It’s not about the money: staff engagement comes first

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A new report from NHS England finds a strong relationship between levels of staff engagement and spending on temporary staff by NHS trusts. Based on research I carried out with colleagues from the University of Sheffield, the report shows that high levels of staff engagement are associated with low rates of staff sickness absence and therefore lower spending on bank and agency staff. The size of the effect is large: an average upward shift of only 0.12 on scores on a five-point scale of staff engagement is associated with a saving on agency/bank staff spend of £1.7 million.

We already know that there is good evidence that high levels of staff engagement improve quality of care. These new findings show that increasing levels of staff engagement will improve quality of care and save money. And we know how to improve staff engagement: improve quality of leadership, develop effective teamworking, ensure good working relationships, reduce workload, have an unclouded vision around care quality, put staff in charge of service change, and ensure trust, openness and fairness. And not surprisingly, those are also the factors that will ensure high-quality, continually improving and compassionate care.

However, the NHS’s current focus on financial performance risks diverting attention away from quality of care. It is vital that leaders at every level recognise that care quality should continue to be their top priority. The danger of letting concerns about financial performance trump concerns with care quality is manifest in how much relative time leaders devote to these areas.

How to improve staff engagement: improve quality of leadership, develop effective teamworking, ensure good working relationships, reduce workload, have an unclouded vision around care quality, put staff in charge of service change, and ensure trust, openness and fairness.

And another danger is neglecting staff. In a context where the demand for and complexity of care are increasing, staff are being asked to soak up increasing challenges with inadequate attention to their needs and wellbeing. This will result in decreased engagement and increasing costs as staff are driven into poor health and increasing stress, which may mean they are off work, necessitating increased spend on agency and locum staff. Fifty per cent more staff in the NHS report debilitating levels of work stress compared to the general working population.

How can the NHS ensure the two inextricably linked issues of the wellbeing of staff and provision of high-quality care? There is much research evidence to draw on. NHS organisations need to ensure that staff feel a powerful sense of belonging and being valued. This means emphasising in practice, as well as in rhetoric, a commitment to high-quality care so that staff feel a link between their work values and those of their organisations. Ensuring effective teamworking, reflection time and debriefs in teams, and support for team-based working will help staff cope with stress and feel part of cohesive and effective work units.

NHS staff are highly motivated and skilled and require the freedom to innovate and improve their work without being excessively controlled and inhibited by unnecessary bureaucracy, hierarchy and rigidity. NHS organisations must develop collective leadership, where everyone feels they have leadership responsibility and there is shared leadership in teams. The voices of all staff need to be heard and valued, so staff can feel they are influential and able to contribute to effective decision-making and innovation.

And engagement will increase when the NHS ensures that people’s talents are developed, their competence is increased, and they are able to learn, in an environment where opportunities for learning and innovation are not stifled by excessive workloads. That requires leaders at every level to address the problem of excessive workloads that damage staff health and wellbeing, inhibit innovation and endanger patient safety, rather than accepting them as an inevitability.

And engagement will increase when the NHS ensures that people’s talents are developed, their competence is increased, and they are able to learn, in an environment where opportunities for learning and innovation are not stifled by excessive workloads.

Engagement flourishes where there is trust – trust in leaders, a sense of authentic openness and honesty in organisations, fairness in relation to career progression and real progress in overcoming discrimination against minority groups (BAME staff, women, those with disability, and discrimination based on sexual orientation). Lack of trust is the single most important hindrance to the development of high levels of engagement in organisations.

And there is a pervasive sense of fear and anxiety in many parts of the NHS, much of which emanates from oppressive regulatory and inspection regimes. As set out in the national framework for improvement and leadership development, the national bodies that oversee the NHS must ensure their cultures are characterised by high levels of trust and engagement – not just so they practise what they preach but in order that their cultures are sufficiently healthy for them to fulfil their functions effectively.

It is unsustainable for staff to bear the burden of the increasing demands on the NHS, with an implicit assumption that their good will and fundamental altruism will carry the service through, regardless of the cost to individuals. That is as dangerous as over emphasising financial performance in a context that must be fundamentally focused on quality of care.

The NHS must model compassion throughout the system – listening to staff, understanding the challenges they face, empathising with them, and acting to help and support them. And that compassion must be modelled in the cultures of all NHS organisations, beginning with the national bodies and boards. In that way, the NHS can truly begin to create the conditions for high staff engagement and for high-quality compassionate care.


Dr Judith Graham

Deputy Director for Organisational Learning,
Rotherham, Doncaster and South Humber NHS Foundation Trusr
Comment date
08 March 2018

Thank you to Michael West for this important publication, and your supportive presentation at this weeks FTSU conference. I have a few comments which I hope will add to the discussion:

The current pace that health and social care services are required to manage and evolve at, combined with the changes in the sense of ‘community’ that comes from more agile and remote working practices, have unintended effects upon engagement; which mean that psychologically informed leadership is essential to avoid the well-researched detrimental effects of disengagement.

Staff need the time, opportunity, and permission to engage, and leaders equally must be equipped and resourced to compassionately listen and engage in a range of ways that support our diverse workforce requirements, to engage, speak up, and interact, within and across systems. These ‘needs’ pose complex educational and cultural challenges, which can be supported via a suite of tools, but require leaders who can be reflexive, and who can value conflict and interact in a boundaried and inclusive manner.

