Authors: Caroline White
Publication date: 17 Jan 2012
What does it mean and does it matter, asks Caroline White
For years there has been no shortage of talk in the NHS about the need for clinician engagement, an issue the Health Foundation described as “complex and challenging” in a recent report on the topic.
The report pessimistically concluded that increasing clinician engagement was “likely to remain difficult” and represented “a longstanding, multifactorial and international problem.”
But wholesale restructuring of the NHS, the drive for quality improvement, and the need to do a lot more with a lot less has generated a real sense of urgency to translate good intentions into practice.
There is no real consensus on what clinician engagement means. But as Mark Thomson, associate director of the management consultancy the Hay Group, puts it, “Engagement means being motivated and committed, taking an interest in the way the whole organisation operates rather than working down a narrow furrow of your own, and discretionary effort.”
Doctors engaging doctors
A growing body of evidence shows that NHS organisations with high levels of staff engagement perform better financially and achieve better patient outcomes and satisfaction. And rates of staff absenteeism and turnover are lower too.
“[Clinician engagement] is more important than it has ever been, because of the unprecedented challenges facing the service at the moment,” confirms Sue Mortlock, head of board development at the NHS Institute for Innovation and Improvement. The institute has produced a raft of resources to boost staff engagement across the board.
“We’ve made lots of changes and cut what we can, but we now have to find innovative ways of delivering patient care,” she says. She acknowledges that progress has been patchy but believes that organisations need to tap into doctors’ professional values much more.
“Their whole training is based around patient care, and if the framing of the agenda is in support of that, they are more likely to engage,” she says, adding, “Sometimes the subtleties of the language we use turn swathes of people off.”
Steve Ryan, medical director at Barts and The London NHS Trust, says that context is crucial.
“Improvements in the 18 week referral to treatment time can be seen as just a government target, but not many doctors would want to see their mum waiting that long,” he suggests. “Starting with the patient at the centre of everything is really important, because it’s very difficult for people not to engage with that.”
And like it or not, doctors listen to other doctors, particularly if they are backed up with solid local data. “If you can use an enlightened doctor to influence, shape, and change the thinking and behaviours of colleagues, that is far more powerful than using someone who is not a clinician,” suggests Sue Mortlock.
But she believes that doctors’ training doesn’t provide them with the competencies they need to engage fully. “Very often doctors come through training without any of the softer management skills around team working and relationships,” she says.
Sue Whittam, associate director for organisational effectiveness and staff engagement at Royal Bolton Hospitals NHS Foundation Trust, thinks that doctors need more of an organisational route map.
“What we don’t do with medical staff is give them the opportunity to understand how organisations work. We have just not invested the time in showing them how to get involved effectively,” she argues.
And, crucially, she adds, “Doctors find it difficult to expose what they don’t know,” a factor that is compounded by doctors’ belief that they wield little influence at work when everyone else sees them as very powerful.
The trust has been running leadership and development programmes in a bid to plug these gaps. Among other things, content includes understanding the implications of the new NHS landscape and financial management.
Understanding how to interpret a budget is really important for fostering shared accountability and responsibility, says Dr Ryan. “Managers who overspend lose their jobs all the time, but not many clinicians in that situation do, so they need to be made responsible. They need to have their feet in the fire.”
A degree of financial savvy is also needed to put a good business case together, says Dr Ryan. “You can’t just say it’s a good idea and it’s got flashing lights on. If you forget to include recurrent revenue costs it will get chucked out.” This is where “co-production” between doctors and managers can be really effective, he suggests.
At Bolton doctors and managers often learn together in an attempt to dispel pervasive beliefs “that clinicians don’t understand what managers want and that managers are just trying to stop or cut things,” Ms Whittam explains.
Good managers at every level of an organisation underpin effective clinician engagement, she believes. A manager who listens, is supportive, and is receptive to ideas will help create an environment in which staff can feel valued and involved.
In addition to the annual staff survey, which can be seen as a bit of a tick box exercise, “big conversations,” and some small ones too, are regularly held with all grades of staff, to gauge what they really think about working at the trust.
“All successful organisations get closer to asking the question directly rather than just relying on a paper based exercise,” she suggests, emphasising the importance of being proactive and ensuring that people really feel heard.
