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

Michael West explores the link between staff engagement, high-quality care and financial performance.

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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.

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