Unlocking improvement through better staff experience

• Learning and Improving Across Systems – Peer Learning Programme 
• Being the best at getting better – our learning & improvement community (16 May 2023)  
• Supporting staff wellbeing during COVID-19: a Northumbrian experience (5 August 2020)  
• Video: ICS Learning and Improvement event - North East and North Cumbria (21 September 2022) 
• Engaging the workforce in real time: listening, understanding and responding to what matters most to our staff 
• Paywall: 'Scared, but not alone': caring for staff during covid-19 (22 July 2020) 
• NHS Staff Survey (April 2024)  
• Understanding, measuring and improving the engagement of staff in major change   
• Staff voices matter (23 October 2023) 
• Digging into the data to drive improvement (4 March 2024) 

MATTHEW: Hello, and welcome to Leading Improvement in Health and Care; a new podcast from the NHS Confederation, the Q Community and the Health Foundation.

ANNIE: There were so many lessons for us as an organisation, but it began with the courage to ask, ‘how are you?’

PENNY: In this series, we'll be speaking to the people leading the way when it comes to improving health and care in services and systems.

JOHN: Even if you were cynical and said that some people just don't care enough about staff experience, they certainly care about retention. So the dual focus of those two, I think has really helped 

MATTHEW: We'll be shining a spotlight on improvement done well, but we also want to find out about the challenges. 

PENNY: We'll be exploring the ways improvement can transform health and care and how to make change last. 

I'm Penny Pereira, I'm managing director of Q at the Health Foundation. Q's a community of thousands of people across the UK and Ireland, collaborating to improve the safety and quality of health and care. Q’s hosted by the independent charity, the Health Foundation.

MATTHEW: And I'm Matthew Taylor, CEO at the NHS Confederation, the organisation that represents leaders across the whole of the health service in England, Wales and Northern Ireland. And this podcast is part of a partnership between our organisations. Penny, can you explain a bit more about the work we're doing?

PENNY: Yeah we’re working with health and care systems across the UK, boosting their ability to learn and improve collaboratively to achieve their goals. We're doing that through a peer learning programme, insight and innovation projects, and we'll be pooling and sharing insights and practical materials throughout the work.

So this podcast series is one way that we're doing that. 

MATTHEW: So Penny, why do you think that learning and improving across systems is important? I mean, there's been talk about improvement, work on improvement in the health service for decades. So what's different about thinking about this through a system lens?

PENNY: Yeah, as you say, there's that model of continuous quality improvement that's been used for many decades at team and sometimes whole organisation level, indeed in the health sector, but also across industries. But actually, we're moving now beyond that. We've got more experience and ambition. So we're seeing as much work really seeking to shift how care is delivered.

So improvement being used to target, introduce innovations, get to the underlying issues, impacting on health, looking across systems. That work is more complex as the people that are contributing to this podcast series will help us understand. I mean, in essence, improvement is about approaches to understanding and working out how to resolve issues. And it does that in a way that is collaborative, it engages staff and service users and it's iterative and it's data driven.

And, that basic approach to change, that applies at all levels, doesn't it? But it's the frontier of change. It's really exciting. There's no blueprint. So through our partnership, through this podcast series, we're going to be learning through examples, piecing together what's happening to move forward from there.

MATTHEW: But one thing that, both a system lens and an organisational lens have in common is the importance of people. And so it's entirely appropriate, I think, that for our first episode we've decided to zoom in on the issue of staff engagement and morale.

Now, actually, Penny, this is an issue that's close to my heart, because before I came to the NHS Confederation, work, good work, was kind of my specialist subject as it were, so it's been really interesting listening to the interviews for this programme because it reminds me of all that stuff that I did about the concept of good work.

But why do you see staff engagement as being so important, Penny?

PENNY: So, it's a core principle of improvement that we need to involve people closest to the work in designing better ways of doing things, if we're going to end up with workable solutions that last.

So that means that improvement is a field that's developed pragmatic ways of engaging staff well that can be used across the work of organisations and systems. And then having good staff engagement also directly influences the quality, efficiency, effectiveness of care that teams can provide.

