Chris Ham presents presents the findings and evidence around the review he chaired into staff engagement and devolved decision-making for the Department of Health. He stresses the need for a culture of high staff engagement and devolved decision-making, due to compelling evidence suggesting this increases quality of care.

1. Staff engagement
and empowerment
in the NHS
Professor Chris Ham
Review for Government
July 2014

2. We have known about the importance
of staff engagement in the NHS for
many years …
› We have been measuring levels of engagement in the NHS
since the first staff survey in 2003.
› Evidence from a range of sectors over at least the last two
decades has highlighted the impact of staff engagement on
performance.
› More recently, analysis of the NHS staff survey has shown
the importance of engagement for staff wellbeing and
quality of care.
› Most NHS leaders recognise the importance of engagement
and a large proportion of providers treat it as a key priority.

3. Levels of staff engagement are rising
across the NHS after a sharp dip in
2010

4. But disparities are widening and some
providers have had low engagement for a
decade …
• Although many providers consider it a priority, boards dedicate limited time and
attention to engagement and the volume of activity and innovation in this area
appears to be relatively low.

5. The purpose of the review was therefore
to consider how to increase levels of
engagement across the NHS, including …
› presenting the evidence that engaging and empowering NHS
staff leads to improvements in services and quality of patient
care
› assessing the range of options for further empowering staff
and strengthening their voice within existing NHS
organisations
› outlining good practices within the NHS and other sectors
and the ingredients within these practices, including the role
of leaders
› identifying options for increasing staff engagement through
innovative provider models, including staff ownership.

6. Mid Staffs highlighted the impact of
working conditions on engagement and
quality of care

7. Many of the most successful trusts have
focused on developing a powerful
strategic narrative for staff in their
organisations
› In some cases, there has been a shift away from developing a
vision at the top, for diffusion to staff in favour of bottom-up
processes which allow staff to identify the organisation’s
challenges and devise the right approach for addressing
them.
› For example, trusts following the Listening into Action
programme bring staff and leaders together in a strategic
dialogue to identify the trust’s challenges and set direction.
› At Hinchingbrooke, Circle brought 1,200 of the trust’s 1,700
staff together for partnership sessions to develop its 14-point
plan to become a top-ten district general hospital.

8. Successful providers are simplifying
hierarchies and empowering staff to
deliver service change
› For example, Salford Royal is organised in four clinical
divisions, led by a clinical chair, managing director and
nursing director. It does not have an operations director and
the executive team act as coaches rather than managers of
the clinical teams.
› As part of this devolution, successful providers have
introduced programmes to support frontline staff in
delivering service transformation, rather than imposing
change from above.
› For example, Salford Royal puts together teams of front-line
staff from across division boundaries to lead service
improvement. Staff are supported by its Performance
Improvement Directorate which provides expertise in how to
trial and test improvements.

9. A recurring message was the need for
stability to create a high-engagement
culture…

10. Research from other sectors suggests
that ownership and governance
influence levels of engagement
› Matrix Evidence’s review found that employee commitment
tends to be stronger in employee-owned businesses (2010).
› The Nuttall review highlighted the evidence that employee
ownership leads to enhanced employee well-being, reduced
absenteeism and greater innovation (2012).
› Most research emphasises the importance of employees
playing an active role in governance and the benefits in
encouraging ‘high-engagement’ behaviours and working
practices in the organisation.

11. Leaders of new NHS mutuals are
accountable primarily to staff and
stakeholders
› In most cases, staff have a nominal financial stake but a
substantial governance role through staff councils and
electing board members. Most involve other stakeholders on
their boards.
› The leaders of new mutuals argued that these arrangements
had altered their relationships with staff and stakeholders.
The governance system underpinned dialogue with staff on
strategic direction and more inclusive ways of working in the
organisation.
› As co-owners, staff felt a much stronger right to express
their views and participate actively. They also reported
greater empowerment resolve problems and find innovative
solutions.

12. The tentative evidence is that NHS
mutuals appear to be achieving higher
staff engagement …

13. Conclusions
› NHS organisations need to renew their efforts to strengthen staff
engagement, building on progress in recent years and narrowing
the gap between high and low performers.
› NHS boards should set aside time to discuss the results of staff
surveys and to act on the results.
› NHS organisations should devolve more responsibility to staff
responsible for delivering services, removing unnecessary layers
of management and empowering staff to take decisions.
› Staff should be supported to improve care through investment in
leadership and training in quality improvement skills.
› NHS organisations should have the option of becoming staff-
owned and -led – as should emerging integrated care
organisations.
› There should be much greater devolution within the NHS, based
on presumed autonomy and proportionate regulation.