The approach seems to have paid off. Productivity levels were around half of what would be expected among some poorly engaged staff, she says. “But as we started to do the engagement work, we began to see differences. We are now hitting 98-100% productivity—and without putting in additional money.”
Ian Dufton, a consultant child and adolescent psychiatrist and clinical lead at the trust, admits that his unit used to feel excluded and unwanted, because it was so different from the other paediatric disciplines.
But that was before “the willingness of the very top of the management tree to wander round the shop floor and informally ask hard questions,” Dr Dufton explains. And it was before his team was given time out to tackle how best to boost efficiency, “rather than a small elite team coming up with solutions and imposing them,” he adds.
The other crucial element, he thinks, is senior management allowing doctors to put their ideas into practice. “If you come up with the solution, you need the authority to enact it. It feels very liberating and is essential for clinician engagement.”
Andrew Goddard, who heads the medical workforce unit at the Royal College of Physicians, thinks that doctors would have more impact if they joined forces at work. “But like all highly articulate and intelligent individuals, we often form tribes and can be protectionist about our own specialty, when we need to think about the bigger picture,” he says. “Some trusts will take advantage of that and divide and rule, which will disengage doctors further.”
He thinks that the current financial climate could make matters worse, as trusts pare back supported professional activities and contracted hours in a bid to save “easy” money. Set against a backdrop of increased patient demand, this leaves consultants “feeling more and more like workhorses,” Dr Goddard contends.
This shrinks not only their local teaching and audit capacities but also their engagement at a national level, he believes.
Opportunities for senior doctors
“Trusts need to recognise that senior doctors have a lot to offer the wider NHS, like [in] NICE [the National Institute for Health and Clinical Excellence] and the General Medical Council,” he says. “They do it because it’s rewarding and makes them feel they can make more of a difference. But trusts are increasingly wary about releasing doctors for this.”
Paradoxically, it is precisely these sorts of intangibles that employers in the NHS are increasingly being urged to promote as part of the “total rewards package,” in a bid to draw in talent, compensate for pay freezes and higher pension contributions, and engage staff.
“It’s about giving people sufficient development and training opportunities and options for transfers abroad and sabbaticals,” says Mark Thomson. “But it’s also about giving them the right admin and IT support, enough office space, and even making sure the bins are emptied regularly.” And a place to park.
“If you do good,” suggests Steve Ryan, “good things should happen to you. It’s about the feedback loop, but we don’t do that very well in the NHS.”
But he is optimistic that the current NHS reforms will forge better relations between general practitioners and consultants. “I’m not saying this is easy stuff, but there has been much greater dialogue between primary and secondary care clinicians over the past year; if primary care fails, secondary care fails too.”
But Dr Goddard is not convinced. “There have been a lot of platitudes spoken about the reforms that doctors will be more involved. With 11 GPs and one consultant in clinical commissioning groups, it’s difficult to see how that is going to allow for closer engagement.”
“We’ve got to work hard to ensure that engagement happens in the new landscape,” says Dr Dufton. “GPs could provide a great many new and interesting ways of thinking, but it will be a challenge to step beyond their practice view.”
“Of course GPs want to be engaged, but they want to do their day job well, and doing that now is very tough,” says Clare Gerada, chairwoman of the Royal College of General Practitioners.
“It’s not just about going to the next board meeting, although it is about making their voices heard. They should engage with commissioning and support those chosen to be leaders and tidy up their own practice,” she says.
“GPs always make a go of it, but they won’t automatically be engaged,” she warns. “What I want from commissioning leaders is not to forget what it’s like to be a GP and start dictating things that it’s not within GPs’ gift to change.”
If doctors were going to disengage, this is the time they would naturally choose to do it, suggests Dr Dufton. “There will always be a group of doctors who see it as part of their purpose in the system to challenge the direction of travel. But that’s not necessarily a bad thing,” he argues. “The aim is to get 80% engagement; the remaining 20% will allow you to question what you do.”
Competing interests: None declared.
- Wilkinson J, Powell A, Davies H. Are clinicians engaged with quality improvement? Health Foundation, 2011. www.health.org.uk/publications/are-clinicians-engaged-in-quality-improvement.
Caroline White freelance journalist, London, UK