So our contributors are going to really help us understand that. 

MATTHEW: Actually what we're going to hear from now is someone who is more at the front line.

We're going to hear from Annie Laverty. Annie's spent many years working in patient and staff experience in the north east of England. She's worked within individual trusts, but across systems as well. 

PENNY: Annie's headed up some really exciting staff focus work as chief experience officer at Northumbria Healthcare NHS Foundation Trust, supported by the Health Foundation, and as executive director of improvement and experience with North East and North Cumbria Integrated Care Board.

She's also very recently started a new position with Newcastle Hospitals, whose latest CQC report shows there's plenty of work to be done when it comes to staff morale.

MATTHEW: We sent Gabriella Jones, our roving reporter at the Confed over to chat to Annie about the staff engagement work she's most proud of and the challenges that she's had to encounter along the way.

ANNIE HERE

GABRIELA: Welcome to the podcast, Annie.

So you've recently started your new role with Newcastle Hospitals, but your last role was with North East and North Cumbria Integrated Care Board. But if we wind the clock back a bit to when you first started in that job, what were some of the immediate challenges that you encountered where you thought: ‘Right, if we can bring some improvement approaches to this we can definitely change things for the better’? 

ANNIE: Well, going back in time, I'll go back to being in a provider organisation with Northumbria Healthcare and I'd started in 2009 as director of patient experience. It was the first role of its kind in the NHS, it was quite experimental and quite exciting. 

What I quickly learned was how much that work meant to staff. And some of the stuff that really sticks in my mind was the work that we did around the pandemic, really. It was actually with the support of the Health Foundation and the Innovating for Improvement Programme, we were able to use technology as a way of engaging with staff and really checking in with them regularly to find out what they wanted to tell the organisation. We called it Corona Voice. And I thought staff would be too tired to focus on the pandemic, too preoccupied.

We got 10,000 responses in the first 12 weeks. People were really, really keen to engage and talk about the things that were on the top of their minds and occupying their thoughts. And we were able to analyse that information and understand it. And seven core needs emerged in that data that was really interesting to look at.

So people said: ‘care about me’, ‘keep me safe’, ‘keep me connected’, ‘listen to me’, ‘lead me’. People saying ‘we want to see our leaders, we need visibility here’, we need to know we've been led through something that's really, really important’. And also then just that bit about ‘notice me and honour my work’.

‘Notice what I'm doing in order to forward the commitment and contribution of the organisation’.

And my sense is that those seven needs that emerged are fundamental needs that people have in terms of staying engaged and it wasn't just about a pandemic and it wasn't just about the organisation in which we were doing the work, I think they are core needs that we can hold on to, but a really, really good reminder for me of the fundamental principles of what keeps staff engaged.

GABRIELA: So you're checking in with staff, but what did that actually entail? Was it a weekly check in? Monthly?

ANNIE: People could just contribute on a platform at any time. So some people could use it daily if they wish to, some people might check in once a month, some people might do it weekly, most people did it weekly. They indicated for us their motivation for work that day and the score that they would give it, how they were feeling, and then they provided some free texts to make sense of the score that they'd given. 

So we kept it really simple. It wasn't a complex survey, it was just asking how motivated are you feeling for work today and tell us a little bit about why, and then the needs in that emerged. Fascinatingly, we could track mortality in the organisation and the mood in the organisation and that's not a surprising thing, but we lost our first staff member, I remember, in the January of 2021. I remember that emotion being very raw in a large organisation with close to 10,000 staff. 

It just became a way of people just expressing themselves and people found that comforting. People gave us feedback around feeling scared, but not alone. And then every week that feedback was fed through gold command, it was fed into exec meetings, it informed the outputs of our health and wellbeing offer because we knew which parts of our organisation were feeling more frightened than others.

So there were so many lessons for us as an organisation, but it began with the courage to ask: ‘how are you?’ And sometimes we're so scared of what the answer is that we don't ask the question at all.

