Exclusive: How all provider trusts rate their leaders and culture

Staff have their say on leadership and culture across every NHS provider trust

Gordon Forbes on the revelations of the LiA Scatter Map 

It’s that time of year when NHS boards try to make sense of their NHS National Staff Survey results.

What did staff say?

How do we compare?

What does it mean for the year ahead?

How do we respond?

All key questions for trust leaders. Particularly so when, to all intents, the NSS results are a staff commentary on the state of leadership and culture in the NHS today. The new themes, and staff responses to them, all lead back to one simple question for the senior executive team: ”How are we doing leading this organisation and in creating a culture where our people can thrive, flourish, and deliver excellent care to our patients?”

It’s sometimes very difficult to make sense of the results, even in the new format: 170 pages on benchmark data; 52 key questions; 10 new themes; 0-5 years’ comparative data and trends; worst/average/best thresholds; and different thresholds for different trust cohorts.

So, in an effort to help CEOs answer some of these questions, we have created – for the 8th year running – the big picture “helicopter view” of how staff across the 230 NHS providers rate their trust leaders and culture.

It’s the Listening into Action Scatter Map. And it plots each trust on a 52 by 44 scale matrix against a performance axis (the Y or vertical axis) and a trend axis (the X or horizontal axis). By reviewing staff responses to the 52 questions, and by comparing the results with those from the previous year, each trust has a grid co-ordinate for how staff rate their trust leadership and culture against their peer group, and whether they are more or less positive than this time last year.

Why does it matter?

It always matters what staff say. They are, in any organisation, your most valuable asset, with the knowledge, expertise, drive, energy, commitment, enthusiasm, insight and ability to make or break the success of any business. Doubly so in the healthcare sector, where what staff do often makes the difference between life and death.

This isn’t the place to get into the long running travails of NHS employment, but the context for this year’s results is one of the most challenging you could find in terms of workforce stability – the ultimate measure that dictates how safe, caring and effective a service is likely to be given how many staff a department or specialty has against budget, whether they are pay-rolled or agency/locum, and how they are feeling as they go about doing their jobs, day-in day-out. All of these factors impact the development and maintenance of a safe work environment and culture – not to mention a happy place to spend one-third to one-half of your daily life! – and, in turn, the provision of safe and effective quality care.

Current estimates hover around 100,000 staff vacancies in the NHS in England. Sickness and absenteeism is between 3.5 per cent and 7 per cent in trusts. Turnover is averaging 10 per cent per annum, give or take a percentage or two. Agency staff costs are still running at prohibitive levels for any semblance of financial rude health. And in this year’s survey, more than one in five staff responding in the acute sector say they are likely to look for a new job in the next 12 months. 

It’s time to pull the people lever

We’ve pretty much tried pulling every other lever in the NHS over the past 20 years or so, and the outcomes for staff and patients still offer huge challenges. We’ve got to change the game and put those who know most about the service back in charge of making improvements to how they deliver it: our doctors, nurses and other healthcare professionals. Everyone else’s job is to unblock the way for them.

Some might say we are already doing this. Well, -ish, I suppose. But not enough, and not well enough yet, by some distance.

At least not according to the average 45 per cent staff response rate across all organisations. Not according to the 54.1 per cent average of staff who say that their managers ask their opinion before making decisions that affect their work. Or the 52.6 per cent average of staff who agree that they are involved in decisions on changes to their work. Or the 56.8 per cent of staff as an average who are confident that their organisation would address their safety concerns if they raised one.

The numbers tell us that around half-of-the-half of staff responding aren’t very positive (does that make 75 per cent who aren’t or might not be?). That’s why we’re in trouble with our workforce. That’s why retention, not recruitment, is the single biggest issue we have to fix. That’s why what staff say matters. Maybe more than anything else.

There is a huge variation in NHS NSS results and outcomes

Variation in the NHS is alive and kicking. Those of you with long memories will remember the “Better Care, Better Value” Indicators of the early 2000s. And the huge variability in trust performance across some key measures at that time, all of which created huge discrepancies in terms of patient experiences in their healthcare.

