The NHS Staff Survey: working through Covid-19 and beyond

Key:

• HM: Helen McKenna

• SB: Susie Bailey

• MW: Michael West

HM:     Hello and welcome to The King’s Fund Podcast where we talk about the big issues and ideas in health and care.  I’m Helen McKenna, I’m Senior Fellow here at the Fund and your host for this episode.  Like many people at the moment, we at the Fund are working from home, which means we’re recording this episode remotely, so please excuse any background noises that you might hear.  Today we’re going to be talking about the NHS staff survey, which is the annual survey of NHS staff.  The results of that were published on 11 March and nearly 600 thousand staff responded.  We’re going to explore what the findings tell us about how NHS staff are doing after quite literally what has been an extraordinary year and also look at what needs to happen next in response to the results.  And to help us think about this, I’m delighted to be joined by two fantastic guests.  We’ve got Susie Bailey, who’s Director of Leadership and Organisational Development here at The King’s Fund and we’ve also got Professor Michael West, Professor of Work and Organisational Psychology at Lancaster University, Visiting Professor at University College Dublin and Emeritus Professor at Aston University and a Visiting Fellow here at The King’s Fund.

Susie and Michael, welcome to the podcast.

SB:       Thank you

MW:    Thank you.

HM:    So there’s a lot to unpack in this year’s staff survey, so what I’d like to start by doing is just asking each of you what stood out in particular from the results from your perspective.  So Susie, could we start with you?

SB:       So as you say Helen, there’s a lot to unpack, but I think the things that really stood out for me was first of all the statistic around people experiencing work-related stress and nearly half of the staff who responded to this survey had experienced work-related stress in the last year.  The number of staff that are experiencing discrimination in the workplace has increased and in those experiencing it from their manager or colleague, it’s at its highest rate in the last five years.  And then I think the other one that surprised me is that I had expected the statistic around intention to quit to have got even worse.  And as it is, it’s slightly improved on last year, but that’s the one that I guess that probably surprised me the most.

MW:    Yes, my reaction to the staff survey, for me it’s really important to try to understand the staff survey, not just in the context of the pandemic, but to understand where we were last January before the pandemic struck.  So at that point we’d seen stress levels rising in the staff survey from 2015, 2016 onwards steadily to reach their highest levels.  And last year, 2020, they were even higher again, almost certainly due to that continuing trend and the effects of the pandemic.  But last January we had the highest level of vacancies proportionately we’d ever seen, very high levels of intention to quit.  One in four nurses and health visitors were quitting within three years of joining the NHS.  Stress levels in primary care were at their highest levels with GPs recording the highest levels of stress that we’d seen since the introduction of the GP working life survey.  So we were in a really difficult place back in January last year and then the pandemic struck.  So what’s intriguing, as Susie says is, there’s been an increase in the number of people saying there were enough staff to do their jobs properly.  Well, we know that staff vacancy rates and sickness absence rates went up.  People saying they’ve had adequate supplies and equipment, that’s gone up as well.  Yet we know that PPE was a huge issue back in the early part of the pandemic, so there may be some digging deeper to try to understand what that’s about.  And it could be that people, when the survey was being administered, now had enough PPE equipment, and so they responded in that context rather than in the context of the whole year.

So yes, it is intriguing.  There are some encouraging things and I think that may reflect some of the really good things Trusts did to support staff and there are some areas where the problems just seem really difficult and challenging, like as Susie says, discrimination and increasing levels of staff stress.

HM:     And hopefully we’ll get to explore some of the issues that you’ve both raised there in this episode, but I guess it’s a question particularly for you Michael, because you actually designed the survey, you were part of creating the survey, what are some of the key trends, positive and negative, that you’ve seen over time?

