The impetus to make a tangible difference to the health and wellbeing of staff at North Bristol Trust (NBT) came after a gruelling winter in 2017/18. Its work since – and a paradigm shift about health and wellbeing – have taken it from below to above average in staff wellbeing terms, saved hundreds of thousands of pounds, and improved performance across the board.
Key benefits and outcomes
NBT has moved from below average to above average in staff engagement and wellbeing terms since 2017, being one of the most improved organisations for health and wellbeing in the 2019 survey. Changes have improved staff health and wellbeing, as well as driving down overall occupancy by 4 per cent, and caring for 6 per cent more patients with 38 fewer beds in 2018/19.
Almost 4,000 WTE (whole-time equivalent) working days were saved due to reductions in sickness, equating to £301,015 saved on sickness costs in one year alone.
The shift to staff health and wellbeing being considered as important as patients’ health and wellbeing put NBT in a good place to look after its staff during the response to COVID-19.
What the organisation faced
The winter of 2017/18 was so bad it hit the national headlines. NBT saw a demand increase of 12.2 per cent, with bed occupancy regularly running at 102 per cent, meaning patients waiting in corridors. Only 71 per cent of patients in A&E received the care they needed within four hours.
The trust had been on a difficult trajectory, being graded ‘requires improvement’ by the CQC, in financial special measures, and feeling the strain of an expensive move from two hospitals to one purpose-built site.
NBT was determined to do better. In 2016 it had launched a new strategy, which for the first time focused on the workforce as the key to improvement, but it had not made enough progress before the trials of winter 2017/18, and it needed to shift up a gear.
What the organisation did
In January 2018 NBT instigated a new staff wellbeing programme, which was shaped through staff feedback as the year went on.
In February 2018, it ran a series of surveys and staff listening events to collect feedback about how to do better. Hundreds of staff from all parts of the trust participated, and more than 750 comments were collected, analysed, and fed back to staff.
Members of the executive board walked the wards to raise awareness of the events and listened to staff in person. The group listening events provided refreshments as an extra incentive to attend.
Two themes emerged: workload, and staff health and wellbeing. NBT created comprehensive plans to address both simultaneously.
Addressing workload issues
It was clear that many of the pressures could be resolved by minimising delays in patient care. NBT engaged professional services firm PWC to help develop an approach to improving patient flow, using a staff coaching and empowerment methodology called Perform.
PWC consultants initially trained 15 per cent of NBT’s workforce, holding bootcamps with staff from all 26 wards, sites and discharge teams, supporting them through a 10-step process. A strictly casual dress code helped to level hierarchies and emphasise the ‘OneNBT’ approach the trust had created.
One quick win from the Perform process was instigating huddles, which took place on the wards, focused on key data, with actions as a result. Discussions could be about the number of beds, outlier patients, anyone who’s in the wrong place, or any other metrics that are decided by the team as being crucial to understanding how an area was performing and identifying how to keep it functioning properly.
The huddles also demonstrated to staff that they were empowered to fix problems in their areas and were supported to do so through a coaching approach. There was a large focus on celebrating success every day, which in turn helped staff to feel pride in their achievements.
This success prompted NBT to commission a Perform Academy, which saw NBT staff trained to become Perform coaches to help further embed the approach and ensure that the coaching style continued. The trust actively sought coaches who represented staff with protected characteristics, to ensure maximum inclusivity of the programme.
Following the implementation of Perform, NBT’s performance improved massively. Despite 2,500 more emergency department (ED) attendances and 3,000 more admissions, there were 600 fewer four-hour breaches in 2018/19, with occupancy down by 4 per cent.
The success of the programme was recognised with an award for Best Clinical Service and Treatment Pathway Transformation Project in 2019 from the Health Service Journal.
NBT accelerated its planning ahead of winter 2019/19, developing a strategic plan in consultation with staff. It launched in the summer of 2018 and key elements included:
- buying equipment early and monitoring stock levels to avoid emergency rentals/purchase
- no corporate staff training during winter months
- finalising Christmas and New Year rotas early
- recruiting additional staff in July rather than September
- ensuring staff took breaks, even during busy times
- a revised discharge process and associated patient information
- expansion of out-of-hospital services such as Hospital@Home
- increased staffing in ED, including mental health, community teams and GP support.
Checking in with staff after the winter of 2018/19 revealed 86 per cent felt better prepared, and 77 per cent knew the winter plan had been designed from staff feedback.
Prioritising staff health and wellbeing
One of the messages to come from the listening events was that the health and wellbeing of staff should be a trust priority. In response, NBT enhanced its wellbeing programme to include 16 interventions available for staff to access.
The support included one-to-one and team-based support, along with practical interventions such as fast access to physiotherapy and psychological support available for staff. A winter staff nurse was based in the hospital’s wellbeing room so staff could get immediate support. A range of other interventions were accessible including online learning and others that were arts based.
A new employee assistance programme was instigated, giving staff access to free financial and legal support, relationship advice and counselling 24/7. The programme is available to staff and their families and NBT was careful to position it as being provided by an independent organisation so that staff had the confidence to use it.
A culture of wellbeing was encouraged, with organised lunchtime ‘walks to wellbeing’ from the site twice a week and an emphasis on the importance of taking breaks.