The LiA Scatter Map big picture shows that the gap between trusts doing well according to staff, and those who are severely challenged, is as wide as the Scatter Map itself.

Our leading trust on the LiA Scatter Map is Leeds Teaching Hospitals Trust for the first year in our analysis’ history (52,36 grid reference) – the whole length and breadth of the Scatter Map away from Birmingham Women’s and Children’s Hospital (-52, -36). The variability in response rates evidence a similar delta. From a low of 24.6 per cent to a high of 71.3 per cent, there is massive variation in how staff are responding to a national survey within a national health service. Why? And what to do about it? How do we learn from what the best performing trust leaders are doing, and spread this to those that are struggling? How do we learn about radically improving response rates from trusts like Chesterfield Royal who achieved a staggering 70.9 per cent this year compared with 33 per cent only two years ago?

What the LiA Scatter Map shows

222 of 230 NHS provider trusts are plotted on the LiA Scatter Map (eight are not included for lack of comparative data from 2017):

• 86 of 89 Acute Trusts in red

• 41 of 43 Combined Acute and Community Trusts in light red

• 16 of 16 Acute Specialist Trusts in orange

• 24 of 24 Mental Health and Learning Disability Trusts in dark green

• 29 of 31 Mental Health, Learning Disability and Community Trusts in light green

• 15 of 16 Community Trusts in blue

• 11 of 11 Ambulance Trusts in light blue.

Each trust cohort is colour-coded differently to reflect their varying survey thresholds for each question. While this constraint makes it difficult to directly compare how staff in one cohort feel in relation another, the LiA Scatter Map attempts to provide this big picture in a meaningful way.

In reading the map, direct comparison can be made within each cohort by following your colour-coding from the top right (grid reference 52,44) along to the left, and then right to left along each row. So for the Acute cohort: Leeds Teaching Hospital FT is ‘top dog’ this year, second best is St Helen’s and Knowsley Teaching Hospitals Trust, then The Royal Bournemouth and Christchurch Hospitals FT, and so on…

This process produces a “best-in-class” trust for each cohort:

• The Newcastle-Upon-Tyne Hospitals FT for the combined Acute and Community cohort
• Liverpool Heart and Chest Hospital FT for the Acute Specialist sector
• Dudley and Walsall Mental Health Partnership Trust for the Mental Health and Learning Disability cohort
• Solent Trust for Mental Health, Learning Disability and Community
• Cambridgeshire Community Services Trust for their cohort
• North East Ambulance Service FT.

Each of these cohort leaders has staff reporting huge deltas of “above average” responses to the 52 questions compared to those responses below average, and a massively positive trend from the same responses in 2017-2018. That’s what it takes to be “top right” quadrant – the best place to be.

It follows, therefore, that the second best quadrant is “top left”: above average on performance, but a declining trend showing work to be done to “get staff back again”.

Third best (or second worst if you want to look at it that way) is the “bottom right” quadrant, with staff rating leadership and culture below average in relation to the 52 questions, a blow softened by an improving positivity from staff from 2017.

And the “most challenged” quadrant is “bottom left”: staff giving below average responses to most questions, compounded by being less positive than last year’s results.

It doesn’t necessarily follow that everyone above the horizontal axis is home-and-hosed, nor that all trusts below the line are mired-without-hope, for there are different nuances at play across the board. So too, a trust could be way to the left of the vertical axis but still very high performing and in the top few in their cohort in the country. Equally, a trust can be “bottom right” but have made massive strides in starting to turn things around with staff.

The only way to assess how you’re doing is to take the performance aspect and trend aspect together, and recognise that the further up the grid you are and the further to the right you are, the better staff rate leadership and culture, and the better basis you have for doing a whole bunch of stuff with them that will make a huge difference to staff and patients – and indeed leaders’ and managers’ day jobs too.

The converse is also true of course. “Bottom left” is not a great quadrant to be in, ever. And it’s very hard to break out of. Ask some trusts who’ve been in special measures for a time now. It is a real challenge to engage and empower staff on a scale and for a long enough period that you see a vertical shift in performance because of the relativity challenge: you can improve staff morale and how they feel quite a lot within your trust, but that improvement needs to translate into being so much better than your peers are doing.

