NHS Employers Virtual Board - panel discussion


18 / 11 / 2013

IOS/mobile users listen here.

Who took part in the podcast?

Steve ShrubbChief Executive of West London Mental Health NHS Trust

Clive LewisNon-executive Director, Gloucestershire Hospitals NHS Foundation Trust

Jeff BuggleDirector of Finance & Performance, East Kent Hospitals University NHS Foundation Trust

Questions and transcript

How would board members like to get their organisations to identify the health and wellbeing needs of its staff?

In a number of ways, firstly by referring to the business case. There is a correlation between sickness absence and the bottom line, and so in a trust with 5,000 staff for example, 1 per cent reduction could mean an additional £1 million on the bottom line. The other element to touch on is having real quality data. The discussions about health and wellbeing and sickness absence normally focuses on the problem, so you have absence levels of 3 per cent if you're lucky - much more likely to be 4 or maybe 5 per cent but that doesn't really tell us much apart from that overall figure. The interesting thing is what makes up that number, so why are people off. 

For example, is there a bulk of people with musculoskeletal issues that's making up the majority or are people off because of accidents at work. The other thing is what about the rest of the workforce because you might find that actually there's a bulk of about 20 per cent of the workforce who are contributing towards this problem and of that 20 per cent maybe there's 8 or 9 per cent that are real problems because they have absence levels of 12,13,14 per cent or higher and it would be useful to really focus on and crack those as an issue because that would have a tremendous impact on the rest of the organisation, but having said that what about the 80 per cent of people who on balance either have no time off ill or they might have one or two days off.  Why do they go unrecognised and noticed?

We shouldn't wander too far away from what we know about human beings when we think about the people who work in the NHS. 1 in 4 people suffer from mental health issues so we can make some predictions about how many of our staff in the NHS will experience this.  Anxiety and depression are the most commonly diagnosed mental health issue but often the word stress is used so there's a lot of evidence, a lot of resource that helps us make sense of the numbers. The numbers are crucial, they're critical, but you can actually add colour and flavour to those numbers.

One of the things the NHS does not very well, is on occasions we seem to forget our staff are actually members of the public. They are human beings. They are members of communities, they are husbands/wives/sisters/brothers.  We seem to view them as public servants and in doing so disconnect from a lot of what we know.

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What evidence and key messages would you need to see in a business case to make you and your colleagues listen and make a favourable decision?

Any business case in this area is broadly the same as any other business case you would see, whether you wanted to build a new hospital, whether you wanted to buy a new piece of kit.  There's going to be a strong governance process around it and you can identify some hard and soft metrics that show benefits of a return etc. Things around sickness, retention, sequent payments at the moment, friends and family tests. Most organisations will have either funding linked or associated with health and wellbeing. There's something around morale, attitude, staff engagement which actually are equally important but in some ways often get ignored in business cases by accounts who will just be looking at the numbers.

Within those areas you can construct a strong robust business case that most of your executives would find add merit to funding. Most of the business cases in this area do stack up and they do make sense. Often there is a leap of faith in some areas but you can liken this to MRSA where executives and boards should invest money because its right for the patient, but actually you can even ignore the patient - its right for your bottom line.  People with MRSA stay longer, and cost a lot more so actually lets eradicate MRSA it saves a fortune. If you can get a cause and effect of something or as strong a link as you can then you've got a very compelling business case and in a lot of business cases there's a strong correlation between one and the other.

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What themes would you like to see in a health and wellbeing strategy and how would you then influence the rest of the board to support it?

There are three or four main elements. The evidence tells us that engagement is actually crucial. One of the building blocks of a health and wellbeing programme is a whole range of initiatives that make staff feel engaged, informed and involved because we know in actual fact that has a fairly direct impact not just on their performance but on how well they feel, so engagement is absolutely key.

The second element is influence. One of the things you want to include in a business case is what the staff think. You should never see a business case that doesn't actually have the views of a large number of staff in it because the health and wellbeing programme should directly describe what your staff want. 

