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Joe Dromey


Head of Policy And Research

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NHS and employee engagement – what works?


Employee engagement is increasingly being seen as a priority by employers. Nowhere more so than in the NHS.

Research has shown that NHS Trusts which effectively engage their employees have higher levels of staff wellbeing and more satisfied patients; they have better clinical outcomes and they are more efficient. It’s increasingly clear that engagement is vital to high quality care in the NHS.

The NHS workforce has faced significant challenges in recent years. Yet employee engagement has stayed relatively stable and has even increased in the last two years. However, with engagement in the NHS being lower than in the labour market as a whole, and with substantial variations between trusts, there is significant scope for improvement.

Although there is much evidence of the importance of engagement in the NHS, there is less known about the sort of approaches and interventions that tend to promote engagement. Today, we release Meeting the Challenge – Successful Employee Engagement in the NHS which we hope will address this gap. The research, supported by the Healthcare People Managers Association and NHS Employers, was based on eight in-depth case studies of NHS Trusts which performed particularly well on employee engagement.

Key quality #1 – Organisational Values

We found that these high engagement Trusts tended to have a strong set of organisational values, developed in partnership with employees, and with patient care being right at the heart. Trusts such as Guy’s and St Thomas’ had mainstreamed their values throughout the organisation, embedding them in HR processes from recruitment to appraisals. In order to reinforce the values, both senior leaders and managers throughout the organisation need to be seen to live them out, demonstrating them in their behaviours and decisions. Sir David Dalton, Chief Executive of Salford Royal NHS Foundation Trust, which has had the highest levels of engagement of any acute trust for the last three years, explained ‘staff have to see that leaders don’t just say things but act and behave accordingly.’

Key quality #2 – Senior Leaders

Senior leaders play an important role in setting the tone at the top of the organisation. They need to be highly visible across the Trust, and to be both accessible and approachable. The Chief Executive and Directors at the case study Trusts tended to do regular walkabouts and ‘in your shoes’ sessions, as well as having open town-hall style meetings. There needs to be regular and effective communication with frontline employees, using a variety of channels. With just two in five employees in the NHS rating communication between the top and the front line as effective, there is some way to go here.

Key quality #3 – Line Managers

Although senior leaders set the tone, line managers are the people who really make the difference to engagement. Line managers must ensure they have effective appraisals with their reports, as part of a year-round process of performance management. They need to encourage and support effective team working, something that has been found to be strongly correlated with engagement. Line managers themselves need to be engaged, and they often need training and support in order to better engage their teams. Whereas management in the NHS has often been characterised as ‘command and control’ in style, case study Trusts such as Kingston Hospital and Derbyshire Healthcare tended to focus on creating a coaching culture which was seen to be conducive to employee engagement.

Key quality #4 – Employee Voice

We found that the Trusts that exhibited high levels of engagement also tended to have a strong employee voice. Employees need to be able both to raise concerns if they have them, to offer suggestions for the improvement of their services, and to be involved in decision-making across the Trust as a whole. In order to support this, responsibility for decision-making should be devolved as close as possible to the frontline – within safe limits – with employees given a say over both how they do their jobs and how their services are delivered.

Key quality #5 – Partnership Working

Finally, given the high level of union membership in the NHS, partnership working is also important in providing the foundations for employee engagement at Trusts. As well as supporting structures for partnership working, both sides need to cultivate a culture of partnership working based on trust, early engagement, and real involvement in decision-making. Oxleas NHS Foundation Trust provided an excellent example of partnership working with the Chair of Staff Side also working as the Head of Partnership, reporting directly to the Chief Executive.

Engagement during upheaval

The NHS is facing challenging times. After years of growth, the service is facing a sustained funding freeze whilst cost pressures continue to rise inexorably. This is creating what the Institute of Fiscal Studies has called an ‘unprecedented squeeze’ which is unlikely to ease at any point soon. Yet at the same time, following the Francis Report into the crisis at Mid Staffordshire, the NHS is expected constantly to drive up both quality and safety of its care.

We found that engagement risks being undermined by ongoing pay restraint, increasing job intensity and seemingly constant organisational change. Yet although the situation represents a challenge to engagement, it also makes engaging with employees more important than ever before. Engagement during times of change is vital in order to both inform decision-making and to ensure the buy-in of employees to the process. Through engaging with employees, Trust can help unlock their immense potential for innovation, allowing them to make services safer, more effective and more efficient.

As Professor Michael West explained, ‘if the sector is going to respond to all of the challenges that face it, then all of the staff need to be involved in developing new and improved ways of doing things and in implementing change.’

By sharing some of the great practice across the NHS, we hope that this research can help Trusts in their efforts to better engage with their employees. Through focusing on driving up employee engagement, NHS Trusts will be able to manage the challenges of the next few years, and continue to improve services to patients in these tough times.

One Response

  1. Engagement in the NHS

    I think this is an excellent article and piece of research, as is so often the case much of it may seem like common sense but this isn't actually all that common! The NHS is a people driven organisation yet it is subject to continuous top down change which needs excellent leadership, communication and most importantly people management. Real conversations between individuals, cohesive teams and supportive human interaction.

    Performance management forms a huge part of this but as a supportive, developmental and connected process, not a simple adherence to KPI's and targets. In the words of Stephen Covey we want effectiveness not efficiency for our NHS and this paper has some really great examples of how to do this.

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Joe Dromey

Head of Policy And Research

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