Staff engagement is the NHS's greatest asset but it's yet to reach full potential

The two of the biggest themes in health service reform are:

• integrating health and social care; and
• improving staff engagement.

But, astonishingly, they rarely appear in the same sentence.

We learnt from the recent election campaign that there is remarkable cross-party consensus around bringing health and social care together. It’s an area where even Andy Burnham and Jeremy Hunt found common ground.

On staff engagement, Chris Ham from the King’s Fund has presented compelling evidence of the correlation between staff engagement, patient satisfaction and death rates from England’s 200-odd NHS Trusts.

Staff engagement, he argues, is not just a “nice to have” - it is a pre-condition for a high performing healthcare system. Doctors and nurses that feel valued deliver better care.

‘Staff engagement is not just a “nice to have”’

At the start of the year, Mutual Ventures worked with Tameside Hospital Foundation Trust in Greater Manchester on a Cabinet Office pathfinder project.

The aim of the programme was to explore the ways in which the principles behind staff engagement associated with public service mutuals could support NHS trusts in the challenges they face.

Tameside was unique among the six pathfinders in exploring this question in the context of a pathway of care for patients with heart disease. It involved the trust itself, local authority, GPs and third sector.

• Tax barriers and staff opposition deter trusts becoming mutuals
• Unleash workforce creativity with staff engagement building blocks

Mutuals support integration

The question posed in the FT therefore became about whether the process or lessons around staff engagement in public service mutuals could support the integration agenda. The firm conclusion was “yes it can”.

Three reasons stood out.

First, integration depends on working together. This means building a shared vision and purpose between organisations (and individuals) with different cultures, attitudes and behaviours. As we learnt from the wave of mutuals that have “spun out” of the NHS (and local authorities), the process of change is easier and more effective when staff feel they can influence decisions.

‘The process of change is easier when staff feel they can influence decisions’

Second, integration depends on doing things differently. Success requires entrepreneurialism and the freedom to innovate. And as this depends on the ideas and actions of individuals, if staff feel able to express themselves there is more chance of solving the most thorny problems.

For example, Salford based mutual Six Degrees Social Enterprise has created a pioneering approach to interacting with dementia sufferers. In partnership with the University of Salford, it has developed a programme for families and carers based on linguistic techniques to embed positive thinking.

Its chief executive argues that removal of rigid centralised management practices has been decisive in allowing it to get the idea off the ground.

Third, integration will only work if staff at all levels are engaged.

Managers will rightly feel the need to lead by example but unless frontline staff feel part of it, the whole process risks being little more than a paper exercise. Foot dragging and obstinacy can scupper even the best made plans.

Even everyday actions

“Engagement” here refers to involvement in decision making, both at a strategic level but crucially in staff’s everyday actions.

Public service mutuals achieve this through staff representation in decision making structures alongside distinctive management practices including devolving budgets and responsibility.

‘The programme allowed us to explore the possibility of engaging staff in a meaningful way’

NHS directors in Tameside saw the Mutuals in Health programme as a chance to explore how these practices of staff engagement could fortify the process of change already underway across its services.

To their credit, they immediately saw that it was not just a case of running a few engagement workshops.

Director of strategy, Hanif Wazir, said: “The programme fitted in with the journey we started a year earlier. We already understood that high levels of staff engagement would play a significant part in improving care outcomes. The programme allowed us to explore the possibility of new models of delivery and engage staff in a meaningful way.”

Smarter commissioning

So what models might be used to “plumb in” staff engagement?

Elsewhere in the Mutual in Health programme trusts have described an “FT plus”.

This involves re-engineering the FT governance model to lever in staff involvement through staff councils and more staff governors.

A more radical option is to spin out services – as wholly owned trading companies, joint ventures with staff, or full staff owned mutuals.

‘Staff engagement can be a potent weapon in the battle to integrate care’

The pros and cons of these options depend on circumstances, who else is involved and where the services are targeted.

The question about different models echoes the conclusion of Sir David Dalton’s recent review of the NHS in which he recommended trusts “consider whether a new organisational form may be most suited to support the delivery of safe, reliable, high quality and economically viable services”.

What is missing from the discussion so far is a solution to the disjointed payment systems, where incentives for providers in a care pathway do not align.

Changes to commissioning structures are the only way around this, and in particular a move to outcomes based contracts.

Smarter commissioning can work hand in hand with greater staff involvement here: to shape a vision of integrated services and to shift attention away from how services are provided to what they achieve for patients.

It’s my view that staff engagement can be a potent weapon in the battle to integrate care.

Ultimately, staff are the NHS’s greatest asset, but also the most under-utilised. The lessons from Mutuals in Health suggest that they have a lot to contribute to the NHS’s vision for an integrated future.

John Copps is senior consultant for Mutual Ventures, a consultancy that specialises in alternative delivery models for public services, and that works with local authorities, NHS bodies and the third sector