Then the third element is the correlation between mental health and physical health, so there is no health without mental health. There are a whole range of programmes where we can help people feel better physically and feel better mentally and if we look at Santander, or BT, they don't just have initiatives based on five a day vegetables and fruit. They have five a day for mental health and wellbeing. You go onto their email systems, their computer systems and on the front page of their intranets links directly to self-help materials on stress. 

There are three component parts - engagement, what I call influence and then using the best evidence around, literally what we can do to make people feel better and when we say better, physically and mentally better.

At West London, we decided that we had to find a way of really getting a sense of what our staff wanted. The organisation had four or five years of very poor staff survey results, so we wanted to find a way of reaching very deep into the organisation and giving people an opportunity to tell the board what they felt was going on and what they felt could make things better in terms of health and wellbeing. 

So we stole something from Harvard which is called the 'Fish Bowl'. We identified 10 per cent of our staff so we had 40 reporters. These were people drawn from a diagonal cut across the organisation looking at seniority, gender, racial background and they interviewed 10 reportees. Forty conversations took place about six months ago where they were asked two open questions - 'What's it like to work in West London Mental Health Trust?' and 'How could you make it better?'

Then they came back and the board had to sit around them in a 'Fish Bowl' and had to listen to the results of those forty reports.  They weren't allowed to say 'Yeah but you don't understand we did X last week'.  They had to stay silent and from that experience there are now six themes that are jointly led by an executive director and a reporter. Those six themes are drawn directly from conversations that took place across the organisation during a period of about two months. What influences a board  isn't good clever, articulate executive directors.  What really influences a board is a sense that they are hearing very directly from the staff that they are there to serve.

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How should we measure success and what sort of outcomes are you looking for has a board?

Measuring success can be done in a number of ways. At the start of your financial year, lets imagine your sickness absence levels are at 5.1 per cent and you can measure where you are at the end of the financial year.  If you've got your 4 per cent improvement that's a measurement but also being able to put that into what that means from a financial point of view. Other measures might be what your information is telling you on why members of staff might be leaving or perhaps why people are staying. 

Other measures could be why people are having time away from the workplace, so you could have an issue - I pick on musculoskeletal for example. You could look at that at the start of the year and then measure it at the end of the year.  One of the things we haven't touched on yet is the role of the line manager and in this topic its absolutely critical because all of the evidence suggests that the number one reason why someone is either likely to leave or be away from the workplace is because of their interaction with their line manager. 

In fact in the Boorman Review the data suggested that when people feel they are listened to by their line manager they are likely to have a third less time off from the workplace compared to those that don't. A measure could be a line managers confidence in some of those soft skills i.e. listening with colleagues and also there ability to be able to engage with a range of difficult or challenging conversations which might include those conversations about getting people back to work. I think our role as a board would be looking at that at the macro level.

A couple of months ago data came out about overall levels of sickness and absence across the healthcare sector and I'm quite sure its gone up - £1.5 billion of costs.  There's been an increase of 1.4 per cent and that's added an additional cost.  If we look at it across the country we should be looking at some of that data and actually doing it now and seeing where we are come to at the end of March and the start of April to see whether this kind of engagement as worked.  Maybe some of the ideas that we've just heard about in terms of the 'Fish Bowl', can some of these be talked about and implemented elsewhere in other parts of the NHS and if its made a difference in one trust, might it make a difference across others?

The only other thing to add is patients. They're a rich source of information as patients are very perceptive. There are a series of questions and outcomes that you can relate to patient outcomes.  Patients have a very clear view about whether their care is been delivered by informed healthy staff or not so.

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You'll have seen many business cases in your time has a finance director.  What makes a successful one really stand out?