But it was invaluable information. Sometimes really difficult to read. Undoubtedly really, really humbling, but such a guide for leadership across the organisation about what was important to staff.

GABRIELA: So at the time when you're seeing these seven key areas of concern starting to emerge, what did you start doing to address them? Was it a case of making some changes straight away, or was it more of a kind of long-term response?

ANNIE: No, it was being incredibly responsive. So the seven needs weren't always what was missing. It was sometimes appreciating what was there. So, ‘keep me safe’, the organisation invested in immediately handwashing in outside all of our hospitals sinks before the people felt differently about walking into their hospital in a pandemic in terms of the efforts that were doing that. Where there were real challenges around PPE the organisation responded dramatically, actually, by building their own factory that produced PPE for their people. ‘Keep me connected’, there were key messages about how people needed communication, when they needed communication, and that some people needed communication in different ways. So some people needed films made to demonstrate how to put on PPE or how to use the equipment because it was deeply unfamiliar to them and they were frightened. 

So using just established channels of communication wasn't enough at this time. ‘Honor me, notice my work’, we were quickly able to put in place a ‘who have you noticed?’, which was just a celebration of everything good that was going on, around the camaraderie, the coming together in the team spirit, the people moving from one established job to another part of the organisation to join a new team to do important work just in the spirit of what the organisation needed. So all of those seven needs we were able to translate that into action, really. Critically important, I think, and probably one of the reasons that the feedback was so strong and in great volumes, people discovered that it was worthwhile getting in touch.

But we saw big impact from an organisation where 43 per cent of staff believed that the number one priority was patients, to 91 per cent of staff believing that that was the case. We moved from below average to being the best place to work in the NHS.

Over a five-year period we watched our complaints halve. That's a big impact for patients, better care for patients but also a big impact for staff who are having to devote half their time to writing complaint letters and devote their time to doing something that perhaps gives them more enjoyment.

But fundamentally this was about changing the stories that were told within the organisation and really being clear that the priority was on what mattered to people. What mattered to people caring for people, what mattered to our staff and what mattered to patients. 

Get it right, do it often enough, make it trustworthy but make it accessible. Find the story in your data. I think having an organisational-wide approach and then being able to look at the data and thinking, well, is there any inequity in our data that we need to be aware of with respect to either patient or staff experience? Who are we serving more than others? Who is silenced in that data? So real stories like that start to emerge. We learned that the financial impact of the pandemic was experienced most by staff with a disability. We could see that in our data. 

We saw a rise in violence and aggression against NHS staff and therefore the organisation could take steps to be really explicit about a zero tolerance of that. And by that they were investing in support in emergency care 24 hours a day that was there to protect staff, etc. Ithink there are quiet parts of your organisation everywhere and I think a commitment to be comprehensive in your measurement allows you to uncover that. Otherwise you're making assumptions about how things are.

GABRIELA: And what would your advice be to people who are trying to do this kind of work in particularly challenging organisational contexts?

ANNIE: I think everybody needs to do it, if I'm honest.

If we only approach feedback in the good spaces where we know what that feedback is going to be, and it's going to be light and easy. So, no, I also think that every organisation will have light and dark spots in it.

I don't think that's owned by only a percentage of the NHS really. I think this is the work of leaders everywhere, in every organisation. And if we're serious about our workforce being our most important asset, then every leadership and every board, I think, should be paying attention to do that.

The challenge in organisations where staff engagement is low is that those organisations that do have the courage to find out are punished for not dealing and for uncovering data and evidence that they're not delivering. And I always think that's quite hard because they're doing more than the organisation that does nothing and doesn't uncover the difficult stuff.

They're braver. Start small, have improvement at the heart, know that you won't always like what you're going to hear, but trust the process anyway and measure really well. And most importantly of all let people know what you're doing as a result of what they've told you. 

GABRIELA: And have you seen people getting serious about this kind of work? Do you think there's meaningful strides being made in other areas of health and care?

ANNIE: The national survey results would suggest we’ve got so much more to do and not enough is going on with respect to that.

