Something needs to change: Can mutual models help the NHS workforce crisis?
Friday, March 22, 2019
The NHS Staff Survey 2018 published last month paints a gloomy picture around job satisfaction for NHS staff[1]. At a time when the NHS has increasing problems recruiting staff, and with Brexit exacerbating things by looming over EU healthcare professionals, there is a pressing need to re-energise the NHS workforce and attract new staff. It’s a hard ask, when universally we recognise healthcare workers are under mounting pressure. In the search for solutions, the ‘healthcare mutual’ model may offer a legitimate way forward by placing workforce empowerment at its centre.
The NHS staff survey is one of the largest workforce surveys in the world, with almost 500,000 respondents in 2019 – just under half of the 1.1 million employees that make up the NHS workforce in England. Overall, it shows dissatisfaction around both pay and wellbeing, with only 36% of staff being satisfied with their salaries, only 29% feeling their organisation takes positive action for their health and wellbeing and almost 40% reporting feeling unwell as a result of work-related stress. This affects the quality of care, with almost 30% reporting seeing an error, near miss or incident that could have hurt patients in the last month. 80% of staff are satisfied with the care they are able to give to patients, which shows a year-on-year downward trend. And nearly a third of NHS staff regularly consider leaving their organisation to find work elsewhere[2], indicating things could get worse.
Another – and probably even more pressing – challenge faced by the NHS is staff shortages. The NHS workforce is growing, but not quickly enough to handle increasing demands linked to an ageing population with complex health needs. In 2018, NHS trusts reported a whopping 100,000 unfilled vacancies, with particularly slow growth among nurses, midwives and health visitors, and, notably, a decrease in the number of GPs[3]. In a recent report by the King’s Fund, Nuffield Trust and the Health Foundation, it’s warned this could reach 350,000 over the next decade.
In January, the NHS published its Long Term Plan, setting a vision for how the NHS will change over the next ten years. One of the goals is to move care from hospital into primary and community health settings, but in the face of such shortages, it is unclear how this will be turned into a reality. 1 in 10 nursing posts remain vacant in England, and the number of nursing students is falling.
The plan acknowledges the central role of staff in ensuring the quality of care, as well as in addressing the major pressures they face. It promises an overall increase in supply, but these problems will not be fully addressed until the publication of a Workforce Implementation Plan later in 2019. Notably, pledges in the Long Term Plan include reducing the vacancy rate for nursing from 11.6% to 5% by increasing clinical placements and making degrees more accessible, increasing medical school places and supporting NHS organisations with overseas recruitment[4]. Although these actions are on the right track, they don’t address staff satisfaction or the improvement of workplace environments that could play a key role not only in recruitment but also crucially in retention, as on average 1 in 5 NHS staff left their role in 2017/18[5]. Therefore, determining a way to significantly improve work environments for NHS staff is critical in sight of pressures on the health system.
In this context, there is a clear need to listen to, re-enthuse and reimagine the NHS workforce. Given the scale of the problem and ramifications for the near future, this is a national priority.
Michael West writes a compelling blog post for the King’s Fund[6] outlining three core needs humans look for in their workplace: competence, belonging and autonomy. This article builds on his post to argue that mutuals can provide a response to those three needs, currently seemingly unmet in a universal way by the NHS.
Public Service Mutuals are organisations that have left the public sector but continue to deliver public services, and, crucially, have an important degree of staff ownership and/or influence in the way they are run[7]. There are currently around 65 health and social care mutuals in England. The mutuals sector is a successful one overall, with turnovers growing on average 50% since launch[8]. 66% of public service mutuals report expanding their services into new areas, winning new service users and developing new products and services[9].
‘The need for competence reflects our need to be able to have a positive effect on the work environments we find ourselves in, as well as to get valued outcomes’[10].
Through the mutual model, this need is met by empowering staff to have a say in the way their organisation is run and by removing obstacles like bureaucracy and unnecessary processes, as well as encouraging individuals to grow and develop new skills that further improve outcomes for patients.
Because of their relative independence from the NHS and ability to be more agile, mutuals are able to identify inefficiencies in the way services are run and make faster decisions to design improved ways of providing services. This empowers employees to have a more tangible connection to the way services are run and feel like they can have a direct impact on quality care.
“The need for belonging refers to the desire or need to feel and be connected to others – to care and to be cared for.”[11]
Mutuals meet this need by nurturing a culture of relatedness, having a clear shared vision for the organisation and aligning all efforts to that vision.
Mutuals are businesses, which forces them to be mindful of financial performance. Employees therefore develop a new layer of values, based on delivering the best quality care in the most cost-effective way. Staff become engaged in the survival of the business, including deciding how profits are reinvested to further meet the needs of their communities.
Being independent, mutuals are also able to create their own identity. Firstly, they have to form a clear narrative around leaving the public sector, which means they will likely have undergone an engagement process to fully form and understand their proposition. In many cases, staff vote on the decision to leave the public sector, which means they’re involved in the process and ultimately supportive of the transition. This spirit of innovation and togetherness permeates all they do, reinforcing belonging whilst collectively working together to give their new entity a commercial edge they can hone to meet their core values.
“Autonomy refers to having free will, choice and control in order to be consistent with our sense of our self.”[12]
Mutuals are designed to ensure staff feel like they have a voice and some influence in the management of the organisation, and that procedures are fair and transparent. Because of this, by nature, they enjoy improved staff engagement.
54% are ‘employee owned’, and all have some – formal or informal – strategy for staff engagement. Mechanisms for employee control range from staff representatives on boards to voting rights, ‘open door’ policies between employees and leaders, forums and feedback surveys. In an SEUK survey of the mutuals sector[13], 100% reported that staff were actively involved in decision-making at least to some extent. Transparency and empowerment are thus two key benefits brought about with the mutualisation of a service.
By responding to the three central human needs cited above, mutuals boast notably higher staff satisfaction than the NHS. 85% find they have a more engaged and happier workforce, leading to improved productivity[14].
Of course, this feeling of success and being the master of one’s destiny leads to improved retention rates, and decreased absenteeism. The SEUK survey finds that, on average, staff absences in mutuals fall by a third after they leave the public sector – a compelling benefit in light of the recent NHS data cited above. Anecdotally, mutuals in the health sector regularly find themselves with among the highest recruitment and retention rates compared to local peers.
The mutuals sector is still a small sector in its infancy. However, it is starting to demonstrate strong benefits that show plausible, attainable avenues to transform the healthcare workforce. Encouraging NHS services to consider alternative delivery models may present a unique, transformative and long-term solution to the NHS workforce crisis. Looking at the options now could help turn the tide.
-Are you interested in exploring alternative delivery models like mutuals? Contact tom.davis@baxendale.co.uk.
