At a time of stagnating salaries and punishing workloads, how are NHS leaders helping staff cope? That was the question posed at the third and final roundtable linked to HSJ’s Top Chief Executives list. Report by Alison Moore
The NHS is an organisation grounded in its staff and the care they provide and enable every day. Poor morale among them is bound to impact on their commitment – the willingness to “go the extra mile” and deliver discretionary effort – and their organisation’s ability to evolve and drive savings and new ways of working.
There’s no doubt staff in the NHS are working under fantastic pressure and for salaries which have barely shifted over the last few years – so it would be surprising if there was not concern about the impact on morale.
But how significant has this been and how can NHS leaders support and protect staff through the “perfect storm” of rising demand, increased expectations and little growth in funding?
These were the key themes of this HSJ top chief executive roundtable drawing on the collective experience and expertise of some of the NHS’s successful leaders.
Opening the debate, HSJ editor and chair Alastair McLellan stressed he wanted to hear about solutions and tactics that people were adopting in this difficult time, both when people were managing up and managing down. As well as their staff, NHS chief executives also had to think about other stakeholders, the NHS centre and others parts of their health economy. “We want to make this feel real to the people who are reading it,” he said.
It is still the case that 70 to 80 per cent of our staff would say they have great job satisfaction, compared with 20 per cent of the general public
Andrew Foster has lived through many difficult periods for healthcare – as head of HR for the NHS and as the chief executive of Wrightington, Wigan and Leigh Foundation Trust. He said that even in the years of significant funding growth, the staff side had told the salary review body that morale had never been lower.
However, he thought there were several significant factors affecting this at the moment – long-term pay restraint; industrial disputes; and the impact of a downturn on the NHS. What felt different about the current period, he said, was “there seems to be a bit of coming together of it… I can’t see a solution in the next two to three years.”
“It is still the case that 70 to 80 per cent of our staff would say they have great job satisfaction, compared with 20 per cent of the general public,” he added.
Clive Kay, chief executive of Bradford Teaching Hospitals Foundation Trust, said the difference now was a “relentless” focus on quality coupled with an increase in activity and acuity: “There now seems to be no down time for the staff at all. I think May was our busiest month in six years in terms of activity.
“I think the staff now are starting to get quite tired. I entirely agree with Andrew that the vast majority of people come to work and love it and want to do a great job. They want to focus on the quality issues but they are getting tired.”
The NHS workforce may have changed since previous difficult periods, suggested Will Hancock, chief executive of South Central Ambulance Service Foundation Trust, who remembers tough times in the 1990s.
“I think the workload has changed and the workforce has changed. People live very stressful lives,” he said, adding there was a need to understand motivations and interests of the people coming into the service. It was a challenge to understand what resonated with a diverse group of people.
There is a sense that there is a system which does not support leaders and treats them badly at times
Mr McLellan said that perhaps neither the government nor the British Medical Association had really understood the motivations of junior doctors over this year’s dispute. “They are not motivated by the same things as the generation before,” he added.
Jackie Bene, chief executive of Bolton Foundation Trust, said: “The whole system is buckling under the strain. Trying to find good solutions is harder and harder as everyone is struggling with the same things.
“It feels there is an acceptance of the system issues and therefore solutions have to come from across the system. There was rhetoric before but it feels real now.
“I am concerned about the morale of the workforce, especially junior doctors, and I think we will see it in the consultants as well,” she added.
Specialist hospitals often have high levels of staff satisfaction and different pressures from acute ones. Roger Spencer, chief executive of The Christie Hospital Foundation Trust, said there was pressure from the rising level of expectations especially around new treatments.
“There is no question that in my area patients are so much better informed,” he said. “The expectations that the staff have to cope with are so much higher.”
There was also a higher level of uncertainty in the system – for example, around devolution in Greater Manchester and the opportunity for major changes. This could be unsettling for staff.
“The tectonic plates are starting to shift, not just the grumbling we have had in the past,” he said. The future prospects of the NHS seemed different today from how they had in the past, he added.
Barking, Redbridge and Havering University Hospitals Trust has had a difficult recent history and has a substantial deficit as well as being in special measures, which may add to the challenges around workforce.
The whole system is buckling under the strain. Trying to find good solutions is harder and harder as everyone is struggling with the same things
Chief executive Matthew Hopkins said: “Part of the challenge in my organisation is that we have not had the workforce aligned to growing demand.”
