Insights into the NHS Staff Survey findings

Hello and welcome to the latest edition of Health on the Line produced by HealthCommsPlus on behalf of the NHS Confederation, soon of course to be the NHS Alliance. 

Before I welcome my guest for this episode, I want to invite you to what will be our very first in-person conference as the NHS Alliance. This will be our Mental Health and Learning Disabilities Conference taking place on April 15th in the beautiful city of Birmingham.

We have some fantastic speakers.These include Professor Pratipa Chitibasen, national clinical director for children and young people's mental health, and chair of NHS England, Dr Penny Dash. Go to nhsconfed.org/events to book your place now. Spaces are limited. 

Also a reminder that current members of the NHS Confederation and NHS Providers will have received a letter from us inviting you to join our newly merged organisation, the NHS Alliance. I really encourage you all to do so. We'll be the only independent membership body that brings leaders from across the NHS together, representing your views to government and supporting you and your teams to improve your services. 

And if you're not currently a member and you'd like to join, please email membership@nhsconfedonfed.org

Now, in a moment, we're going to be discussing the NHS Staff Survey results with Dean Royles, interim CEO of NHS Employers. But before that, the department has at long last published its neighbourhood health framework. We've been waiting for months and so I thought it was a great opportunity to get some key takeaways about that framework from Jack Sansum, the Confed’s assistant director of neighborhood health, who's been really focusing on this neighbourhood area for some time. 

So Jack, welcome to Health on the Line. The framework sets out an ambition to shift care closer to communities. We've been waiting for it for a long time. I mean, I'm sure you haven't had that much time to read it or digest it, but what would you say is kind of their headlines? I read it last night. I thought, you know, there were some interesting things, some good things, but I thought it probably told us less detail than we might have expected. Is that unfair? 

Jack Sansum

I don't think that's an unfair statement, Matthew. I think overall, I actually see the framework as an important moment in terms of continuing to drive this change. I think it gives clarity to members following the ten-year plan because, you know, we saw that ambition, which we were really supportive of. But actually, I think explicitly more than previous attempts, it does actually have the national direction but also includes what we've been wanting to see: references to that local flexibility and system accountability, which are really meant to align in this agenda. 

I really welcome the fact that it's permissive, it's not prescriptive, and actually really importantly recognises that neighbourhood health, neighbourhood working, is not just the NHS's business; it's about changing those relationships between your statutory services and communities.

I do think within that are some really kind of tangible targets for systems to continue working towards, which I think they'll welcome. But there are also some big unresolved questions around this broader shift of models of care and resources. 

Matthew Taylor

Well, I couldn't have put it better myself. That's exactly my reading of it. I thought that the two things I really liked about it was that permissive approach, let different models develop in different places. There's already some good practice, let's build on that rather than kind of driving a coach and horses. I liked all of that.

And I also did like, because this has been a bit of a battle for us over the last 18 months or so, that the Department really does, NHSE, does really seem to get the idea that this neighbourhood can't just be about the NHS. It has to be a broader public service offer and communities have to have a stake in that. I was cheering at all of that. 

But then my kind of reservation towards what this still feels like we're quite a long way away from understanding how the money will flow, who's going to provide this. What are the kind of contracts going to be like? 

And a particular obsession of mine really, which is given what ICBs have been through and how they've been stretched, who's actually going to do the work on the ground of making this happen? 

Jack Sansum

That's a really important point. And I mean, in terms of who is going to be driving this forward, I'll come on to that. But I think, again, going back to this, the idea that this is not a prescriptive model and that it does really avoid prescribing what this should look like. It's got real focus on the role of health and wellbeing boards. And I think their responsibility for developing those neighbourhood plans, defining local outcomes and neighbourhood geographies. And I think what that really means is that models can generally be shaped around communities rather than around kind of prescriptive national structures. I think that flexibility can be a huge enabler, if local partnerships are strong. 

One other thing I'd focus on is the commitment to scale integrated neighbourhood teams. And I think there's that initial focus on some high priority cohorts or frailty end of life, multi long-term conditions. And I think that can create a core engine for proactive care. And I think where the challenge and the difficulties are is that there needs to be some clear governance structures in place. And then you look at your wider kind of other enablers in terms of your data sharing, delegated budgets, but INTs [integrated care teams] can be a real drive for this shift. 

Now, where work will continue is that this will need some formal contractual models to actually clarify the roles that you were kind of speaking about, about who drives this, the funding and enablers, which will also drive this and the incentive. So we've seen alongside the neighbourhoods frameworks being published that NHS England have also put out another document, which kind of provides a little bit more clarity around the role of single neighbour providers, multi-neighbour providers and their interaction with IHOs. 