But interestingly, it took a pandemic for us to start asking the question, how are our staff doing in it? And yet it seems like such a fundamental thing that we should be asking ourselves in healthcare. So, there's so much more that we still need to do.

MATTHEW: Well, Penny, that was fascinating what jumped out for you from that interview?

PENNY: Well, I think it's my job on this podcast series to draw out some of the general principles from improvement that people can then apply in other areas. What was really striking me from Annie's story was that brilliant use of measurement in an improvement mode. So, measurement that doesn't just accept some centrally defined targets and some headline measures and then moves to action. But rather measurement that is granular, that is much more real time, and is then used as part of an active cycle where they were really understanding where are the pinpoints for highs and lows of staff engagement? What are the things we need to address? And then feeding back to people, real time, the changes that are being made. There's so much when people are talking about improvement, when people are taking a very people-focused approach to the work of organisations, that is sometimes dismissed as being a bit soft, not really rigorous.

And yet, when I think about the measurement practice in the story that Annie described, and I compare that to some of the ways in which we make decisions in organisations. To me, this is how we should be approaching change. What did you think, Matthew?

MATTHEW: I like this kind of combination of hard data and soft skills in a sense that you have to have the data and you have to keep the data up to date, to really know what's going on. But the reason for that is in order to have that in-depth engagement with staff, recognising the vital importance of staff feeling empowered, feeling listened to. What I heard from Annie was courage, really. It's not easy to really openly and authentically ask people how they feel, because you're never going to be told that everyone loves their job and loves the organisation and loves you as the chief executive.

So, you've got to be willing to hear that. And it's so easy to fall in the one hand into kind of complacency: ‘Oh, my organisation's doing great. You know, we've got strong ratings. What could possibly go wrong? The staff should just be grateful for being here’. Or on the other hand, a kind of fatalism, which says, ‘well, look, you know, the health service is under immense strain, you know, I've got vacancies, it's really, really difficult. What's the point of asking stuff? Because I know they're going to tell me that it's a bit crap’. And actually the courage to say, ‘I'm not going to fall into either of those traps of complacency or fatalism. I'm going to keep going back over and over again and asking the right questions and reflecting on what I'm told.’

There's a kind of courage and discipline to that, isn't there, Penny?

PENNY: Absolutely. And it's an invitation because yes, you will hear difficult things, but as Annie says, you at the moment may also be walking past brilliant practice. So even in the most challenged organisations, you will get amazing work that is happening. I mean, particularly at the moment when things are so challenging in the health sector, that feels really important. So the way in which we approach this in itself contributes to the end goals that we're seeking to achieve. It's not just that we're using data to find the areas to target, although that's part of it. The measurement process in itself is part of process.

MATTHEW: I also felt was significant this point about learning from the pandemic. I mean, the pandemic is a huge thing in people's lives. That's also been a challenge and adjustment, which is how do you use some of the commitments we had to staff engagement, staff empowerment, staff welfare, and use them in the context which is not a national emergency, but it's kind of business as usual. That is something I hear quite a lot as I go around talking to people. Just one final thing I draw from Annie's interview, Penny, is that between trust leaders, organisational leaders, and system and collaborative leaders, well, Annie, of course, spans that, but actually the reality is now can't remember the last time actually I spoke to a trust leader who didn't have some kind of significant role in a collaborative in a place or in a system. So it is quite a big shift, isn't it, Penny?

PENNY: Absolutely. And I guess I would say we're also talking about leaders who, even if their predominant role is leading within an organisation. I mean, these are massive organisations and the data that Annie was describing describes how an organisation is made up of many, many parts with some quite different experiences and the work of trying to support collaboration, trying to give clarity of leadership and priorities, those are skills that we needed even when we're working within organisations and are becoming all the more imperative as we now should all be thinking in system terms.

MATTHEW: Well, it was a great interview, but our second interview kind of steps back from the front line that Annie is talking about and looks at the role of NHS England this area. So, so tell us about our second interview, Penny.

PENNY: Yeah, I was really interested to get a wider perspective on the work that Annie was talking about, so I decided to chat to John Drew, who's been leading work on staff experience engagement at NHS England to get his perspective.