Actions from the centre have not always helped chief executives to keep up the morale and commitment of staff: he pointed to this year’s incident reporting “league table”, which was suddenly released to the press with little warning for organisations, as something which would not have happened a few years ago. The pace and the desire “to make a difference” was leading to misjudgements, he said.
“As a system leader my job is to filter out the noise for my staff so we don’t make errors,” he added.
Karen Lynas, interim managing director of the NHS Leadership Academy, said: “I think there is no hope at the moment, that’s the sense I am getting from very experienced leaders.
“We would normally get someone who would say that this will happen and we will do these things. I think there is a deep weariness of spin.”
Capsticks partner Rachael Heenan confessed to often seeing organisations at a time when things had all gone wrong but said she sensed there was a lack of working together throughout the system. Lack of support if there was a problem could leave managers feeling exposed.
“You know that when you are in a tight corner no one has got your back,” she said. “People are thinking what is my future in the NHS?”
Jon Restell, chief executive of Managers in Partnership said: “There is a sense that there is a system which does not support leaders and treats them badly at times,” he said. “There has been a hollowing out of key parts of the system.”
There was no longer a level of the NHS which supported – and sometimes bullied – leaders below them.
“I am struck by the paradox that people are genuinely still into their job and like coming to work – but there’s still the hope thing. The word I get is that I love my job but I don’t think I can sustain working at this pace.”
There was a need to help staff pace themselves, he said, rather than waiting for the light at the end of the tunnel.
Tom Cahill, chief executive of Hertfordshire Partnership Foundation Trust, said staff still loved to come to work and, as chief executives, “our job is to create the environment that enables them to do that”.
It feels there is an acceptance of the system issues and therefore solutions have to come from across the system. There was rhetoric before but it feels real now
However, he said the intensity of pressure for the front line was the greatest he had seen in 30 years in the service and everything was now “nailed down”, which limited room for manoeuvre.
“We can think of it as Domesday but you can think of it as an opportunity. If you start to think of it as Domesday then your staff will,” he said. “The only light they can see at the end of the tunnel is ours.”
But what were the leaders round the table managing to do which made things better for staff? Several chief executives talked of how they were managing relationships with others in the system – including at the centre – to help and sometimes to protect staff.
Mr Hopkins said there had been a focus on building really effective relationships at all levels – including commissioners – and not skirting round the issues.
“I think the special measures regime provides some formal structure around reporting,’ he said. His trust had a fixed agreement with NHS Improvement which laid down how they would work with each other which gave clarity around accountability and behaviours and ensured there would be “no surprises” from either side. The trust was also benefiting from working with the Virginia Mason Institute – one of five trusts to do so.
But he said that understanding when to push back and when “to let it play out and just suck it up” had been a key leadership learning point.
Mr Foster pointed out that the most populous group of staff were Agenda for Change band fives and on the whole they would have little awareness of many of these concerns.
“Staff engagement in all its various aspects is what it is all about,” he said. “It is making people feel they work for an organisation that cares for them.”
He said the management team needed to be “an impervious layer” which dealt with issues such as regulators while letting as little as possible “dribble down” to staff. While regulation could not be dealt with by being told to go away, it could be “reinterpreted” for the staff.
Professor Kay added: “I think at the level of the Care Quality Commission one of the most important things that we have done is not to see them as an awful enemy, not just at the senior management level but throughout the organisation.”
In a system, organisations may also be required to give up their sovereignty and that can require a mindset change
Instead they were seeing it more as an opportunity for peer review, which everyone in the organisations knew was the right thing to do. They had tried to build better relationships with the CQC managers.
“I like to say that every day is a CQC day,” he said. “I say to the staff imagine the CQC disappeared tomorrow – we would still carry on by and large measuring ourselves against the same standards. We are trying to say that we are going to do this whether the CQC exists or not.”
But his aim was to protect the staff from the increasing burden of unnecessary bureaucracy and allow them to do the day job, he said.
Mr Restell, however, questioned whether the umbrella role of the chief executive – protecting the staff from the downpour – was sustainable in the long term. There could be a danger of downplaying some of the challenges if the centre could punch a hole in the umbrella, he said.
But Mr Cahill said they should still try to hold up the umbrella and protect staff who were trying to change things. He had seen some positives from CQC inspection and it reminded him that staff were proud of what they tried to do.