It's touching on all the aspects that colleagues have given in terms of the very clear hard metrics and articulating very clearly what is the added benefits and an engaged workforce is good for patients, it's good for outcomes. How many times have you been served by somebody at the shop, if there looking a bit disenchanted actually you go away thinking that wasn't a great experience.  If they say 'Hi, how are you?', the Americanism of 'Have a nice day', you actually go away thinking what a pleasant experience shopping can be. So its having the hard metrics, and its having the soft added value because the reality of all this is that all our organisations have limited resources and your bidding for something in an environment of limited resources but there is some compelling evidence that actually spending in this area makes a real difference, a real benefit.

There's so much wealth of evidence and you just need to know the buttons you have to push.  You have to show how this makes a return, how this changes our sickness rates, changes our retention rates or improves our friends and family test, or actually improves moral in the organisation, or improves staff engagement. 

Things like the 'Fish bowl' exercises make a difference.  I'm sure all of us, have exercises where you try and ask staff what do you think, how can we make a difference.  My organisation has done things around a staff physio scheme where you can see a cause and effect.  Where this has been  introduced sickness rates have gone down for short term, two or three days sickness.

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How do we get and keep board members attention so that health and wellbeing becomes a regular agenda item?

Essentially I think we're distilling down what you've heard from the three of us because you would have had to have been very unlucky with your non-executive and executives to have got a group that didn't understand the argument that was put forward just now. So there is not just a performance, financial argument; there's a moral argument and a duty of care. We happen to be demonstrating that the duty of care has a direct link to the care we provide patients.  Its hard to think back over twenty years as a CEO to think of a non-executive or executive director who couldn't have been influenced by putting this argument forward. Either because they just saw the financial gain, either because they saw the system was going to hit them on the head with a stick if they didn't deliver a target, so its very difficult to imagine a board, particularly in the last two years with the Keogh report, the Francis report, with two or three pretty damming CQC reports. Its very difficult to imagine how you wouldn't get a board to do it.

The bigger challenge is the second part of the question, so how do you move this from being a business case where you're asking for an amount of money to it actually being seen as a metric?

The way you do that is to get your board to engage very frequently with your staff. You generate conversations not just visits. You actually think through how you actually set up numerous conversations between staff and board members. If you get those conversations going then even the crustiest executive director or the crustiest non-executive director sees first hand what engaged, enthusiastic, valued staff feel like. It is far easier now than when we attempted to do this ten years ago.  I think we actually do have the data such as Professor Michael West's' data. You'd have to be a pretty closed board director to say 'That might apply to the rest of the NHS but doesn't apply to West London.' 

Its a combination of engagement, getting those conversations going and delivering the evidence. There's loads of business cases, not just in this area, in lots of areas and most of them are terrible because actually they're not written in language that makes sense to the person who is reading it. They're probably written from a writers perspective not from the readers perspective. 

Its around knowing the language to include and the metrics and the quantification to include in the business case because that's what sells it. If somebody had written 'Lets get some physiotherapists to give everyone a bit of musculoskeletal massage' that probably wouldn't have seen the light of day. Where as if someone actually turns it into a 'What you'll see is sickness rates drop from X to Y because lots of people go off for one or two days.' Actually they wrote it in a language that someone could understand and it makes sense to the reader. Even if you write something to say, buy me a brand new piece of kit, write it in the language that works for the reader. Often we write it in the language that works for us which might be different.

Sometimes HR has a bit of a bad press because of its failure to be able to present the business case, because of its failure to demonstrate that its close to business rather than it being a function out there on its own. I think if I was to present something back to our colleagues this afternoon it would be to really try and grab hold of this aspect around the business case to make it relevant so your working really close with your colleagues from other functions and not just on an isolated basis in your own function.

From an occupational health perspective, where the overwhelming evidence for health and wellbeing gained momentum, it felt like an add on to the portfolio of responsibilities that we already had for staff health and staff protection.  We've kind of got used to that now and we've taken that on and we talked in the room beforehand about the successes each trust has been able to share, with actually very little if no financial investment. 

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