Quadrant shifters

That is not to say that it doesn’t happen though. We have seen “quadrant shifters” this year as we do every year – trusts who have gone from “bottom left” to “bottom right”, or “top left” to “top right”, or even “bottom left” to “top right”. 

So congratulations to leaders and staff at Royal Orthopaedic Hospital FT, Chesterfield Royal Hospital FT, Kettering General Hospital FT, South East Coast Ambulance Service FT, and Brighton and Sussex University Hospitals FT, all of whom have presided over a 100+ place improvement based on the LiA Scatter Map positions. Kettering General missed out by a whisker on going from “bottom left” to “top right”, while Chesterfield achieved it.

At the other end of the scale, some trusts have declined markedly according to staff, with the five biggest negative movers: Central London Community Healthcare Trust, South Western Ambulance Service FT, George Eliot Hospital Trust, Wrightington Wigan and Leigh FT, and Cumbria Partnership FT, all of whose results have declined substantially according to staff since 2017. Work to do.

As far as an overall comparison is concerned, it is also possible to read across cohorts on the LiA Scatter Map to get a notional “league table” across the board nationally for all trusts.

What to do with your results?

First and foremost – and sorry to be on a bit of a downer to start – don’t be satisfied with where you are, wherever you are. Last year’s top rated trust from the NSS still had a less than 50 per cent response rate. More than one in four staff at the trust had witnessed a harmful error, near miss, or incident in the last month. One in four didn’t think the incident reporting process was fair. One in five staff weren’t happy with the care they could provide. The message is, even the best have more to do, always, especially so where the impact of not getting it right is so stark.

The second thing to not do is more of the same if it’s not working. For some, results will indicate a large dollop of success on the back of last year’s efforts to improve things for staff and patients, and if it has, “keep at it” as my headmaster used to write on my report card. If something’s working, don’t stop. Do more of it. Strive to be even better this year, or to do what’s working even better or more widespread. But if what you usually do isn’t working, and didn’t work, it’s time to change.

Lots of responses are what we would class as “transactional”. There’s the “whack-a-mole” approach, named after the game, where you take a few response areas – even a theme – and focus all your energies on shifting the responses in that area or those question in the year ahead – only for new areas to pop up next year. There’s the “scatter-gun” reaction, where myriad questions with poor staff responses are all highlighted and worked on without much thought to convergence of time, effort and outcomes. Transformational programmes and turnaround initiatives have their advocates too. But be wary about the never-ending projects conveyor belt that sucks up resource at an alarming rate and struggles to translate progress into improved patient outcomes.

There’s a place for some aspects of all of these responses, but only where they are all focused on the one thing that does make a difference: asking your doctors, nurses and healthcare professionals what they want to change as part of their day job, stopping doing a bunch of stuff that gets in their way and adds no value or delivers no improved patient outcomes, and asking “How can I help?” if you work in corporate services or a support role. In this lies results.

There’s a very simple pull-through here. Engage your staff around what matters to them (and trust priorities too), and see morale improve. When morale improves, the culture will shift, fundamentally and positively, and that will impact safety. When that happens, the quality of care will get better – it’s the core business here after all. So when you’re looking at your results, these are the themes to focus on first, in that order. And then you have a sustainable, frontline-led, achievable, realistic and outcome-orientated approach to change, that will not only get you to “top right”, but put you firmly on the pathway to being a systems leader.

One last thing

It’s not the job of HR or the workforce team to do this. Nor does it fall to a few over-loaded individuals to work longer, harder, faster, doing what they’ve always done to try to turn things around. Nope. It’s the job of every leader and every manager, working shoulder-to-shoulder, all on the same page. You’ll find, when you look at your trust’s position on the LiA Scatter Map, that staff have already told you what, and who, needs to shift the culture and lead by example. Let’s listen to them, and act on what they say.

Happy reading all.

Gordon Forbes, founding director, Listening into Action