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Cut the platitudes and get staff motivated

Illustration about staff motivation

Twenty-four years ago, when I joined the NHS management training scheme, I was told by a series of weathered hospital administrators that “cost walked on two legs”. In one sense, their comments reflected the austerity of the times, but it also revealed their own sense of purpose and what they thought their job was: to manage money and let other people get on with clinical care.

‘The best leaders move way beyond the tired platitude that “staff are the most important asset”’

Not surprisingly, the 1989-90 reforms were called Working for Patients and most subsequent reforms have included the word patient. Unfortunately Robert Francis QC is about to remind us that we are still some way off patient-centred care. Will anything change?

Since 2009, I’ve had the privilege to work in about 40 countries. I’ve met hundreds of organisations and most have similar mission statements, largely centred on their desire to be the best care provider for their community, excel in education and develop world class research.

I don’t doubt their sincerity but I often question their methods. Put simply, staff make or break a mission, vision, values and purpose, yet little time is really spent effectively motivating them − and holding them to account.

In the best organisations that I have seen and researched, it is clear their leaders fundamentally believe “value walks on two legs”. These leaders move way beyond the tired platitude that “staff are the most important asset” and spend an enormous amount of effort nurturing them and motivating them. They are realising value, not just managing cost. There is now a decent research base that shows motivated clinical teams produce better clinical care.

Authentic dedication

Globally there is a pressing need to value healthcare staff more. The triple whammy of ageing populations, fewer (taxpaying) workers and more healthcare demand will stretch even the best organisations to retain the best staff to provide decent care.

Traditionally, developed countries have spent their way out of workforce shortages, but the days of health grabbing up to 2 per cent more of GDP growth per annum are gone.

‘The best organisations seem to have an inner self-confidence and discipline to pursue their mission’

Short-term salami slicing of staff budgets is usually counterproductive and international evidence suggests costs tend to bounce back shortly after crude austerity drives finish. KPMG estimates that a workforce shortage of up to 22 per cent could exist in some developed countries by 2022. Social care will face problems much sooner.

It is possible to improve efficiency, staff productivity and patient care. We have identified five characteristics that successful organisations have adopted to create a seemingly paradoxical synergy in which staff productivity improves while professional motivation blossoms to deliver compassionate care.

Great organisations have an authentic dedication to, and strategic approach for, long-term value (quality of care divided by the costs of securing these outcomes). They also empower professionals and give them greater autonomy; systematically apply leading-edge business and care process redesign methods; improve clinical and managerial information so that is routinely used in day-to-day activities; and they have unambiguous staff performance management and accountability frameworks.

New habits

These characteristics are obvious but it is surprising how few organisations create an environment where all habits flourish systematically and simultaneously. The best organisations seem to have an inner self-confidence and discipline to pursue their mission and implement these changes despite wider turbulence in local or national systems.

Global examples include Virginia Mason in the US; an integrated health and social care provider in the Netherlands called Buurtzorg; Narayana Hrudayalaya, led by Dr Devi Shetty in India; and more locally, the work being undertaken in Salford.

‘People abroad say we go through a lot of structural change and overcomplicate our reforms’

Of course, the adoption of new habits involves questioning the old ones. The pursuit of long-term value for patients should not be continually distracted by short-term targets; you can’t give healthcare professionals more autonomy with a centralised control and command system; scarce resources should be found to invest in Lean and care improvement techniques that all staff should adopt and clinical information should be actively used not just passively reported “up the line”.

Value for patients

Finally, good habits include holding professionals to account. People often talk about the devolution of responsibility in an organisation as if it’s a natural blessing. Clearly it isn’t.

However, devolved responsibility coupled with transparent accountability is powerful. Most staff will welcome this approach but some will fear it will be used indiscriminately. It will certainly differentiate.

Around the world I have seen that people have great respect for the NHS and its values. They frequently comment, however, that we go through a lot of structural change and tend to overcomplicate our reforms so they are not properly implemented. 

As we await the Francis report, let us try and remember that people create value for patients − and they can destroy it too. No doubt there will be changes to regulation and management, but the most sustainable change starts and ends with the staff that care.

Mark Britnell is chair and partner of the Global Health Practice at KPMG and a former trust chief executive and director general in the NHS

Readers' comments (4)

  • Sue M Dale

    Great article for policy makers - why just one practical tip - lean? You recognise that it's people and what they think, care about and do that matters - so bring on the basics of Human Factors training and implementation into all NHS sites at last. Francis report says HF training must be included in medical schools. WHO checklists were a very small start. Care for staff and they care for patients and finances. KPMG is key - You need to fund for an Open Safety Culture, decent staffing ratios and proper breaks, plus Human Factors training and implementation at all levels.

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  • Mark Britnell is correct in focussing on the key role of staff in ensuring quality of care. The KPMG report has some interesting international case studies especially those from Netherlands and Virgina Mason hospitals. Levels of staff engagement are closely correlated with patient care. There is widespread activity to improve staff engagement across the NHS including the excellent work at Salford highlighted in the report . For more examples see NHS Employers website and the recent article in HSJ about the Listening into Action programme.

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  • Mark Britnell uses the Porter and co definition of value: value = outcome / cost. This is wrong. For if that were true then logically value would always increase as costs decrease, regardless of whether the outcome is valuable to the patient or not. That makes no sense.

    So what Mark and others, perhaps, really mean is VALUE FOR MONEY (bang for our buck) and/or RELATIVE VALUE (how much more or less valuable A is than B). But either way, why start there? Why not start with defining value itself? Perhaps the assumption is that value is so obvious as to need no definition?

    As for lean, well there is plenty of evidence that this is not the heaven sent answer to managements known problems. That very assumption – that we already know what our real problems are – runs directly counter to the teachings of the originator of "lean" (a label he would have rejected), Taiichi Ohno

    Finally, Mark seems to fall into the trap that it is a people problem. Our evidence is that in most systems 95% of performance can be attributed to the system design itself (the design and management of work)

    Ultimately Marks analysis of high performing organisations describes doing the same things only better. Yet genuine transformation means doing better things. Do this and there will be no need to 'get staff motivated' because they already are.

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  • Well, first of all managers could stop yelling at their staff. They could stop abusing their good will, and co-manage with them. Many highly skilled and senior staff are leaving, most with sad hearts. Can you think of a more absurd strategy than burning out your best nurses and doctors ? Only someone wedded to extreme short-termism would do that. Frankly, much of what passes for NHS management is gross incompetence. And even then they won't listen. Sad, sad business. Let's hope the Report tomorrow is the beginning of the end of the nightmare

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