And I think this is going to be really interesting. We're expecting some formal consultation on this where we can really get into the details of this and how these models will actually take shape. Because that's been a really core ask from members since those ambitions were outlined in the ten-year plan. 

I do think to your point around the wider structural challenges that we're seeing in systems at the moment, there are the risks around limited local kind of capacity. And I suppose the framework doesn't really fully resolve that issue around who is convening and who is actually driving this forward in systems, just given the challenges that we are facing.

Matthew Taylor

Yes, we're going to, I think, rely a lot on our colleagues in local government here. I mean, you think of where I am, for example, just outside north-east and north Cumbria, a huge area with, I don't know, must be hundreds of single neighborhoods, the same in London. ICBs are not going to be able to get down into those places and bring people together and convene them, which really takes me to my final question, Jack, which is, you know, this area, neighbourhoods, has been a real priority for us for some time in all sorts of ways. As I said, we're delighted that the argument we've made that neighbourhoods have to be a whole public service community based concept seems to have been won. 

What concretely, Jack, are you hoping that the NHS Alliance can do to support our members in making the shift to neighbourhood health? 

Jack Sansum

Thanks, Matthew. And I think obviously this area is going to be a hive of activity as we launch The NHS Alliance. And I think, you know, we're already deeply embedded in kind of shaping that national direction of policy travel. But actually our focus now is on making sure that our members have the capability, confidence and actually the practical support to deliver this. 

So if you look in the framework, there's really interesting things that kind of come next out of this in terms of the trialling of new payment models to support this shift. We're already working alongside our colleagues in the Department on that. Really key for us to be shaping the design and development of those single and multi-native provider contracts. 

There's also some lines around, you know, the broader implementation that systems are going to have. And we've seen this through the national implementation programme that's been running for the six months. There's some ambitions in terms of what comes next in that. I think we'll be really at the forefront in driving that. 

And as ever, really, we need to ensure that our members' voices are really kind of driving national decisions and that means that emerging national policy is actually really grounded in the real operational expertise that they bring. 

Matthew Taylor

Great and if you want to know more about the work we've been doing on neighbourhoods then you can go to the Confed website or I'm sure, Jack, you wouldn't mind people emailing you directly that's jack.sansum@nhsconfed.org [or jack.sansum@nhsalliance.org], is that right Jack? That is and I look forward to hearing from you all. Brilliant, S-A-N-S-U-M in case you didn't get the pronunciation of Jack's surname. 

Brilliant. Jack, thanks so much for joining us on Health on the Line. 

Now, you will, I'm sure, have seen the NHS Staff Survey results have just been published. Overall, those results reflect a workforce feeling undervalued and under pressure. There are some more positive signs, such as staff experiencing compassionate leadership and increasing support from their line managers.

But we still, I'm afraid, have a staff that feel less than able fully to raise concerns. Now, while it's important to recognise and listen to what staff are saying, what I want to know is what are the next steps for leaders, especially in combating levels of racism and unwanted sexual behaviour that also turned up in this survey. 

So with me to discuss all this, we couldn't have anyone better than Dean Royles. Dean is interim CEO of NHS Employers, which is part of the NHS Confederation and therefore the new NHS Alliance. 

Welcome Dean to Health on the Line.

So Dean, let's start with what you see as being the headlines of this NHS Staff Survey. You've been around for a while as well, so perhaps as well as reflecting on the kind of headlines, maybe say something about the kind of history of the survey and the trends in those results over recent years.

Dean Royles

Yeah, thanks Matthew. 

I know for this podcast we're going to be talking about the kind of aggregate national results of the staff survey. The NHS Staff Survey is, as far as I know, the largest survey of staff that takes place in the world. So something like around 760,000 people completed this survey. So we've got rich data that tells us a lot about what staff think about the NHS. It's also been going now for probably around about 15 years.So, we've got year-on-year data used by researchers in universities to get real sort of insights into what's going on in the NHS. 

And while we're to be talking about the kind of the overall results, I think one of the important things about the staff survey and how people receive it, is that people look at it locally. So of more interest to leaders in the NHS is what have our staff said about their experience of working for us this year compared to what they did last year? And then you know, it’s the things that we did to try and make it better - did they work or not? Or do we need to be doing something different? 

But I think this podcast is useful because it paints that overall picture as well. And we can sort of see that sort of aggregate working up of the feelings of NHS staff. 