JOHN HERE 

JOHN: There's quite a lot of research on this, that the sense of having a certain amount of autonomy and discretion and decision-making power is actually a fundamental driver of motivation and particularly for people that are professionals, if you like. So they've, been through an awful lot of training to develop knowledge and expertise with the expectation that one of the things that comes with that is the ability to make decisions that matter.

But if they feel that isn't there and actually the decisions are taken elsewhere and they're just being asked to essentially follow a process forever, that's pretty demotivating. So it is fundamental, I would say.

PENNY: Yeah, I guess linking this to the productivity agenda not only about 45 per cent of healthcare sector costs are the kind of staff costs, and actually staff are making an awful lot of the decisions about how to make use of resources. And so how we can think about that capacity productivity challenge in a way that's deeply human, in a way that's really respectful of the discretionary effort that helps the health sector work at the moment. I know it feels really important to me.

JOHN: Yeah, I think one of the challenges here is actually about the framing and so productivity ought to be, in my view, a kind of positive term, you know. It's about being more effective, making the best use of the skills and the people that we have, the resources that we have, because it's not just people, it's also equipment.

But I think to some people, productivity has a negative connotation, which is completely understandable, that it’s about basically trying harder or working faster, without anything changing fundamentally that enables you to be more effective. So, I mean, I think in healthcare, a key concept here is actually flow. So if we can create flow in a process, that will lead to the whole thing, including people, being more productive. But creating flow does require changes to the way things are done. A good example of that would be dedicated elective sites are proven to and will create more effective flow for that pathway.

So, we've seen quite a significant investment in dedicated elective sites as part of the elective recovery programme.  That's kind of an organisational-wide decision that helps teams and people to make changes locally that will be more productive. But it kind of requires a marrying, I would say, between high-level strategy and investment with the engagement of staff and teams to make changes.

PENNY: Yeah, as you say, improving flow across an organisation or across a system will mean an awful lot of teams making changes to their particular processes around them. If we could tap into the frustration that I think people feel when the processes around them aren't working well and see that as the way into reducing waste and then improving productivity, it could perhaps help us reclaim the productivity challenge in a way that resonates with staff a lot more. Actually that prompts me to some of the work that you've been doing around the staff survey and thinking about how the staff survey can help us understand the ability of an organisation to introduce changes. Can you tell us a bit about how you see the staff survey as a source that can help us guide this work?

JOHN: That's easy for me to talk about. I'm passionate about the staff survey as really a bit of a gold mine, I think, in terms of the value it can bring, but it does require sort of intelligent digging and making sure that we're understanding what the data is telling us. The staff survey, as people will know, I hope, was redesigned in 2021 to align with the elements of the People Promise.

And the People Promise came from staff, so those are the themes that people said matter most to them and really drive and determine their experience of work. So I think that's fundamental. Putting it most bluntly, even if you were cynical and said that some people just don't care enough about staff experience, they certainly care about retention. So the dual focus of those two, I think, has really helped elevate the importance of understanding and improving staff experience. 

Then embedded within the staff survey, one of the key measures is staff engagement. The evidence for it being very strongly linked to all sorts of outcomes, including quality of care is very strong, and embedded within engagement are three measures: motivation, involvement and advocacy. And involvement, as you said, includes very specific questions about people's ability to make suggestions and make improvements happen in their own area of work.

PENNY: Thinking about what Annie was describing in her story, that link to the real priorities that we know staff have, that the People Promise captures and that was reinforced in the things that they found through the work they've done in Northumbria, and then using that as the basis for a really strategic organisational focus on staff experience and engagement. I'm reflecting that Annie nonetheless talked about it taking a bit of bravery for boards and leaders to prioritise really listening and focusing on staff engagement. Is that something you're seeing? I mean, how widely now are boards and executive teams feeling able to prioritise this? 