A planned meeting for five consultants with the CQC team had seen 80 turn up: this sort of enthusiasm could then be used to drive improvements.
In specialist trusts like The Christie, there is often an emphasis on accreditation of clinical services rather than the inspection approach of the CQC. Mr Spencer said this led to a focus on improvement – something which should be the intended purpose of the CQC.
Increasingly, chief executives are being asked to work with other organisations and to be system leaders rather than the leader of their single trust.
Mr McLellan asked how they coped with managing in a system.
Ms Lynas said there was a possibility that people assumed that what they had done in one organisation translated across the system.
In a system, organisations may also be required to give up their sovereignty and that can require a mindset change, said Ms Heenan. Acute providers were now saying they were not the solution – and that in itself was a change, she said.
It can be hard for recruits to be given a consistent message, even when leaders are focused on staff engagement and communication
But Mr Cahill added there was a need to follow through on what was agreed round the table: sometimes organisations said they were committed but their actions did not bear this out.
However, Professor Kay said that in his area there had been much more talking between partners than in the past. He felt there was a need to resolve difficult issues and an independent chair could be the way forward.
Mr Foster’s organisation is one of those planning to join a chain in the Greater Manchester area – albeit one which is largely retaining its independence as a standalone organisation. He said there had been a shared joint vision for an IT system and operating systems. This could require some loss of sovereignty but he distinguished it from the approach of a chain which was a head office and subsidiaries.
Mr Hopkins said sustainability and transformation plans needed to start from what they wanted to achieve, rather than becoming tick-box exercises which risked wasting time and money.
Staff engagement is often seen as the key to improving morale and care – but how have the panellists approached this? In Bolton, power and budgets had been devolved downwards to the frontline.
Dr Bene said this was risky but at the heart of staff engagement. “We had to put in a big new performance framework… it was done in a very adult way,” she said.
Mr Hancock advocated working with recruits at an early stage and even before they joined the organisation to offer them a “warts and all” view of work.
But Mr Restell warned of the dangers of paying lip service to engagement and then not doing much about it. Modelling the behaviours you wanted to see from managers and staff was a very powerful tool but he added that “even in the best run organisations you will have pockets of misery.”
It can be hard for recruits to be given a consistent message, even when leaders are focused on staff engagement and communication.
Sustainability and transformation plans needed to start from what they wanted to achieve, rather than becoming tick-box exercises which risked wasting time and money
Mr Hopkins said his induction process focused on the values and behaviours they expected from staff but he had been tackled by a new recruit who had then been told there was no budget for a name badge for them!
With tough times ahead, there will be no easy answers to keeping staff on board: but those round the table were committed to enabling staff deliver the care they wanted to.
FIND OUT MORE
Read the first two Top Chief Executives roundtables: www.hsj.co.uk/topchiefs2
- Alastair McLellan, HSJ editor and roundtable chair
- Jackie Bene, chief executive, Bolton Foundation Trust
- Andrew Foster, chief executive, Wrightington, Wigan and Leigh Foundation Trust
- Matthew Hopkins, chief executive, Barking, Redbridge and Havering University Hospitals Trust
- Clive Kay, chief executive, Bradford Teaching Hospitals Foundation Trust
- Roger Spencer, chief executive, The Christie Foundation Trust
- Tom Cahill, chief executive, Hertfordshire Partnership Foundation Trust
- Will Hancock, chief executive, South Central Ambulance Service Foundation Trust
- Rachael Heenan, partner, Capsticks
- Jon Restell, chief executive, Managers in Partnership
- Karen Lynas, managing director, Leadership Academy
- Agenda for Change
- BARKING, HAVERING AND REDBRIDGE HOSP NHS TRUST
- BOLTON NHS FOUNDATION TRUST
- BRADFORD TEACHING HOSPITALS NHS FOUNDATION TRUST
- British Medical Association (BMA)
- Care Quality Commission (CQC)
- East of England
- HERTFORDSHIRE PARTNERSHIP NHS TRUST
- Managers in Partnership (MiP)
- Manchester devolution plan
- NHS Leadership Academy
- South Central Ambulance Service NHS Trust
- Staff wellbeing
- THE CHRISTIE HOSPITAL NHS FOUNDATION TRUST
- Top Chief Executives
- WRIGHTINGTON, WIGAN AND LEIGH NHS TRUST
- Yorkshire and the Humber
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