MW:    I think that what we’ve seen is some slow and steady improvements in terms of staff engagement and people feeling that time passes quickly when they’re at work, they feel a sense of identity with their organisations.  I think that there is also a sense that people feel really proud about the work that they do.  I think the really worrying side of this is the sense that we’re just seeing stress levels inexorably rise.  For me, what’s important to understand, and it goes back to what we were saying about the situation last January, it’s clear we are not really well meeting the core work needs of people in the NHS at work.  And that’s why we have such high levels of stress.  So we can put in place all of the mindfulness and yoga, and that’s all great, I do those things as well, but unless we’re meeting people’s core work needs, all three of them, then we’re not going to solve this problem.  And that’s about making sure people feel that their needs for autonomy and control at work are being met, they’re working in just and fair cultures, their voices are heard, there isn’t discrimination, their working conditions enable them, in terms of the technologies, they’ve got some influence over work rotas and schedules, that their needs for belonging are met through working in supportive teams and having compassionate leadership.  And their needs for making a real contribution are met because they’re not – and this is a key issue – having to deal with chronic excessive workloads the whole time.

That’s the number one predictor of staff stress and it’s the number one predictor for staff intention to quit.  We have to address that issue of chronic excessive workload continually.  And I think what the staff survey has told us is that over the years, there has been a decline in people’s perception that there’s enough staff to deal with the work that they’re faced with.  Curiously except for this last year.  And that’s also been true in relation to having the resources and the equipment etc that they need.  So I think our focus should be on using a framework like the ABC of core needs to help guide the kind of changes that we need to transform our organisations for the future.  Some really shining beacons in terms of what they’re achieving, in terms of staff engagement, staff wellbeing, there are so many good practices going on that do bring about change.  So we see Trusts really brought about major change, which is evidenced in the staff survey over the years, and we can learn from what they’ve been doing to achieve the kind of organisations we need to be achieving.

HM:     I agree totally and I think there have been some standout improvements, for example the Isle of Wight, I think, we’ve seen particular improvements.  How much are Trusts that make that kind of significant jump or improvement, are they I guess showcased and learning spread nationally to make the most of what those improvements are and how people can learn from them?

SB:       I mean, Helen, if I can speak as someone who used to work as an NHS Manager in a number of Trusts, I think the NHS has got better at sharing good practice.  I think there is greater sharing of the ideas and the experience.  It’s very contextual, so you can’t necessarily lift and shift something that works in one place in the country and assume that it’ll work in another.  But I think what we are seeing is an increasing number of organisations who are understanding that cultural change, that making improvements to people’s working lives, is a lifelong endeavour, it’s not a one-off fix.  And so there’s a growing number of organisations that are doing deep cultural work and actively involving their staff in ideas and innovations to make that happen.  And I think we’re also seeing cultural change and focus on health and wellbeing being much more of a shared responsibility, both at national and local level as opposed to it all being the responsibility of local organisations.  But fundamentally this is about the lived experience of staff day in day out, shift in shift out, so it’s something that actually you need to engage your whole workforce in.

MW:    And Isle of Wight, as you mentioned Helen, is a really good example of what Susie is saying.  So Isle of Wight for the last two years has been on a culture transformation voyage, so they’ve been deliberately focusing on how to transform their culture, they’ve renewed their vision and developed a set of values in consultation with staff.  They’ve focused much more on ensuring clear goals at every level, developing support and compassion, and compassionate leadership in the way that they’re working with staff across the organisation to promote engagement.  There’s been real support for learning and innovation and they’ve been putting a great deal of effort in to developing effective teamworking, so it’s actually a really good example of precisely what Susie is saying.  And we’ve got lots of other examples around the country of where that culture transformation has been going on.

SB:       And where people are celebrating what’s happening in their culture, so what we’ve also seen is a number of organisations celebrating with their staff about actually the progress they’ve made.  So cultural change shouldn’t always be seen as something that’s negative, it’s actually about celebrating and noticing the improvements that are being made in people’s lived experience of coming to work.

HM:     So what do we know about other health systems, are there other health systems that are getting the staff side right or are doing better?  I mean, I know the NHS performs incredibly well internationally on lots of dimensions, but is there stuff that we can learn from elsewhere?

SB:       Well, I think the simple answer to that question is there’s always stuff we can learn from elsewhere, so I think what’s really important is that we see leadership as lifelong learning.  And we should always be open and curious to experience that comes from other health systems, but also other industries, other sectors.  So it’s staying curious about what others are doing and paying attention to how others are improving cultures and paying attention to those core needs at work, as Michael was just describing, seem to me to be so important.  And one of the stats, looking at people’s enthusiasm for their work, it’s still quite sad to see that just under a third of people feel either sometimes, rarely or never enthusiastic about coming to work in the NHS.  Now as a former manager of people in the NHS, that just seems really deeply sad to me and considering how much time people spend at work and the training that people do in order to join the NHS, and generally the kind of commitment and intrinsic motivation people feel to come to work, to find that you’re not enthusiastic about what you’re doing, that’s something that we need to pay attention to.