Emerging, existing, and new leaders at all levels across professional groups need support, and in some cases training, to understand different reasons for disengagement to ensure internal and cross-system compassionate leadership. Through listening events, some organisations have identified a number of reasons staff may not engage using the methods currently monitored regarding ‘engagement scores’. Reasons provided varied from staff not wanting to complete a staff survey due to the lag between completion and result/feedback; not wanting to ‘bother’ people who are busy; or because engagement events may preclude certain groups of staff or staff who work different shifts.

Leaders also must be cognisant of the time needed to meaningfully engage, individual and team preference, and the need to co-produce and effectively communicate solutions and options that have been considered but not selected. In a similar way to school exam papers - you get 1/2 mark for the right answer and 1/2 a mark for showing your working - reflective events have shown disengagement can come from only hearing a result and not seeing the ‘working’ or engagement behind this.

Lean structures and brief communication may be financially beneficial - but quality impact assessments, focused upon creating leaner structures, must consider the effect upon overall engagement time and ability within any restructure, so as not to hinder staff (and risk financial instability) - ensuring that sufficient time and resource to constantly and meaningfully connect with the whole team is considered.

The sense of community, commitment, and belonging that is nurtured through good levels of engagement requires a whole-system culture commitment, time to nurture, and a particular focus upon support services.

Much research has focused (rightly) upon the patient and staff benefits of high engagement in frontline operational staff teams. However, arguably, when we are in an increasingly technologically dependant time - we need to assess engagement levels with parity, considering the ‘engagement‘ effects of potentially dislocated streamlined support services.

Staff within these services can be at increased risk of disconnecting with the values of patient-focused care, if they are not engaged with feedback about the positive impact their roles and achievements have upon patient wellbeing, and also the wellbeing of frontline staff.

The richness of NHS workforces really do positively affect patient experience. Engagement with groundskeepers who mow the last lawn a patient in a hospice will see, or the accounts persons who ensure the most cost-effective purchases to enable most resources to be patient-facing - is essential to avoid disengagement and disconnectedness with NHS values.

Yet it is increasingly difficult to ensure meaningful engagement that considers socioemotional needs and performance support, when these service staff may have a different sense of organisational identity, due to the lack of the ‘place based’ community employment, due to the pan-organisational support provided - distant from patient contact or feedback.

In summary- the report and links provide essential recommendations in order to support healthily engaged systems, hopefully these reflections can add to this important and complete discussion.

Mitzi Blennerhassett

author, bmj patient reviewer, reluctant patient activist,
Comment date
08 March 2018

Thank you for this supremely important article. Staff engagement is vital to compassionate healthcare, yet when in my role as a patient I am constrained by feelings of guilt: being a burden, adding to doctors' workloads. I sit in a crowded hospital waiting area and feel for the person who apologises as she informs me that the clinic is already running 40 minutes late. As a seasoned patient, I know well enough to bring a book with me and marvel at the patience of a young mother who deals expertly with a bored toddler, despite there being no toys or distractions available. Other patients sit in glum silence. Any newcomer is the focus of their inquisitive stares. When it is my turn to see the consultant she comes out to collect me! The walk may meet her needs for a little exercise, but, along with her manner, it also partly expresses her compassionate approach and my smile becomes a grimace as pain slows my progress and I add to her delayed clinic. When she apologises for my wait I want to explain how little it matters; that I realise interactions with patients can (or should) vary according to need; that delay just shows her humane approach; that I feel for her. The reason for my visit is long term radiation damage from cancer treatments in 1990; this is the first time I have seen a doctor with specialist knowledge who may be able to help alleviate symptoms which have such an impact on my quality of life, so I have come armed with a list of questions and I must not waste a moment... Despite not wishing to appear rude, I find myself interrupting her, worried that if I don't mention something it will be forgotten. Her communication is excellent, her patience is amazing, but I'm talking more than I should and gabbling in places as stress takes hold: it's so vital that I get all the information I need. The consultation is overshadowed by my understanding of her workload. And my understanding, as a patient activist, of what working within todays NHS can mean for staff. Staff engagement is vital, but so is a compassionate workplace. I would have given this piece the title 'Not JUST about the money'.

Dr Daniel Fascia

Clinical Lead for Transformation,
The Yorkshire Imaging Collaborative
Comment date
08 March 2018

I'm so glad that this work has been published and can only hope that a huge number of NHS workforce leaders read it and act rapidly. Morale is rock bottom and many of these "leaders" seem to think that chastising senior staff is the way to squeeze more out of them. The effect trickles down and soon you have an entire hospital disengaged.

In reality they need to take a look at their own leadership strategies and ask not 'how can I squeeze more out of you' but 'what can I do to improve your workplace so that you are able to work more effectively'.

At The Yorkshire Imaging Collaborative we are taking a different approach, by inviting in depth engagement of the workforce to help redesign regional imaging services. Consultants and radiography staff are designing and undertaking exercises to show better workflows and drive efficiencies because they have the in depth knowledge of their subject, not authoritarian managers.

We are fortunate to have been sponsored in this approach by some forward looking executives who have recognised that authoritarian top down "leadership" does not motivate staff to be at their best.

David Peach

NHS user
Comment date
09 March 2018

Nurses Banks are privately run so with encouraging Private Enterprisers into the NEW NHS MODEL the situation will get worse.

Mr R W Ebley

Comment date
14 March 2018

In order that change is effectively undertaken all levels of government and other public funded organisations need to demonstrate good management

Independent management accreditation is required to achieve this

Thank you

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