Matthew Taylor

And as I said, if you look at the headline stats, perhaps the ones that have got the most attention, you know, they're not great. High levels of kind of burnout, not brilliant morale, a fall again in the proportion of people who would recommend a job in the NHS. I mean, you know, that's not great news, is it, Dean? 

Dean Royles

No, I mean, I think there are some concerning results about that. And you also mentioned sort of violence and sort of sexual safety as well, Matthew. One of the things I would say about when you look at the results is, you know, this is a huge survey, but it's also hugely transparent. So we're comparing what our staff said this year compared to last year, what we haven't really got to compare it with is what our other sectors are saying. We don't really know what staff think in retail or the banking sector. 

There are some national surveys, the Civil Service Producers Survey, we get some of those sorts of information that we can compare to. The CIPD, the Chartered Institute of Personal Development, also do a ‘at work’ survey that allows us to do a bit of comparison. They're very difficult to do like on like. So I think it’s right to be saying there's some concerning things in there, but also I think it's worth exploring about: are what our staff's saying hugely different to other places as well?

And some of the retail giants, for example, do publish bits of their data, but don't publish it all. So if you look at things like, would you recommend the NHS as a place to work? It's not that dissimilar to what the CIPD produce about people that are working generally. It's not that dissimilar to what people are saying in the civil service. But it is a key barometer survey and one of the things that we know is it fell this year when we want it to be rising year on year. And we can maybe explore about why that might have been this year.

Matthew Taylor

Yeah, well, absolutely. Let's get into that. I write a newsletter to chief executives every fortnight and this one, I started by saying that the issue of low morale runs through the NHS like the motif through a stick of Blackpool Rock. It feels like at every level, people are feeling under pressure that maybe there's a kind of sense of, I described as inexorability, that this pressure just goes on and on and on.

Do you think that's what we are seeing when we see that further deterioration in the survey? 

Dean Royles

Yeah, I think overall, Matthew, in terms of the survey itself, there's something like 85 questions. Some have gone up, some have gone down, but they’re broken up into themes around what people think of the NHS and broadly across those themes, it's remained stagnant year on year. So I think when NHS leaders look at that overall, they'll have mixed feelings about that. They of course want the things that they're doing to have made a difference to the people that work in their organisations. 

But also if we look at last year, thousands of people were faced with losing their jobs in ICBs. We had a difficult flu season. We've had pressure to bring waiting lists down. We've had industrial action. We had concerns about pay awards coming through. And when you put all those things together, there'll be something that says, well, it could have been far worse, couldn't it? Given that sort of context coming through.

But also what people want to do is have a look at what happened locally to us.Did what our staff say this year compare favourably or less favourably to what they said about us last year? That's one of the really interesting things I think for people looking at the survey. 

One of the things I would encourage people to do is to look at the stuff in your organisation. What did staff say about you year on year? Because that's stuff that you can influence. Some of the national picture is hard to do, particularly when we're on national terms and conditions of employment. 

Matthew Taylor

And there was something of a contrast, Dean, wasn't there in the survey between, as you say, these kind of disappointing overall results in areas like morale and burnout and kind of recommending the NHS as an employer. 

But there were some better results when it came to kind of line management, people feeling they experienced compassionate and effective leadership. I found that interesting because it kind of suggests that overall people in the health service feel under pressure, but they do recognise often that the managers around them are doing their best to help.

Dean Royles

Yeah, absolutely. And a really important indicator on this… if you think, Matthew, about what makes a difference to you at work, what makes me feel good about the work that I do. I think people would say that there's three broad areas, really. Are my terms and conditions and the policy I work with, are they right for this organisation coming through? What really influences how you feel about it is do I get on well with the team of people I'm working with mostly each day? Because if those relationships are sort of dysfunctional in some way, I'm unlikely to be enjoying work, if I'm not feeling it in that sense.

And then importantly, what makes a huge difference to everyone is do you get on with your manager? Do you feel your manager is supporting you? So I think that is a very satisfying thing in this survey. So we've seen that improving year on year that staff feel as though they can raise their concerns with their manager, that their manager listens to them, that their manager helps ]them through problems, to get through them. Something like 75 per cent of people around saying those sorts of things about their manager. So that's hugely important. And it does contrast, doesn't it? You know, we've talked about, you know, raising concerns. Why is it that people don't feel you can raise concerns when actually we get some good indicators from that, how they get on with managers. And again, I think that one of the interesting things about when you've got a big survey is you can ask yourself those questions.

