· Features

Prof Michael West: Radical transformation needed in the NHS to improve performance

Those working in the NHS have to respond rapidly to increasing demands from patients and the public with limited resources, while retaining a highly professional and compassionate approach to quality and safe health care.

Alongside the brilliant progress in the past 10 years in improving outcomes and reducing waiting times for treatment, is the understandable weakening of public confidence as a result of care scandals (Mid-Staffs, Winterbourne View, Morecombe Bay), and the unrelenting barrage of hostile media coverage. What is the reality?

In the biggest ever such research programme, funded by the DH Policy Research Programme, we used observations, interviews, archival data, surveys and national data sets to study acute, mental health, ambulance and primary care across the whole of England.

We found bright spots and dark spots in every organisation and indicators of how to create healthy organisational cultures.

Using data from the annual NHS staff survey we found that staff engagement was strongly associated with patient satisfaction, quality of care, financial performance, staff absenteeism and even patient mortality.

Where staff were intrinsically engaged in their jobs, were proud of their organisations and were involved by their managers in decision-making, NHS trusts were high performers in terms of quality and safety.

We also found that as good HR management (HRM) practices increased to cover more staff in hospitals, patient mortality subsequently fell.

But HRM is not always well implemented in the NHS. For example, appraisals and team working are often poor and praise is too rare.

Command-and-control style cultures pervade many organisations, and staff are often expected to work in environments that are not conducive to compassion, caring, respect and dignity for staff or patients.

Too many staff find themselves spending time on tasks that appear to add no value to patient care and where they have little sense of being able to control, influence or innovate. Nurses are among the most stressed groups in the UK workforce (along with teachers and housing and welfare professionals).


For NHS trusts to perform well, there must be a radical transformation in the extent to which staff are involved in decision-making: consultation on change, and on care quality problems and solutions.

In the best care settings, managers make the most of input from experienced, skilled and motivated staff, and ensure that through consultations there is alignment between them and the frontline.

In the best NHS trusts there are good systems to plan workload demand to ensure staff are able to deliver high quality care with the right level of resources. Staff health and wellbeing is considered vital.

In the best care settings we found that staff worked in well-structured teams with clear, challenging and measurable objectives (true of only 40% of NHS staff).

And there is a need for all teams to ensure they improve the effectiveness with which they work with other teams within both health and social care to deliver high quality patient care.

We found that the most effective teams regularly took time out to review their performance and how it could be improved. Offering more praise and being supportive to hard-pressed staff is essential, but so is dealing with disruptive, hostile or poorly performing staff, and especially at senior level. Patient experience, concerns and complaints should be key sources of learning for all staff.

All organisations are faced with issues of supporting capable and committed staff to give their best in the face of continual pressures.

If we want NHS staff to treat patients professionally, compassionately and with respect and dignity, we must manage NHS staff in the same way.

There is a need for national leadership: a clear and integrated approach from Government ministers and the range of national agencies and stakeholders regulating care. People management processes must be core to this strategy.

Professor Michael West, Lancaster University Management School and The King's fund and author of Quality and Safety in the NHS: Evaluating progress, problems and promise