The changes had a great impact on staff engagement and happiness, shown in the results of the staff survey and the Happy App measurement system the trust had been using for a few years. Staff sickness levels also fell, generating associated budget savings.
Results and benefits
Winter 2018/19 was completely different for NBT. Despite 2,500 more ED attendances and 3,000 more admissions, there were 600 fewer four-hour breaches and overall occupancy was down by 4 per cent. Overall, there was a 6 per cent increase in patients cared for, handled with 38 fewer beds.
Elective activity increased – a sure indicator that the system was coping with winter pressures and able to deal with non-essential activity. Patients’ length of stays decreased by 13 per cent.
A comedy postcard flu campaign designed by staff resulted in NBT ranking fifth in the UK for the proportion of frontline staff vaccinated, with 87.9 per cent of all frontline staff choosing to have the flu jab, up 15.3 per cent on 2017.
Staff engagement metrics told the story of a happier and more engaged workforce, evidenced by more than 3,500 contacts to the trust’s wellbeing offering. There were 3,923 WTE working days saved due to a reduction in sickness levels. This equated to a saving of £301,015 on sickness costs.
Staff’s self-reported happiness scores, using Happy App, improved from 46 per cent (rated a neutral result) in 2017 to 59 per cent (rated a positive result) in 2018. The 2018 staff engagement survey, conducted in November, also showed an increase in staff engagement from 6.8 to 6.9. Studies have proved a direct link between better staff engagement and improved clinical outcomes for patients. In addition, 84 per cent of staff felt able to share and comment on trust activity throughout the winter.
In the 2019 staff survey, NBT improved its wellbeing score from 5.7 to 5.9 and staff engagement from 6.9 to 7.1. This was an improvement from 5.6 and 6.8 respectively in 2017. On health and wellbeing, it moved from well below average to average, and on staff engagement it is now above average for similar trusts.
This has continued to be true for NBT during the COVID-19 pandemic response. With staff health and wellbeing so firmly embedded into its culture it has been easy to make swift changes to support its teams. Clinical psychologists have been seconded into staff support roles, taking the team working on staff wellbeing from two full-time equivalent to 10.
A dedicated wellbeing message has been sent to all staff every day during the pandemic. The executive board are a familiar site on the ground, talking and listening to staff. A variety of swift programmes have been instigated – and accessed by staff – during the response phase, and staff have taken the initiative to put support in place for themselves and their teams, including reallocating unused rooms for wellbeing spaces and starting yoga sessions before the start of shifts.
People have confidence the organisation will look after them. Post-COVID-19 pulse surveys have confirmed that during that difficult period, 57 per cent of staff said they felt cared for by the trust and only 18 per cent said they did not.
There were notable improvements in perception of action on health and wellbeing by the employer and support from line managers. On staff engagement there was an improvement in questions on staff feeling their feedback was acted on.
There was a big improvement in the willingness of staff to recommend North Bristol as a place to work, rising from 59 to 69 per cent. Staff turnover reduced from 17 per cent in 2017/18 to 14 per cent in early 2020.
The biggest obstacle faced by NBT was creating a cultural shift among staff so they felt they could use the support provided.
Frontline staff are so used to putting the care of their patients first – at great personal sacrifice – that they naturally don’t take the time to look after themselves, especially if that would mean being away from the ward during a shift.
Consultants were supported to adopt a different mindset, moving from being the ones with all the answers, to being able to ask for help.
A theme emerged: caring for you means better care for patients. This became a key message for the wellbeing campaign, creating a paradigm shift to help staff know that their health is equally important as their patients’. Like many NHS organisations, patient health had always been the number one success factor, but now NBT positioned staff health as equally important. This is what started to create a shift in attitudes.
A network of champions helped to overcome obstacles. NBT recruited some formal ones but informal networks also sprang up as the initiatives became more embedded. Wards created their own wellbeing boards, drop-in events and started boxes for donations of practical things colleagues might need in the middle of a busy shift.
Building wellbeing into the normal working day has also helped staff understand that they are not only able to look after their own wellbeing, they are expected to. An initiative called ‘Start Well, End Well’ was created by a team of clinicians, psychologists, and members of the quality improvement team. It was their idea in response to what they were seeing on the wards. Start Well, End Well is a quick discussion at the start and end of each shift to debrief what went well and what could be improved, but it ensures that a team starts and ends a shift with their own wellbeing in mind.
It’s a clear signal that the culture has changed when clinicians create initiatives without any central involvement.
To ensure that any new members of staff understand the cultural wellbeing imperative, the head of people strategy, Guy Dickson, does a slot to set expectations.
- Adapt the approach and resources for different groups to ensure all your staff can engage and feel able to access support.
- Identifying a consultant champion can help encourage consultants and junior doctors to engage with wellbeing campaigns, rather than feeling that they should have all the answers.
- Identify the best time of day/year to hold activities and events, to ensure that all staff groups can access them.
- Your staff have the answers. Create the conditions for them to make suggestions and ensure they can be confident they will be acted on, to lead to effective change.
- Guy Dickson, Head of People Strategy, NBT Guy.Dickson@nbt.nhs.uk
- Dr Olivia Donnelly, Staff Wellbeing Psychology lead, Olivia.Donnelly@nbt.nhs.uk