Frontline staff should be involved in improving the NHS and empowered to exercise their duty of care responsibly. By Brendan Martin
Staff need to work together to improve the patient experience
After years of top-down reforms, there is a thirst in the NHS for a change of management culture to support improvement from within. As the Francis report suggested, staff need to work together to improve the patient experience and to support each other to learn from mistakes.
‘Top-down imposition of “reform” solutions have failed while more systematic approaches to employee engagement have succeeded’
At a time of growing pressure on resources, employee engagement can also help with productivity improvement. As common sense predicts, and evidence confirms, where senior managers have been serious about it, rather than ruling by command and control, the results have been encouraging.
The reasons are fairly simple: involving staff effectively leads to sustainable improvement in care standards and resource use because knowledge about frontline realities is valued and mobilised. This also increases job satisfaction and staff morale.
Despite this, many senior NHS managers still tend to see employee engagement as a luxury they cannot afford, and are reluctant to take the risk of devolving power when the buck will stop with them anyway. Those worries are understandable, particularly in the current climate.
Therefore, it makes sense to start small and increase the scale, scope and depth of staff involvement, so that trust can grow from the results.
It also helps to learn from experience elsewhere, which is why Public World, a London-based international social enterprise, is working to make the lessons of best international practice more readily available in the NHS.
Over the last 20 years we have researched public service reform initiatives in more than 70 countries, in projects with clients and partners as diverse as Oxfam, Public Services International and the World Bank.
It has been seen that top-down imposition of ‘reform’ solutions have failed, while more systematic approaches to employee engagement have succeeded, and we believe the lessons of international experience can benefit the NHS.
The best workplace
To take this forward, a roundtable was recently held in London that brought together NHS leaders and senior managers with representatives of unions, professional bodies, the medical colleges and charities such as Point of Care.
‘Empowering frontline staff with the freedom to exercise growing responsibility is what staff involvement to improve the NHS is all about’
With the participation of NHS Employers, two dozen participants shared their own insights and lessons and heard Lars-Åke Almqvist outline the approach developed in Sweden by the social enterprise Alamanco over the last 20 years.
Having grown out of Sweden’s largest public service workers union, Alamanco has built its track record through scores of projects involving hundreds of workplaces and thousands of staff. That process of evolution is important because enabling organisations to develop systematic feedback loops is central to its methodology.
We have summarised it in a document called The Best Workplace. The methodology is fundamentally simple and it enables staff involved to increasingly manage the process themselves. But it does require training and initial guidance by skilled facilitators.
The process involved groups of staff charting and making a journey of transformation together. They identify what is within their collective control and what is not, which means their aim is to make the best possible use of the resources they have.
They establish an understanding of where they are now and where they need to get to, before discussing how to get there and agreeing on an action plan to do it. The process ends with evaluation of the experience, and can then start again to achieve further improvements.
The groups discuss not only what staff are doing day-to-day and how they do it, but also why they do the jobs they do. Healthcare is a vocation, of course, but we all know that there are also conflicting pressures on us and that our motivations from day to day are affected by them.
Learning how to resolve conflicts is part of the process. Indeed, starting out from frank acknowledgement of tensions and differences among staff is a key factor.
‘In the NHS there is plenty of well justified weariness about endless structural reform’
By accepting the sometimes divisive roles of hierarchical and professional boundaries, and differences of personality and attitude, the Best Workplace model builds shared purpose through honest appraisal of workplace relationships.
The groups learn how to resolve conflicts constructively, led by ‘conversation leaders’ who receive special training from the facilitators, so that the role and cost of external support gradually tapers off while the process continues.
Will this work in the UK? In Sweden, after all, ‘social dialogue’ between employers and employees is deeply embedded, whereas the industrial relations culture here is more adversarial. Our research in the US and elsewhere suggests that the trick will be to adapt the methodology to a different culture in a way that also helps change that culture as necessary.
Amid its 1,700 pages and 290 recommendations, paragraph 1.118 of the Francis report leapt out at us: “The patient must be first in everything that is done: there must be no tolerance of substandard care; frontline staff must be empowered with responsibility and freedom to act in this way under strong and stable leadership in stable organisations.”
Empowering frontline staff with the freedom to exercise growing responsibility is what staff involvement to improve the NHS is all about. By mobilising and developing knowledge at the frontline it creates value from a resource that is systematically undervalued − and undermined − by command and control approaches to change management.
In the NHS there is plenty of well justified weariness about endless structural reform. Professionals are also fed up with politicians blaming them for the failures of their own policies. Power without accountability has caused many of the problems of the NHS, but accountability without power is toxic too, and that is the deal many NHS staff are asked to accept.
It is time that healthcare staff were given the freedom to exercise their duty of care with responsibility.
Brendan Martin is managing director at Public World