During a time of great flux for the NHS, staff engagement should be a high priority but it will make little difference unless politicians and national bodies are willing to give more responsibility to providers at a local level

Healthcare is first and foremost a people business. Around 1.4 million staff in the NHS in England provide care to 1 million patients every 36 hours.

The quality of that care depends on the skills, commitment and compassion of staff.

‘“High touch” matters are transforming care as much as “high tech”’

Technologies may be transforming how care is delivered but “high touch” matters as much as “high tech” in shaping the outcomes and experience of patients.

This is why engaging staff in improving NHS care - at a time of unprecedented financial and service pressures – is an issue of the highest priority.

Take the leader’s lead

The relationship between staff engagement and organisational performance has been known about for some time.

The good news is that levels of staff engagement across the NHS, as measured by the annual staff survey, is increasing. Despite this, there are wide variations in engagement from examples of excellent practice in some organisations co-existing to stubbornly low levels in others.

‘Boards must learn from and emulate what high performing NHS organisations have achieved’

In a report commissioned by the Department of Health and the Cabinet Office, an expert panel I led put forward a series of recommendations for strengthening staff engagement throughout the NHS. We argue that doing so is first and foremost the responsibility of leaders in the NHS, starting at board level and extending to frontline clinical teams.

Boards must use data from staff surveys to track changes in levels of engagement in their organisations and to prompt action when the results show cause for concern. They must learn from and emulate what high performing NHS organisations have achieved by devolving decision making and supporting staff to bring about improvements in care.

The mutual method

We also argue that there should be support and encouragement for NHS organisations to become staff led mutuals.

This would build on the public service mutuals created under the Transforming Community Services policy, early experience of which demonstrates the benefits of staff taking ownership of organisations providing care to NHS patients.

I had the opportunity of visiting a number of social enterprises during our work and speaking to the leaders of others. Those I met explained how different it feels working with colleagues as co-owners in delivering care compared with being employed by the NHS.

‘Many mutuals have been successful in increasing levels of staff engagement’

The sense of liberation expressed by leaders and staff was palpable and is supported by evidence from staff surveys that many mutuals have been successful in increasing levels of staff engagement.

One option would be for NHS trusts to become staff led mutuals completing an appropriate authorisation process with similar rigour to the foundation trust authorisation process, including trusts providing acute services.

Another would involve emerging models of integrated care choosing to become mutuals where several organisations come together to create a joint venture to deliver services such as urgent care and care for older people.

Setting up a new organisation of this kind would have the advantage of all partners having a role in its creation, rather than one being seen to be in the lead and “taking over” from others.

Alongside the FT model

Strengthening staff engagement in existing organisations and supporting the emergence of more public service mutuals will make little difference unless politicians and national bodies are willing to devolve more responsibility to providers at a local level.

It is for this reason that the panel argues for a proportionate approach to regulation based on presumed autonomy for providers. Regulators must model the types of leadership behaviours that deliver high engagement by demonstrating understanding of the challenges faced by some NHS organisations and offering support, rather than ever tighter oversight.

In putting forward these recommendations, the panel is conscious of the desirability of avoiding further top-down restructuring.

We are clear that any moves to mutual status should be on a strictly voluntary basis, where leaders and staff in an organisation both have an interest in this, and following detailed consultation between staff and staff side trades unions.

‘Regulators must model leadership behaviours that deliver high engagement by demonstrating understanding of the challenges’

In practice, some organisational change is inevitable, given the need to resolve the future of the 98 trusts yet to achieve FT status and the innovations emerging spontaneously from local discussions about integrated care.

These developments will impact on providers through mergers and takeovers, the development of joint ventures and debate about the potential role of chains.

Bottom-up organisational change of this kind is quite different from government mandated restructuring across the NHS which must be avoided at all costs.

At a time when the provider landscape is in a state of flux and there is increasing questioning of the FT model, it is opportune for the place of staff owned and led mutuals to be considered alongside other ways of strengthening engagement throughout the NHS.

This would enable the journey of mutuality that started with the creation of FTs in 2004 to be continued in a wider range of organisations and settings.

A period of accelerated evolution and evaluation of alternative organisational models would shed light on the relative importance of ownership and governance compared with other critical factors such as leadership and culture in securing a highly engaged workforce.

Professor Chris Ham is chair of the review of staff engagement and empowerment in the NHS and chief executive of the King’s Fund