So I think leaders wherever they can get inspiration about what they can try with their teams in order to improve things, they need to do that, so I think we remain open to ideas wherever they come from, whether from within our system or globally.

MW:    Yes.  And I would add to that, I think there are great examples within the NHS of where they get it right.  So Northumbria is always held up as a good example.  They introduced a Facebook page for their staff and 7000 of 11,000 of their staff have joined that Facebook page so they can speak up about problems that are concerning them.  They provided free food and parking and accommodation during the pandemic, so better enabling people’s sense of autonomy.  Merseycare has introduced this restorative culture cutting disciplinaries by over 70%, suspensions by over 80% to create cultures of learning and justice rather than fear and blame.  Self-rostering has been introduced in some organisations, improved teamworking has been happening in many places – Royal Bournemouth and Christchurch, North Staffs, Merseycare I mentioned already, Barts has done great work around developing teamworking.  Wales is introducing a national compassionate leadership strategy for the next 10 years, for the whole of health and social care, and providing support materials free across the country to everybody to help develop compassionate leadership.  Berkshire has retrained half its staff in compassion and compassionate leadership and in terms of reducing chronic excessive workload, then we see East London Foundation Trust which has cut 85% of clinical audit activities in the context of its quality improvement culture.  Lots of great use of new technology during the pandemic to reduce workload, so we’ve got great examples of where these things are happening within our system.  These beacons of light, we have to raise the level of illumination overall and reduce the variability I think.

SB:       On a simple level, it’s like ask your staff, ask the question, don’t assume that you have to import an idea from elsewhere.  It’s great to be inspired by what others are doing, it’s great to go and visit and see what others are doing but ask your staff for their ideas.  Because they’re full of great ideas about things that can make such a difference to the lived experience of people coming to work.

HM:     And their context is so important, obviously, solutions have to be rooted in what’s going to work for them, so I totally agree, Susie.  And just thinking about some of the findings that I think, Susie, you particularly highlighted, the number of black and minority ethnic staff who reported experiencing discrimination at work, so I think it’s nearly one in five, 17% black and minority ethnic staff experienced some form of discrimination from a manager or colleague, which is considerably higher than the 6% of white staff reporting the same thing.  And also higher than the 15% reported last year, so Susie, what are your thoughts on what’s going on there?

SB:       Well, it’s a shocking statistic, isn’t it, particularly when you draw the contrast, as you say, and the experience of white staff.  I think in a year in which the Black Lives Matter movement has been so prominent, again really disappointing to see that that number of staff are experiencing that in their daily lives and they’re experiencing it at work and outside work as well.  So it’s something that we’ve obviously seen a number of organisations paying particular attention to, doing a lot of work, the Workforce Race Equality Standard data continues to show that we’re not making enough progress in the NHS and we’ve certainly heard from a number of Trusts and regions where leaders are paying more attention to this, are really trying to make some changes both in the way that they lead organisations, but also creating safe spaces for staff to be able to share their experiences.  And really we need to treat that lived experience of black and ethnic minority staff as knowledge and really use that data in order to change things and make sure that the NHS is a safe and inclusive workspace.

MW:    I think it’s really it’s an issue we must grasp hold of now.  The NHS was created in 1948 on what I think are two core values; the value of compassion and the value of inclusion.  And I think actually they’re the two genetic strands of the NHS.  So I think what the staff survey tells us is, okay, we know that we’re doing better in terms of board representation of women and people from minority ethnic group backgrounds, that’s good.  We know we’re doing better in terms of the disproportionate use of these disciplinaries in relation to people from minority ethnic backgrounds, but as Susie said, the lived day to day experience of people from minority ethnic backgrounds is getting worse.  So I think now is the moment where we have to stop simply scrabbling around the edges of this issue and see that it’s a core issue that should be part of every individual’s work, every team’s work, every department, every directorate, every organisation in the NHS.  So we have to have culture change strategies that address what every individual must do to create a more inclusive positively diverse environment characterised by equity, what every team has to do, what leadership has to do, what every organisation has to do, and what ICSs have to do.  And I think it’s pretty clear what we need to achieve such a comprehensive strategy and I’ve certainly got the privilege at the minute of working with NHSEI around articulating that.

