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  • Writer's pictureAndrew Laird

Employee empowerment: the right sort of change in the NHS

Updated: Apr 6, 2021

Following more news reports that the NHS is in “crisis” and unable to deal with “renewed pressure” on its Accident and Emergency departments, director at Mutual Ventures Andrew Laird explains why low morale, organisational culture and “iron cage” bureaucracy are at the heart of the problem.

Change is hardly a new concept for the NHS. A succession of top down reorganisations have left many staff fatigued and disillusioned. In the latest King’s Fund quarterly monitoring report nearly half of finance directors at Clinical Commissioning Groups (CCGs) and NHS Trusts count staff morale among one of their top three concerns. This is extremely concerning for a service built on interpersonal interaction with patients.

It’s not hard to see why staff are feeling downbeat. The same King’s Fund monitoring report shows that 74% of NHS Trust and CCG Finance Directors (out of 90 respondents) thought that there was either a high or very high risk of failure with regard to the “Nicholson Challenge” to achieve £20bn of productivity gains by 2014/15. In reality this must mean increasingly frustrated finance managers putting increasing amounts of pressure on staff. It doesn’t make for a happy work environment.

One of the most important ways to solve the problem of NHS funding not stretching far enough is to increase productivity. Systems and processes are important in achieving this but an organisation can only truly thrive if its staff are motivated, happy and able to identify and implement better ways of working. The evidence clearly shows that many NHS staff are not.

Alongside the pressure to deliver savings, unnecessary bureaucracy is also a morale (and therefore productivity) killer. I have previously written about the “iron cage” which can constrain public sector workers and holds back the development of their services and the fulfillment of their staff team. This kills morale and productivity not just because the bureaucracy itself takes its toll but the mere thought of the form filling that is needed to try out a new idea or even take sensible action is usually enough to put people off. This is quite a depressing situation.

There are very positive signs that the powers that be have recognised this issue and are trying to tackle it. The recently published Dalton Review on NHS providers builds on the findings of Chris Ham’s report on staff engagement and empowerment in highlighting the importance of a positive organisational culture.

Evidence highlighted in the Dalton Review shows that increased staff engagement has a positive correlation with decreased patient mortality, infection rates as well as reducing staff absenteeism. It’s clear that increasing staff engagement creates happier staff and a positive culture which can lead to improved productivity resulting in better outcomes for patients

In his Five Year Forward View, Simon Stephens, the new chief executive of NHS England, highlights that “England is too diverse for a one size fits all care model”. He is not suggesting allowing “a thousand flowers to bloom” but rather identifying a small range of models and then supporting local areas to identify and implement the most suitable one.

This is very encouraging and ties in with Chris Ham’s work which recommended that health and care organisations adopt structural changes to encourage better organisational culture and morale. Ham and his co-authors (including Julian Le Grand) argue that a staff-led mutual model, if properly implemented, can lead to a happier staff group which in turn can result in better outcomes for service users.

Our organisation, Mutual Ventures, spends a lot of time supporting groups to design and develop such models and the Cabinet Office and Department of Health are now exploring this through supporting nine “pathfinder” projects.

This programme involves a mix of individual services such as a cardiology pathway looking to “spin out” of an NHS trust and Foundation Trusts looking to explore mutualising as a whole. This programme aims to unearth potential solutions to the challenges faced by Foundation Trusts that try to fundamentally alter their modus operandi, given that their structures and governance arrangements are enshrined in legislation.

The critical thing about this programme is that it must be driven from the bottom up and maximise the involvement of staff in the process. This will allow each new organisation to have its own distinct structure and character and respond to the issues health and care staff know are the most important. This in itself should be re-energising for staff groups.

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