organisations co-existing with stubbornly low levels of engagement in others. The challenge now, to borrow Nye Bevan’s phrase, is to universalise the best through NHS boards taking staff engagement seriously and making the changes needed to increase levels of engagement to acceptable levels.

Second, having studied the experience of public sector mutuals, we argue that they should play a bigger part in the NHS in future. On my visits to some of the public service mutuals created under the Transforming Community Services policy, I have been impressed by the testimony of leaders and staff in these organisations of how different it feels compared with being employed within the NHS. The sense of liberation and ownership expressed by leaders and staff was palpable on these visits and is supported by evidence from staff surveys that many mutuals have been successful in increasing levels of staff engagement.

One of the reasons is the work they have done to devolve decision-making and flatten hierarchies to empower staff as co-owners to improve patient care. The experience of these mutuals, working mainly in community services, lies behind our recommendation that it should be possible for other NHS organisations to go down this route where there is interest in doing so. This might entail NHS trusts choosing this option when they have completed an appropriate authorisation process with similar rigour to the foundation trust authorisation process, including trusts providing acute services.

It might also build on emerging models of integrated care, with several organisations coming together as a public service mutual to create a joint venture to deliver services such as urgent care and care for older people. Setting up a new organisation of this kind would have the advantage of all partners having a role in its creation rather than one being seen to be in the lead and 'taking over' from others. At a time when there is considerable flux and fluidity in relation to the future provider landscape because of uncertainty about the foundation trust pipeline, the panel believes the time is right for a period of accelerated evolution and evaluation of alternative organisational models.

Third, our report makes a plea for there to be much greater devolution of decision-making within the NHS. Providers of NHS services – whatever their organisational form – should operate with presumed autonomy, and regulators should create space and the opportunity for leaders to innovate in the delivery of care. As the Fund has argued recently, there needs to be a fundamental shift away from improvements in care being driven from the centre through performance management to reform being led from within the NHS itself. This means developing the collective leadership on which service transformation depends and supporting staff through training and development in quality improvement methods and skills.

These three core recommendations are based on a simple truth. Health care is first and foremost a people business in which 1.4 million staff in the English NHS provide care to 1 million patients every 36 hours. The quality of that care depends on the skills, commitment and compassion of staff and engaging and supporting them to improve care at a time of unprecedented financial and service pressures has never been more important.

Chris Ham chaired the Review of staff engagement and empowerment in the NHS in an independent capacity.

This blog is also featured on the Public Finance website.


Ashok Patnaik

University of Huddersfield
Comment date
05 August 2014
I agree with Hannah Boss. Views supportive of SEs are more likely to come from top management than front-line clinical staff.

Hannah Boss

NHS community trust
Comment date
25 July 2014
"I have been impressed by the testimony of leaders and staff in these organisations of how different it feels compared with being employed within the NHS."
Possibly more 'leaders' than staff!
Testimony of all the soc ent staff applying for posts in NHS trusts tells a different story and those that I work with that have left soc ents tell of no less top down management than before.
Everything that they feel was trying to be achieved in the TCS trusts they have found being achieved in our NHS trust. The problem isn't the set up, its the hierarchical politics within any trust, regardless of if its NHS or not-for-dividend or for-profit

Jenny napier

GP and research fellow,
Queen Mary's University
Comment date
20 July 2014
A public sector mutual ... now, was that not the original model of General Practice when the NHS first formed?
Very interestingly, this idea of engagement within an organisation, which is small enough for a collective form of leadership, chimes perfectly with the latest research on how people are motivated - which is mainly through meaning, curiosity and problem solving, rather than by using carrots and sticks. See Daniel Pink's book "Drive" for a lively presentation for the case of trusting employees involved in heuristic (non-algorithmic) work.


HR Consultant,
Comment date
16 July 2014
Stories like this - http://www.theguardian.com/society/2014/jul/15/hospitals-red-flag-events-staffing-nice - must make you weep? How can employees engage and innovate when the NHS is subject to too much oversight, over view, regulation and political interference?

Hugo Limachi

Continuous Improvement trainer, coach and adviser (Primary Care Development Facilitator),
NHS Cumbria CCG
Comment date
15 July 2014

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