But now is the moment when we have to address that issue and I think the staff survey results are a clear indication that despite all of the efforts and the use of the Workforce Race Equality Standard, we are not really digging deep enough and transforming the seabed that is our health service.

HM:     And it’s obviously morally unacceptable what’s going on and I think it’s also, my assumption would be, you can’t possibly hope to be delivering a fair and inclusive and equitable service to patients and the public if you’re not treating staff equitably and in an inclusive way?

SB:       That’s absolutely right, Helen, and I think what we absolutely need to do is engage staff and teams in those conversations, because this is a conversation for everybody.  It’s absolutely the responsibility of leaders to take action in the way that Michael has described, but it’s fundamentally around conversations at a team level and we need to make sure that we’re not placing all the emphasis of the work that needs to be done on the people who are being discriminated against.  So the importance of allyship in actually tackling and challenging discrimination and making improvements to culture.  And I think when you look at the data on all the protected characteristics, this is unacceptable in a service that is meant to be delivering compassionate care for all.

HM:     And presumably it ends up becoming a retention issue as well?

SB:       Absolutely, yes.

HM:     So just thinking about pay, I think the Government gave its evidence to the Pay Review body, they recommended that staff get a 1% pay increase this year, which I think has angered almost everyone, both in the NHS and in the general public, how important is pay in terms of both incentivising people to join, as new recruits, but also to help them want to stay working in it?  Because you’ve talked about a number of other things that are obviously also essential?

SB:       So I don’t think pay is a particular incentiviser in the NHS, but I absolutely think it’s a demotivator.  And I think given the experience over the last year, particularly it’s been Michael’s and my privilege working with Ethan here at The King’s Fund, to work with nurses and midwives and really listen to their experience, it’s a demotivator not to get a pay rise that recognises their skills and their commitment and the sacrifices they’ve made.

MW:    Yes, I agree.  If you look at the academic literature, pay seems to be not a motivator particularly, but a demotivator.  And my reaction to the 1% announcement was, it just felt profoundly damaging.  I mean, if there’s one thing we want to do at this minute, it’s to appreciate the fact that so many people have risked their own lives and the lives of their loved ones in the mission of caring for people in the community during COVID.  I think the real damage will also be done in terms of how people might be attracted to work in the NHS, given the levels of salaries, and given what skilled and motivated people will be able to find in terms of work elsewhere.  So it’s a deeply unhappy moment, I think, for the NHS at a time when we should be focused on attracting and retaining and supporting staff.

HM:     Yes, I totally agree.  And thinking about recovery from COVID-19 and what comes next, obviously as it stands we are currently and thankfully seeing deaths and hospitalisations from COVID-19 declining, and obviously therefore people’s attentions are starting to turn to longer term recovery, over the last year many people have referred to NHS staff as heroes, as being superhuman and to some people that might imply that this group won’t be affected by the issues that we’ve been talking about.  But of course we’ve seen in the staff survey data and it was obvious that COVID-19 was going to have a serious impact on the physical and mental health of NHS staff.  We’ve seen stress-related illness reaching an all-time high.  For me, this just raises questions about the language that we use to talk about NHS staff and whether referring to them as superhuman is just actively unhelpful.  Susie, what’s your view on this?

SB:       I think it’s deeply unhelpful and we hear frequently from NHS staff of all different professional backgrounds how unhelpful they find it.  It’s great to thank people for what they’re doing and of course people need to hear that, but to put the label on them of heroes means that it’s not okay to not be okay.  So given what we were talking about at the start of this conversation around the level of work-related stress that people are experiencing, calling people “heroes” just places even greater burden on them, I think.  So I think we need to change the language and the thing that’s really important about recovery is that we need to accept that people’s experience during the pandemic has been very variable.  So people have been doing very different roles and finding themselves in different situations, so we can’t have something around recovery that is a one-size-fits-all.  There needs to be a range of things to support people, that needs to be in place for a long time, and that actually one of the benefits that has come out in the year and is reflected in some of the survey results, is that there is much greater emphasis on the health and wellbeing of people working in the NHS than there has ever been.  It shouldn’t have taken a pandemic for us to pay attention to that, but we need to hold on to that and make sure that, as Michael says, that we’re really addressing people’s core needs at work and not just a sticking plaster on top of something when things go wrong.

