How can we engage 1.4 million NHS staff? Start by celebrating their achievements and ensuring that they feel empowered to drive change, says Hannah Forbes.

When groups of NHS staff are asked how much of their personal energy at work is dissipated through things that get in their way, many say 60-70 per cent. They cite day-to-day frustrations that are not resolved, management diktat and bureaucracy, feeling disconnected with the “bigger picture”, paperwork, a blame culture and more.

This means the health service is running on less than 50 per cent of its potential. Surely we cannot go on ignoring this?

Employee engagement and empowerment are the driving force for any high performing organisation. Imagine a workforce connected around a clear vision, leaders all on the same page, people collaborating across the usual boundaries around what great looks like and being empowered to make it happen.

It is not hard to see the impact of an engaged, empowered workforce in terms of service quality, safe care, competitive edge, culture and leadership style, staff turnover and sickness, as well as previously intractable problems that simply require everyone to be pulling in the same direction.

The evidence is irrefutable. More than a decade of Gallup research demonstrates that engagement leads to measurable improvements in performance. Engaged employees average 27 per cent less absenteeism than those who are actively disengaged. Organisations in the top quartile of engagement levels have 12 per cent higher customer advocacy and 18 per cent higher productivity. Plus, research by Towers Watson-ISR suggests there is a 50 per cent gap in operating incomes between companies with high and low levels of engagement.

The question is: why is this not a top priority for the NHS?

With pressure on the public sector to deliver better for less, employee engagement has never been more important. This means connecting senior leaders with what matters to staff, fast-tracking corporate-wide actions in response, engaging all the right people around all the right priorities, empowering and “giving permission” to staff to take ownership of the positive changes they to want to see, and shouting about their achievements so they feel proud and others want to follow.

The aim is an energising shift in culture and working style – with a clear alignment between strategic goals and the engagement effort.

Listening in

Listening into Action came about after a call to arms by NHS chief executive Sir David Nicholson in 2008 around the need to engage and mobilise the nearly 1.4 million people who make up its workforce. Twelve trusts around the country were enlisted to help with the initial learning and testing of ideas, and this was then further developed through the involvement of 40 pilot trusts in the South West.

Four years on, through intensive work with nine acute hospitals and hundreds of teams – wards, pathways, departments, specialties and support services – a systematic approach for aligning strategic goals with a compelling and sustainable engagement effort has emerged. Based on that success, NHS medical director Sir Bruce Keogh is taking a keen personal interest in the spread of Listening into Action at a national level.

The approach is simple, structured and based entirely on what NHS leaders and staff say works for them. It is about “inverting the pyramid”; removing obstacles; connecting leaders with teams and teams with the strategic goals of the organisation in a way that makes sense to them; regaining the confidence and enthusiasm of clinicians; and working together for a common purpose.

LiA has already been used across whole hospitals, all focusing on how staff will improve outcomes for patients and for themselves.

Engagement pioneers

Ten trusts have elected to be “national pioneers for staff engagement and empowerment” through the adoption of LiA over the next year, starting in May. As well as the direct benefit for each organisation, this will provide unprecedented learning and insight for the wider NHS.

The trusts are:

  • Kettering General Hospital Foundation Trust
  • Northampton General Hospital Trust
  • Pennine Acute Hospitals Trust
  • Royal Cornwall Hospitals Trust
  • Wrightington, Wigan and Leigh Foundation Trust
  • East Sussex Healthcare Trust
  • Taunton and Somerset Foundation Trust
  • Hull and East Yorkshire Hospitals Trust
  • Oxford University Hospitals Trust
  • NHS Lothian

It has also been used to build understanding between GPs and consultants, to connect people across the usual boundaries and as a vehicle for development of the NHS values. It is always led by clinicians with managers helping to “unblock the way”, and the feedback from staff is consistently good. This is about being allowed to focus on what really matters and getting on with it.

Learning over the past four years based on work with 40,000 clinicians and staff has been extensive. Here are the top 10 lessons from which all trusts can benefit:

1. Alignment between strategy and engagement effort is of the utmost importance. There is no point in engaging for engagement’s sake. First leaders, and then the rest of the workforce, must be connected around the organisation’s strategy in a way that makes sense to them.

2. Don’t assume that the executive and senior leaders are aligned around a clear set of strategic goals and articulation of the vision – this is often not the case and needs to be addressed before anything else can be done.