JOHN: Well, I think it's improved a lot. And I think the pandemic actually, which was awful in lots of ways, one of the side effects or the benefits perhaps in terms of learning is just the very powerful reminder that this is all about people. And therefore, I think that all sorts of measures including the staff survey became really paramount during the course of the pandemic. We introduced two other things that were new, one was the monthly pulse survey to enable us to understand how people were feeling month by month. And in a world which the NHS is that relies heavily correctly on data to understand what's going on, it really helped to bring fresher data to the table.

And then the second new thing was the quarterly pulse survey, which actually asks those exact nine questions that make up the staff engagement score, every quarter for every organisation in the NHS, and that I think has also really helped to keep the data fresh. I mean, as you say, staff engagement is a leading indicator, but the way we need to process the data before publishing it, the time it takes, given about 650, 000 people complete the staff survey, means that the data is lagging behind the current situation, whereas the quarterly data comes out quite quickly. So every organisation gets a read during the course of the year on how the staff engagement is changing. 

So I think all of that, together with the link back to retention, means that boards are able to use this data in a different way to perhaps how they would have been able to do in the past.

PENNY: That principle of measurement for improvement came through so strongly from what Annie was talking about. So, using rapid as close to real-time data, complementing that with the data that comes less frequently. 

Are there other things that people are doing at a local level to supplement that? What would be your advice in terms of kind of proportionate, focused use of measurement to supplement what's in the national sources of data?

JOHN: I would definitely say don't rely on an organisational average to give you a complete picture of what's happening, because in any organisation there'll be teams that are working incredibly well together, very fired up, very motivated, and you see that in the scores. And then there'll also be teams that are really struggling for whatever reason, whether it's a local cultural thing, or whether it's something about the context of their work, or not feeling properly recognised, that are struggling.

So, it is so important to drill down into the data and do that kind of analysis. We're also, this year actually, introducing even better analytical tools that will be available through the public website to enable organisations to filter the results by more than one demographic characteristic.

So that might sound a bit nerdy, but it essentially means that you could say: ‘we want to look at the experience of internationally recruited nurses in our organisation’, or ‘we want to look at the experience of non-white physiotherapists in London’. That, I think, will really help to understand the experience of different groups of staff and then come up with targeted interventions that will make a difference and link into what staff networks say. Because in the end, this is actually about listening. It's about listening and responding, and that builds trust as well as driving improvement.

So I think that would be one thing I would say. The other is, is actually to try and link what the staff survey is telling you with what other data is telling you. And I think what that does is it broadens the coalition, if you like, of people that are working on improving staff experience, because there's multiple benefits from doing it. So, that could be about linking to measures of operational performance, it could be about linking with the professional lines of accountability, so working with nursing teams, medical teams, AHPs, to make sure that you're cutting the data in a way that's useful for them to put alongside other measures that they consider important.

MATTHEW:  So, Penny, what would be the particular things you'd want to draw out of your interview with John?

PENNY: So what really feels important to me in what John was describing is how having the space and skills, being invited in to improve the service you're part of, that in itself boosts morale and engagement. And I was really interested with the way that John was helping us think about the staff survey questions that relate to staff engagement, the way those are a powerful indicator of an organisation's ability to improve. And actually there being a correlation with overall organisational performance, as he was describing it.

So, to me, this is drawing quite a clear line between some of foundations of engaging people well, focusing on improvement and organisational performance. I mean, those things are never going to be entirely straightforward to demonstrate improvement. But for senior leaders, I was really struck by his recognition that an awful lot of people are now focusing on staff engagement as a leading indicator and one of the most important things to be tracking because of the number of things that it then impacts on.

MATTHEW: Yes, and I was fascinated that John wanted to reframe and reclaim the productivity agenda.

PENNY: Absolutely. So, taking an improvement approach, you would tend to think about actually what is happening around you that is really adding value to service users or patients, and what are the things that are waste. And there are all sorts of tools within the improvement toolkit that help you spot and understand those types of waste and do that in a way that involves the teams of people and recognises that. Say, a form of waste might be people needing to move around more than necessary, there might be ways in which we use our equipment that isn't optimised, almost all of those things they all have a connection to the people and their ability to feel productive.