HM:     And Michael, just thinking ahead to this growing backlog of planned treatment, so recovery could look fairly taxing as well.  From your perspective, what steps can leaders take to support their teams in the coming months?

MW:    Well, first to say that we know that there’s been a huge impact on staff, so the Health and Wellbeing Hub set up by NHS England Improvement has had over 700 thousand contacts on it.  From the number of studies that have been done during the past year, we’ve seen increases in anxiety, stress and depression amongst staff and in some groups of staff working in particular areas like ICU, there have been worrying increases in symptoms of post‑traumatic stress disorder, which bear unfavourable comparison with soldiers returning from combat zones.  So it is a real issue, we do need, I think, to be having a discussion about how we create some rest space for staff rather than just saying now you’ve got to catch up on the backlog.  And thinking about how we can give extra days for recovery, because if we don’t, what we’ll do is lose more staff.  They’ll be so exhausted, they’ll be like waterlogged sponges that are then being asked to take on more water as it were.  People will just leave and that will be disastrous.  And of course there are some people and some organisations and some teams that have grown through this crisis.  We’ve learned how to work in teams better, we’ve innovated at a pace and at a scale we would never have imagined possible, we’ve collaborated across health and social, there’s been some amazing things happened and some people have grown and developed as a consequence.  But we do have to recognise that it’s not just about taking care of staff at this moment to come out of the pandemic, I think how we treat staff at this juncture, at this point in time, if we get it right, they will remember it for a long time.  If we get it wrong, like the 1%, they will remember it for a very long time. We have to be thinking in terms of transformation for the future.

Because if we want to deliver high quality continually improving and compassionate care for patients and communities, we have to deliver high quality continually improving and compassionate support for staff.

HM:     Absolutely.  So final question for you both.  Imagine that we’ve travelled forward in time to March 2022.  All the restaurants are open, people are out in the streets, life may or may not have resumed, if there was one metric that you could see changing in next year’s survey results, what would it be and why?

SB:       I guess for me, I’m going to be sneaky and pick two.  So first of all it would be amazing to see improvements and see a reduction in the number of people experiencing discrimination at work.  That fundamentally is something that we have to tackle consistently.  But the other one is that at the moment, we are making people sick by coming to work in the NHS, and we have to tackle the stress that people are under.  So I’d really like to see an improvement in that statistic, because it’s been getting worse over the last five years, so I’m going to have those two.

MW:    And so in addition to what Susie says, Helen, I’m going to pick actually something that might seem slightly odd, but it’s quality of teamworking.  We know that when teams work well together, even if you just take two parameters, teams that have clear shared objectives and that meet regularly to review performance are much more effective and much more innovative and much more productive and team members have much better mental health.  Most people’s work experience plays out in their day to day experience of working with their colleagues.  And currently we think only about 40% of staff work in teams, relatively stable teams with clear objectives and that meet regularly to review performance, that has a huge impact on outcomes in terms of care quality, errors, injuries for staff, stress levels, even financial performance.  So I would love to see that there’s been a real commitment to building teamworking back far better for the future.

HM:     Brilliant, thank you, and let’s hope that we see improvements on those areas and more in next year’s survey.  Thank you so much Susie and Michael for joining me today.  There is so much in what you’ve said that I think we can all draw inspiration from regardless of our role in the health and care system and lots for us to think about.

MW:    It’s great talking to you, Helen, thank you.

SB:       Really enjoyed it Helen, thanks a lot.

HM:     Well, that’s it from us.  You can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast.  And we’d love you to subscribe, rate and review us on Apple podcast or wherever you get your podcasts as it helps others to find us and also helps us to improve the show.  You can also get in touch with us via Twitter, @thekingsfund account, or my account at helenamacerena and finally thanks as always to you for listening but also to our podcast team for this episode – Producer Sarah Murphy, Policy Adviser Jonathan Holmes and also thanks to our colleagues for their advice and assistance.  We very much hope you can join us next time.