What does the NHS Staff Survey 2024 really tell us?

Following the announcement that NHS England is to be abolished, health care leadership must go beyond the usual structural changes and tinkering to support the transformation of health and care in England – transformation not simply of structures but of cultures and processes to ensure high-quality, compassionate care for patients and for staff. It is clear what the solutions are – fix social care, implement prevention (eg, tobacco, exercise, alcohol and diet), promote better community and primary care – but good intentions will fail if the NHS (including primary care) does not become a great place to work, and where the voices and influence of staff, patients and communities inspire, shape and lead transformation.

Health care is evidence-based, and the solutions to the current crisis should be evidence-based. Much of that evidence lies in the data from the NHS Staff Survey – the largest, longest-running staff survey in the world, with 20 consecutive years of intelligence from over 650,000 staff every year. Academics, policy-makers, practitioners, think tanks and researchers have analysed the information and identified powerful predictors of NHS trust performance.

The most important factor is staff engagement. Staff engagement is associated with care quality, staff retention, quality improvement, innovation, patient satisfaction, use of resources, agency spend and, in the acute sector, avoidable patient mortality. Of the three elements that contribute to staff engagement (pride in the organisation, engagement in the work and involvement in decision-making), staff involvement in decision-making is the most important. This is telling, given that NHS organisations are among the most hierarchical and directive of all industry sectors, despite having the largest and probably most skilled and motivated workforce.

The staff survey reveals what enables staff engagement: compassionate, supportive leadership. Moreover, compassionate and supportive leadership promotes patient satisfaction and the ability of staff to feel they can influence decision-making, and is associated with lower work pressure. Working in an appreciative environment (celebrations of success, expressions of gratitude, mutual support) with good teamworking, agreeable relationships between colleagues, and as minimal a hierarchy as possible are also key factors influencing levels of staff engagement.

Data from the NHS Staff Survey shows that compassionate, supportive leadership mitigates the effects of organisational change on morale, engagement and stress. During times of challenge and change, leaders must recognise that the priority is not just effecting changes to structures and processes but increasing the support for staff.

The survey reveals that staff reports of equity and inclusion are associated with higher levels of patient satisfaction. Cultures of equity and inclusion ripple out into how patients are treated so that patients are more likely to be treated with compassion and civility. In contrast, a powerful predictor of patient dissatisfaction is reports of chronic staff work overload – the more pressured staff feel, the less satisfied patients are and the poorer the quality of care.

There is clearly still much work to do to improve poor team and inter-team working in the NHS. Just 40% of staff report working in teams that have clear goals and that meet regularly to review and improve performance. Yet the evidence shows that working in well-functioning teams is essential to care quality, staff retention, staff wellbeing, financial performance, less violence towards staff, lower error and infection rates, and avoidable patient mortality. Effective team and inter-team working is how we shift from hierarchical, vertically structured, target-driven cultures to horizontal, team-based cultures where teams are empowered to innovate and improve quality. Data from the NHS Staff Survey shows that 46% of staff report strained relationships at work and only 54% of staff believe that teams within their trusts work well together. And yet, when multiple teams co-operate effectively, organisational performance is better.

Staff burnout, stress and overload are associated not just with worse quality of care, but also higher levels of staff turnover, more errors that harm patients, and worse financial performance in trusts. In the NHS Staff Survey only 34% of staff agree that there are enough staff for them to do their jobs properly, and fewer than half (47%) say that they can meet all the conflicting demands on their time at work.

The survey also reveals that although the number of NHS staff reporting burnout has decreased since the pandemic, 30% report feeling burnt out at work often or all the time. Among ambulance staff, the figure is nearer 40%. Over 460,000 NHS staff are going to work each day feeling the impact of burnout. Compassionate leadership addresses burnout, stress and work overload effectively, not simply through limited health and wellbeing programmes but through the demonstrably more effective interventions that improve key factors, such as work overload, poor supervision, teamworking and conflict.

The transformation of cultures across the NHS needs change at every level, with those working within it, those receiving services from it and those leading it being involved. There must be clear shared vision and values, distinct purpose and goals at every level (not just empty target-setting), equity and inclusion that is the responsibility of everyone (rather than virtue signalling), support and compassion for and between staff from politicians, national bodies and local leaders, and with a commitment in practice to constantly improve team and cross-boundary working.

There are bright spots where some or much of this is happening. Over the past five years, Berkshire Health has retrained all its staff in compassionate leadership and their staff survey data is impressive. Northumbria has been nurturing these cultures for more than ten years and have sustained their outstanding performance. The NHS in Wales has a ten-year strategy to develop compassionate leadership across all of health and social care. Mersey Care has transformed its culture from fear and blame to transparency, learning and trust.

Leaders must make much better use of the powerful staff survey data and not just be satisfied that some of their scores are better than the mediocre average. The aspiration must be to reach the level of the best scoring trusts. And then to commit to continual improvement.

The evidence is clear – the power for change will come from the people who are the NHS and the communities they serve. If we are to ensure high-quality, continually improving health and care for all in our society, we must ensure high-quality, continually improving and compassionate support for all NHS staff.