I think sometimes we have this idea in our mind that, there's this kind of old-school sense that you run organisations to try and squeeze out as much time and effort from people who in essence are otherwise going to be slacking off unless you're really driving productivity in a way that's pushing people to work harder.

When, I mean, the people who work in healthcare, perhaps more than other sectors even, think people want to be doing a good job, right? And so finding ways in which they are able to be productive is really important to people, because if you can get it right, staff recognise that that's actually part of how they're going to be providing high-quality care to their patients and be able to work well with the team of which they're part, as you say, those are really critical motivators for staff.

MATTHEW: Well certainly Penny, when it comes to staff engagement, Q has done some very focused work on this. Just tell us a bit about the kind of research and development you've done in this space of staff engagement.

PENNY: Yeah, we've done a major project last year looking at staff engagement in major change. The process itself was a really good example of the value of engagement. So, we co-created ten principles and a practical measurement tool with more than 300 key members and others who are working across the health and care sector. 

They shared their experience engagement and we consensus-built some principles for how to improve our approach to change. Having the right sort of measurement approach came through as critical from Annie and John, so we then focused in that spirit on creating a guide, a measurement tool, that people can adapt and use locally.

So it's a really practical takeaway that allows people to follow through on some of the principles that we've heard from Annie and John. 

MATTHEW: Penny, what I found interesting listening to John, as someone from NHS England, I agreed with every word that he said and I was particularly taken by the point that he made about how we have to kind of get off this kind thinking that the way to deal with the challenges of rising demand, rising expectations, limited resources, is simply the kind of intensification of activity.

But what's fascinating to me is that I think many people out in the field will be surprised to hear that from NHS England, because in a sense they will think, well, NHS England is an organisation that is responsible for setting stretching activity-based targets, for driving performance in a slightly kind of short-term way animated by kind of political priorities.

Now, I think the reason I make this point, Penny, is I think as a leader myself, one of the things that is so important to leadership is to understand that how you think about yourself, the messages you think you're giving out, the way you view the world, is very rarely the way in which it is seen by the people who are hearing these messages, the people you have authority over. And so there's a circle here, Penny.

One of the reasons staff engagement is so important is because if we assume that people see us in the way that we hope that they see us, and they see the organisation the way we hope they see the organisation, we're going to get things hopelessly wrong. Because how it feels at the front line, how it feels if you're a middle manager is very different to how it feels if you are the boss or if you are at the centre.

PENNY: Absolutely. And if we think about all of the steps in the way, the counter stories, the other bits of data that people might be absorbing between a frontline member of staff and the head of an organisation, there's an awful lot of other signals that can get in the way of the clarity of intention and the things people believe they are signaling are important at an organisation.

And when you scale that up to something like NHS England and how it's perceived by people at the front line, and thinking about the power dynamics and the other things that are playing out there, it perhaps shouldn't surprise us that we end up with these highly simplified, perhaps easy ways of criticising what's above you or below you in the system, as the reason why things aren't working. As opposed to a more nuanced understanding where NHS England, like the organisations that Annie was describing, it will have bright spots and, spots that are less well informed by improvement principles than the things that will actually work.

So I, think part of the work that we'll be doing on this podcast series, shining a light on some of the stories, the opportunities of operating in a different way. This can help us think of a different way of operating that could, if taken to its full extension, really have some profound implications for the way that health sector operates.

MATTHEW: Well, what a great way to end, Penny, because that's all we've got time for on this episode. We're going to be back over the coming months with more insights from across the improvement world. So please do make sure to subscribe to this show, wherever you get your podcasts. And if you like what you've heard this week, go ahead, share this episode, or even better, get in touch with us to let us know your thoughts.

You can find us on X @NHSConfed and @HealthFdn

PENNY: I really do hope we get some feedback. It would be very much in the spirit that we've set with this first podcast in the series. If you'd like to know more information about our learning and improving across systems partnership, then please email improvement@nhsconfed.org. And you can find more information about some of the things that were referenced in this podcast, in the show notes.

Thanks. See you next time.