Published: 01/09/2005, Volume II5, No. 5971 Page 14 15

HR may have won its place on the board, but now it must prove it can deliver measurable productivity gains, argues Andrew Foster, while Jane Keep maintains that it is this 'soft' arm of the NHS that keeps organisations' culture, values and sense of responsibility in good health


Andrew Foster became Department of Health director of workforce in May 2001, having previously been a trust chair and HR policy director of the NHS Confederation. He prepared the report HR in the NHS Plan. Since 2003, he also assumed responsibility for development of the social care workforce. He is working on a new workforce strategy designed to support the NHS improvement plan.


Jane Keep is a visiting senior fellow at Birmingham University's Health Services Management Centre and an independent practitioner on strategic change. She has researched, written, taught and practised HR, values, organisational development and change for 16 years at senior, national and local levels across the NHS, the wider public sector and more recently the voluntary sector.

Andrew Foster: Former health secretary Alan Milburn once described one of his senior civil servants as the 'director of cake and eat it'. All of us really want to have our cake and eat it and I want NHS human resources to retain its emotional intelligence, but also to be a hard-nosed deliverer of business success. What does this mean?

The debate about whether HR was important enough to be dealt with by the board has now been won, and progressive organisations accept that their performance is almost entirely a function of their staff. But the only way of demonstrating this is in terms of business and service outcomes such as financial efficiency, improved access, service quality and patient satisfaction.

So what is good HR? I believe that it is applying the understanding of people - the touchy-feely bit - to the creation of evidence-based systems and processes that deliver business success.

Those skills are about to be tested as never before. Last year the NHS as a whole failed to achieve financial balance and 2005-06 looks very challenging, too. Most trusts will need to improve productivity and reduce costs in order to achieve their local delivery plans. HR knows how to do this. Huge savings can be achieved through productivity, better recruitment and retention, reduced sickness absence and better use of temporary labour. Enormous service improvement can be achieved through better skill-mix and patient-centred role design.

Trusts also need staff to respond to a policy agenda that seeks to install patients and their choices as the driving force for service improvement. In order to change how the NHS works we need to adapt the way that staff work, and this is a job for HR. But it is not about selling employees out or just giving them new orders. It is about engaging them and their strong patient-centred values in finding solutions.

What about the HR function itself? As we change the way the NHS works, are we 'hard-nosed' enough to change the way HR operates? The need to be ever more strategically and business oriented means that we should be increasingly prepared to let go of our more transactional functions. HR needs to be tough enough to reform itself and contribute its own share of efficiency gains through approaches such as shared services.

It is not therefore a question of whether HR should be soft with a hard centre or even hard with a soft centre, but whether it can deliver measurable productivity gains and service improvement through progressive people management.

Being a good people manager is the means, not the ends.

centrally directed system to a patient-led system'. What is HR's contribution?

As well as continuing to build workforce capacity and capability, there is a need for a more responsive (patient-led) environment, which requires a shift in power, responsibilities and boundaries, together with changes in culture and behaviour.

While the tangible transactional tasks of HR are valued and evident (eg recruitment and selection), is it fair to describe some of the cultural and behavioural tasks as 'touchyfeely'? 'Touchy-feely' is a subjective stereotype, stemming from a lack of tangibility. Good HR looks 'below the organisational iceberg': at values, attitudes and beliefs; at the clarification of boundaries of expected and acceptable behaviour and relationships; at dealing with value and other conflicts; at staying within the margins of social responsibility.

Without these, achieving a patient-led service may be impossible. Creating a Patient-led NHS states: 'The system itself, and the way people work in the system, can often get in the way. There can be barriers, blockages, professional and organisational boundaries.' Dealing with these issues requires being in 'touch' with the 'feelings' (sensibility) - of staff, patients, and all those affected by any changes.

So what is 'hard-nosed'? is not it dehumanised? Expecting automated responses to set protocols? Instead, do not we need 'professional, and effective', rather than hard-nosed?

Can't being 'touchy-feely' also be professional and effective? Without working in partnership, involving and engaging, implementing Agenda For Change will not be achieved. What could be more business-like than delivering the biggest-ever pay reform in the UK?

HR is the arbiter of culture, the barometer of values, the socially responsible 'people governance' aspect of the organisation: the discipline that keeps the organisation in legislative and social and psychological order. What's the problem with 'touchy-feely'?

The trick is to connect HR 'touchyfeely' inputs to tangible health and service outcomes, and to develop a language for new 'metrics' to include 'softer behavioural aspects'.

Let's stop messing around at the margins, now's the time to be in touch, and to create depth and feeling in the breadth of the modernisation agenda. Touchy-feely HR, we need you more than ever.

Andrew Foster: NHS staff have incredibly powerful values, though different groups have important differences in their values. I well remember a survey conducted by the NHS Confederation in 1999 which revealed that 80 per cent of managers thought that values of managers and clinicians ought to be the same but only 20 per cent thought they actually were.

This illustrates the highly charged and complex emotional minefield within which HR must operate. I agree with Jane that HR needs welldeveloped empathetic skills to move forward in a way most likely to carry the hearts and minds of staff. But HR is not the same as philanthropy; and emotional intelligence is a means, not an end.

Jane cites Agenda For Change as a good test of HR effectiveness. If so, how are we doing? Less than 50 per cent of staff assimilated, when we should be at 80 per cent. Far too many organisations did not get off the starting blocks until April, even though there have been years of preparation and the strongest advice to learn from early implementers and be prepared for a fast start.

Fifty per cent should not be seen as a failure, because the challenge has been immense. But 50 per cent is an average, which conceals just how well many organisations have done - and also how dismally many others have performed.

My definition of 'hard-nosed' is not about implementing Agenda For Change, it is about deriving benefits - the hard-nosed benefits of improved efficiency, better clinical outcomes, faster access, harmonised team working, lower sickness absence and introducing new roles designed to better meet patients' needs. It is by these measures that HR will be judged.

Jane Keep: Having your cake and eating it makes you fat. HR could become hard-nosed, yet fat: too broad in its agenda.

HR may be in the boardroom, but HR folks still are not voting members on all boards. HR may be a foundation trust assessment criteria but Monitor hasn't really looked beyond the financial and service development side of applicants, at workforce productivity, potential 'breakdowns' of new relational or cultural issues, and how damaging these could be to these 'new' organisational types.

Whispers are still heard from chief executives of the 'ineffectiveness' of HR. Is this a language, perception or tactical issue? Is it presentation or outcomes? Good HR is the synergy of both 'soft' and 'hard' issues, requiring focus on the quality of ingredients: not in the singular, but as a richly distilled blend.

To make patients and their choices the driving force, HR should enable the workforce to free themselves from barriers of old habits. It must help them understand the choices which they face - choices which also impact on deep, long-held beliefs or value conflicts around trust, flexibility and respect.

HR can start this by looking within their own function, designing robust 'touchy-feely' metrics; receiving critical feedback on their own productivity around relationships, tactics and products; measuring the use of resources; and reviewing each transaction (including dialogue). Then HR can truly understand how it adds value.

Policy-makers can support this with a whole-systems perspective, which looks at paradoxes in current national plans and behaviour metrics in relation to wider NHS policy. This will help create a critical appraisal and development of a truly robust HR - touchy, feely and productive. .