Matthew Taylor

I think you're right, Dean. It was interesting though, even though people were positive in some dimensions around line management and compassion, they felt it was less safe even than last year to kind of speak out about concerns that they had. 

Another thing that was worrying, Dean, was the evidence of a kind of deterioration in our relationship with the public, staff concerns about inappropriate sexual behavior, bullying, violence, a sense that maybe that reflects what's going on in wider society coming into the NHS, or maybe reflects impatience with patients because they're having to wait around in A&E for hours, or maybe even reflecting a kind of media negativity about the NHS that almost primes people to feel dissatisfied when they engage with health service. 

Dean Royles

Yeah, absolutely. You know, the survey gives us a number of indicators around that sort of violence. So you've got bullying and harassment and intimidation, but hugely worrying in this survey, Matthew, is physical violence towards staff. And you have to ask yourself, don't you? Physical violence towards staff in 2026 and I think some of that is probably drawn out of the frustration that people have coming into a health service that isn't offering the sorts of care that they expect for themselves or their loved ones at the time when they're most in need of that care. 

But there can be no excuse there for violence to the staff that are trying to do their best in that situation. And interestingly, on the violence stuff, staff do feel increasingly confident to be raising that issue with their managers and expecting something to be done about it. 

But also in that picture, Matthew, we've got the racial abuse to members of staff. And again, you know, 2026, when, you know, people are being sort of intimidated and abused and discriminated because of who they are. And I suspect that some of that is a reflection of the things that are going on in kind of the wider society and within our communities. And again, that's jumped again this year for staff, really, really worrying. There's got to be a key message here about that sort of ‘no excuse for abuse’ here.

I know many NHS organisations do a whole host of stuff - CCTV, security, body-worn cameras, poster campaigns coming through, being very public leadership about the intolerable treatment to staff. But it means that year on year we're spending taxpayer money to provide security and cameras, that sort of thing, that all of us would much rather be spent on improving the quality of care that people so want.

Matthew Taylor

Yeah. And Dean, that links into something which I'm a bit of a kind of broken record on, which is that, you know, I do think the ten-year plan was a missed opportunity to talk a bit more about the role the public themselves can play in helping us improve the NHS and make it sustainable. There are lots and lots of ways, I mean, this is at one extreme, you know, we shouldn't really have to ask the public not to be violent or to be abusive, but in all sorts of ways, actually, the way the public interacts with people does make a difference. 

And I think politicians are worried to say that because they feel there might be a backlash of people saying, well, I've got to wait a year for my operation. How dare you ask more of me? 

But the reality is the NHS is a relational service and the way the public uses the service, engages with staff, takes responsibility, it is really important. 

Now, Dean, a couple of other kinds of questions. 

I'm about to become non-executive director of a local hospital. When I look at staff survey results, I think there's going be a couple of questions I'm going to ask myself. What a wonderful opportunity for me to ask you these questions before I go on the board. 

The first is what is the relationship between the staff survey and other areas of performance? I guess if you're Wes Streeting, you want to go, okay, these staff survey results are important, but in the end what the public care about is waiting lists and access and quality and safety.

What do we know about the correlation between performance and staff survey results?

Then secondly, I haven't looked at the results for the hospital I'm going to be sitting on the board of yet, but if they are disappointing, what are your top tips for what you need to do to start turning this round? 

Dean Royles

Thanks Matthew. What a great question. You know, we do this survey, it's useful and we can sort of do research on it and see what staff think about it. But is it making a difference to performance? And actually some really good evidence that it does, particularly around the area of staff engagement. 

So you mentioned earlier about morale and what we mean by staff engagement is are people engaged in the issue like the welfare of their organisation? And there's three indicators in the survey that sort of measure this. 

So the morale that they feel at work: are you enjoying work? Do you feel as though you're making a contribution? 

Involvement, are you involved in decisions that affect you, are you able to make suggestions for improving things at work, when you do that do you get listened to?

And then the third area is that area of advocacy. From what you see, would you recommend this as a place for people to get care and would you recommend this as a place for people to come and work at? 

And those three sort of core areas give us a staff engagement score. And what we know is that there is a correlation between high levels of staff engagement and for example, lower levels of sickness absence.

We know that there's a correlation between higher levels of staff engagement and higher levels of patient satisfaction with service. 

So these are really core indicators for improving the organisation. And I think that the fact that that's a barometer indicator is one that people really look at because you know that does make a difference. Better staff engagement is better quality of care, lower sickness absence, more likely to have higher ratings with CQC, for example.