3. Although many organisations have had “listening events” before, staff typically say that little or no action followed. This has increased cynicism and events are often remembered as “just another initiative” that came and went. With LiA, the focus for action, the pace with which it happens, the emphasis on sustainability, and the direct involvement of staff builds credibility and belief in the approach being something different.

4. Engagement and empowerment must happen at a number of levels simultaneously:

  • a corporate response, through fast changes which help to unblock the way for large numbers of people;
  • department-wide engagement around the aspirations and ambitions for improvement;
  • specific ward, specialty or function engagement of all the right people around their own local opportunities.

5. The focus for engagement is outcomes. If it is not about directly impacting care for patients, work life for staff and the performance of the organisation, what is the point? All too often, organisations have engagement programmes which are not directly linked to specific outcomes. This is a waste of time and does a disservice to the talented and committed people who work in the NHS.

6. Once aligned with the goals of the organisation, clinicians and staff must feel empowered and be given “permission” to take ownership of the changes they want to see. The safety net is a set of simple ground rules (see box, above). Sadly, after years of disenfranchisement, most teams need to be explicitly told by senior leadership that they have permission to take action, and middle management must also be aligned with this message or it will get undone along the way.

7. The engagement effort needs to be structured, rigorous, and a top priority. Staff engagement is the main way to drive up quality and performance, with use of tactical interventions such as lean and other techniques to help where there are complex processes that warrant it. These interventions are not an end in themselves. The carefully crafted organisational journey over an initial 12 months delivers the real possibility of achieving a fundamental shift in culture and performance

8. Organisational processes and systems must be adjusted to enable and leverage the engagement effort. Consider the impact on leadership development, culture, performance measurement, staff recognition and incentives, recruitment and communication so that everything is moving in the same direction.

9. The initial 12 months of adoption and spread is to jolt the organisation and create a groundswell of momentum and reset the level of ambition. This is what LiA is about.

10. Finally, a high profile campaign makes the process transparent, accessible and compelling. The unwavering commitment from the senior leadership is communicated, visibility of actions and changes build belief that this is something different and better, and sharing of stories and outcomes “fuels” an organic spread which has the potential to gain a life of its own.

Key questions

What leaders should ask themselves about their trust:

  • Q1: How would you score your organisation on employee engagement and empowerment? 
  • Q2: What are you currently doing that is going to achieve a wholescale shift over the next 12 months and beyond?
  • Q3: What is more important than engaging staff in terms of outcomes for patients and the teams delivering services?

Ground rules

Clinicians and staff should feel they have “permission” to drive forward positive changes in their area, as long as they stick to the following rules:

  • Rule 1: We will not compromise care or cause harm to any patient
  • Rule 2: We will not spend any money we do not have or waste any resources
  • Rule 3: We will not compromise the reputation of our team or our trust

If a leadership team gets this right, the result is a workforce connected around strategic goals and empowered to take ownership of actions that will most benefit patients, staff and the organisation.

The strongest driver of staff engagement in the NHS is a sense of being valued and involved. But year on year, the national staff survey shows that too few staff feel involved in important decisions, consulted about changes that affect them, encouraged to suggest ideas for improving services or that the organisation values their work. The NHS needs to embrace a wider and more sophisticated concept of staff engagement.

Wrong priorities?

Top reasons why trust chief executives de-prioritise staff engagement:

  • See it as “soft stuff”
  • Not the right time
  • No money to invest
  • Other leaders are not supportive
  • Already doing enough

At the first acute hospital to pioneer adoption of the LiA approach, staff responses to questions about engagement improved significantly in the first year. These results have sustained and improved since then, taking the trust from below the national average on all relevant questions, to above it on all. Not surprisingly, positive outcomes for patients, for staff and for the trust have followed.

It is critical to point out that, while a positive shift in staff survey results is good, talk about this in the boardroom needs a reality check. Having local results that go up a percentage point or two may sound good, but the truth is that the national average is not good in the first place. If only 40 per cent of staff feel valued or able to influence change, there are another 60 per cent who do not. A step change is needed to get the kind of mega-shift that is needed right across the system – in every trust in parallel.

Staff engagement and empowerment – aligned with strategic goals and outcomes for patients, made compelling and inspiring, and prioritised by leaders – is a game-changer for the NHS. This has never been more important.

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Listening into Action