And then on the local question, again, one of the things I would encourage people to do is in the same way that we can look at the national survey and see on things like staff engagement or morale or recommending a place to work. There's a huge variation between the highest and the lowest NHS organisation. It's something like 34 per cent at the lowest and 79 per cent at the highest, you know, in the same sector. Huge variation in what people say and what we get on the national stuff here is the issue like the average of that. 

And I would encourage you in your organisation to have look at that in your organisation, bearing in mind in your organisation, it's the same labour market with the same values, the same organisation, the same equipment, you know, the same estate that people have got. And what you'll see is that there's a variation between departments that have got low levels of, if you like, staff engagement or advocacy, and they'll be somewhere it's brilliant. And then you start to ask yourself your question: why is that? 

Is there more we could be doing to support those areas where it's lower? Is there something about the support they're getting from managers that people sort of appreciate that? And I think that's where the real interest in the survey comes from is that local variation within the organisation, and great that we can discuss it on a national picture and people can benchmark themselves against that. But looking internally, variation between the highest and the lowest should point you to the right direction. 

Matthew Taylor

Yeah, I absolutely agree, Dean, although it's important, isn't it, to recognise that there are some kind of systematic trends here. I mean, specialist hospitals, which always tend to be near the top of performance of the tables, also tend to be near the top of the kind of staff satisfaction surveys. There are particular bits of hospitals, for example, emergency departments, which are clearly particularly challenging to work in. 

So you're right, we need to look at those comparisons, but we need to compare like with like. If you're stuck in a district general hospital that's got a huge backlog of capital and major kinds of problems, don't compare yourself with a national specialist hospital. You need to compare yourself with hospitals like that. Then similarly, when you look across the different departments.

Dean, this has been a really useful conversation for me. Let's just look forward. There's this new staff standard framework, which is being developed as I understand it. How important is that going to be in setting out expectations and principles to support NHS staff? 

Dean Royles

Yeah, so this has been a commitment, Matthew, to have some mandatory standards for staff. And these have been worked up at the moment. Trade unions are involved in these as well. And I suppose what they'll do is provide, if you like, a floor of expected standards on the way that we treat staff and in that regard I think it will be helpful that there's a sort of common understanding of what you know the minimum expectant standard is for the way that staff are treated at work. I think many organisations will definitely see that as a floor and will want to do much better than that coming through, so I think that will come in. I guess we'll support people through NHS Employers when they come in, about how you can make best use of those. 

Part of the worry with them is that they become a vehicle through which you can do lots and lots of reporting. And we end up reporting on the standards rather than sort of using them as a way to improve the service for staff. So the standards will have, for example, an impact on the national oversight framework score. 

So I think that they can provide a useful tool, coming to the NHS. But what I would caution against is, you know, let's have a lighter touch as we can as possible for those leaders that are already tied up with providing lots of reporting and upward management and just reporting more on it. And we end up sort of hitting the target as it were, but missing the point about really improving the things we've talked about. Have you got a good team that you work with? Have you got a manager that feels supported? Have you got the equipment to do the job well? Do you feel valued in your work? I think are really important for the care that people then give. 

Matthew Taylor

Yeah. And as you say,  many argue, argue this, that engagement is in the end, the most kind of critical thing because as long as staff feel they can engage, can be listened to; you don't want to kind of tickbox approach where what you're doing with staff is satisfying, can people up the hierarchy. You need to listen to staff in terms of what they say is important. 

Dean Royles

Absolutely. And that happens at local level, doesn't it? I know we've emphasised that in this survey. It's really important that we have a look at this, the temperature of the NHS through this survey on the whole, bearing in mind it's telling us everything that goes on from a specialist hospital into people that are spending their time working in people's homes within the community, from ambulance services to people working in secure forensic units. 

There's a range of work going on there, but that local impacts what we can do locally in our organisation to improve the experience of staff, have them engaged and have a vested interest in really the success of the organisation that wants to provide great care.

Matthew Taylor

Well, Dean, thank you so much. And thank you also for reminding me there at the end. I think I slipped into the old NHS habit of only kind of talking about hospitals. But as you say, this is a survey of staff all across the NHS. 

Thanks, Dean, for sharing your thoughts with us today. 

If you have any interesting experiences, good practice that you would like to share with the world, then do contact us. You might end up on Health Online.

In fact, just the day before yesterday, I got a fascinating email about a virtual hospital of good practice. In the next few weeks, you'll hear about it on the podcast. So, if you want to put something in the shop window, please contact healthcomsplus@nhsconfed.org. 

Thanks for listening and goodbye.