Hinchingbrooke Healthcare NHS Trust

Submitted April 2006

Background

Hinchingbrooke Healthcare NHS Trust is comprised of Hinchingbrooke Hospital, an acute general hospital in Cambridgeshire with 342 beds, a busy accident and emergency department and high volumes of day surgery, outpatient and diagnostic work. The Hospital employs 1,800 staff.

The Healthcare Commission awarded the Trust a zero-star rating in 2002 after which the newly appointed management team and their Chief Executive initiated a performance improvement plan. The Trust was awarded two stars (out of a possible three) in 2003, which it retained in 2004 and 2005.

Why a stress management initiative?

In 2003 there was a growing feeling of stress amongst staff. As the Director of HR and Communications, puts it “The S. word was taking on a life of its own – it was the new buzz word”. Two attacks on staff at the Hospital led to serious alarm on the part of the staff, following which the Health and Safety Executive (HSE) issued an Improvement Notice in relation to security and staff safety. Occupational Health saw an increase in stress related illnesses, and the 2003 NHS national employee attitude survey found that Hinchingbrooke was in the 20% of trusts with the highest degree of work pressure felt by staff. There was a perception that middle management acted as a ‘damp proof course’ inhibiting both downward and upward communication flows.

In July 2003, following complaints about bullying and long working hours at West Dorset General Hospitals NHS Trust, an HSE inspection found that West Dorset had no stress policy in place and had not undertaken a risk assessment for work related stress. HSE served an Improvement Notice.

The West Dorset case was the catalyst that enabled Hinchingbrooke’s Chief Executive to call for urgent action on stress management, with the enthusiastic support of trade unions and staff. The Director of HR and Comms (DirHR/Comms) and the Occupational Health Nurse Manager both relatively new to the Trust, worked together to devise and manage the initiative.

Hinchingbrooke’s employee assistance programme provider was asked to report on work related issues that were contributing to stress. The Occupational Health Nurse Manager produced a report to the Trust Board, detailing the case for action and suggesting the way forward, which was agreed. In November the Chief Executive published an article to all staff, putting stress on the agenda. His article included the following passages:

"As we all work harder to achieve more, it is inevitable that we will feel the strain and the pressure of work will increase. None of us is exempt from feeling, at times, that it is becoming more difficult to cope.

We will be looking at sources of stress within the Trust and drawing up an action plan for addressing these where possible. This project will involve staff at all levels as we make a concerted effort to reduce stress by tackling its sources."

The 2004 diagnostic survey

In early 2004 HSE published its draft Management Standards on Work Related Stress, launched in their final form later that year. The six Standards (Demands, Control, Support, Relationships, Role, Change) aimed to provide a workplace with high levels of employee well-being and minimal stress.

The Trust wanted an on-line employee survey questionnaire, which would:

• Measure the Trust’s true levels of stress against all of the HSE Standards;
• Identify which areas of the Trust were performing well and which were suffering the most;
• Use HSE benchmark percentages as a guide to the Trust’s performance;
• Provide a fast turn round of results to meet staff expectations.

The NHS national employee attitude survey designed by Aston University, which is administered annually to all trusts, had been used for the first time in the previous year. The national survey did not contain questions covering all six Standards, and those that were covered were not investigated with a sufficient range of questions to be fully HSE compliant. Trusts can add their own questions to the national survey, but it was decided to opt for a separate survey, designed specifically around the HSE stress standards.

The survey selected offers the following features:

• HSE benchmarked and compliant.
• Allows for an unlimited number of optional extra demographic questions agreed at the outset, enabling the data to be sorted and reported to the organisation’s specification in terms of business unit, job function, job grade and demographic group. Hinchingbrooke selected the demographic categorisations used in the national NHS (Aston) survey.
• The questionnaire is sent electronically as one email to all employee email addresses. Paper copies are sent to staff with no email account, people on longer-term absence such as those on maternity leave, and, if required, to staff with email addresses who have not responded by a set date.
• The questionnaire takes six minutes to complete. Staff with email addresses complete the questionnaire on line to an external website with the data stored and analysed on an external server. This means that several people can enter their responses at once, staff are assured that their answers are confidential, and the external provider undertakes all analysis automatically.
• Reporting uses traffic lights, following HSE conventions which compare the organisation’s performance with HSE benchmark data (the scores of a nationally representative sample of nearly 2,000 employees collected in 2004). The traffic light coding is:
  • Green (doing very well - need to maintain) represents results in or close to the top 20% of the scores of the national benchmark sample.
  • Blue (good, but need for improvement) represents results better than average but not yet in or close to the benchmark top 20%.
  • Amber (clear need for improvement) represents results below average but not in or close to the bottom benchmark 20%.
  • Red (urgent action needed) represents results in or close to the bottom benchmark 20%.
• The reporting tool can suggest targets for improvement, using an HSE methodology.
• Each of the six management standards is investigated through several questions. Thus Demands is reported in four elements:
  • Do you have to work excessively fast?
  • Do you have to work very intensively?
  • Do you have enough time to do everything?
  • Do different groups at work demand things from you that you think are hard to combine?
• The external provider trained Hinchingbrooke to generate reports and queries from the server database, and additionally offered the option of supplying the data as an Excel spreadsheet from which Trust staff could generate reports.

The Trust administered the survey in July 2004, giving staff three weeks to respond together with an extra week’s grace for late returns. A snag emerged when it emerged that 400 staff email accounts were for staff who had either left or had never accessed their email with the result that their in-boxes were full. After the inoperable email accounts had been discounted, the response rate was above 80%.

The results were reported for the Trust as a whole (shown at Appendix A), for each Associate Director’s area, and for each of the pre-selected demographic and functional staff groups. For the Trust as a whole Demands were coded red (urgent action needed), with Control at amber (clear need for improvement). Discussion with HSE showed that the two were linked; giving staff increased Control would help in management of Demands.

The reporting for each Associate Director’s area flagged up areas for attention specific to each. Staff in one department felt bullied, suggesting that the department head’s management style needed adjustment through sensitive counselling and coaching. The Trust was clear that feedback to staff was key. The survey results were communicated promptly in a process managed by the Trust’s Communications Manager:

• July: survey;
• August:
  • Results presented to the Trust Board by the DirHR/Comms and the survey provider, with positive points and issues that needed attention.
  • Table top A5 flyers and posters across the Trust including the library and restaurant areas, with three key success messages and three areas for improvement.
• September:
  • Three page booklet for all staff, explaining the issues.
  • Time to quiz the HR Director in the staff restaurant;
  • Article in the staff magazine.
• October: opportunity to discuss with HR and senior managers.

The report for each managerial area was sent out individually to the relevant Associate Director to discuss with staff, collect their ideas for action and submit an action plan within one month. The actions were sometimes as simple as setting up monthly staff meetings.

The ‘Valuing Staff’ campaign, Autumn 2004 to Summer 2005

The Trust delivered a ‘Valuing Staff’ campaign over the following year, with the involvement and support of staff trade unions. The campaign was publicised at the outset by a stand outside the staff dining room set up and staffed by Occupational Health. Initiatives were progressed in nine key areas, as follows.

• Written guidance to managers and staff.

• The ‘Policy for Managing Work Related Stress and Psychological Well Being in the Workplace’ sets out the Trust’s approach and details the responsibilities of the Trust (at corporate level), managers, employees, Occupational Health, HR, safety representatives and the Health and Safety Committee.

  "The key message is that psychological well-being should be approached at different levels. At the corporate level to develop policies and processes to minimise the risk occurring and at the management level to provide leadership and good management practices that encourage team working and good communication between individuals and their managers. At an individual level to recognise the nature and causes of stress and to manage stress effectively by aiming to achieve a good work-life balance."

• A booklet ‘Managing Stress at Work: Support for Managers and Staff’, covering ‘what is stress’, how to recognise stress, managing stress and sources of support.

• The Trust acted to better predict patient demand and to provide appropriate staffing levels from day to day.

• An algorithm service now predicts accident and emergency attendances. This has proved highly successful in enabling managers to match staffing to demand in the accident and emergency department and in emergency admissions wards.
• Elective admissions for planned work proved to be less hard to predict. So the Trust re-designed the processes, moving as much surgery as possible to day case or 23 hour stay work so reducing demand on in-patient beds and building more predictability into the system.
• Middle managers re-deploy staff from one ward to another from day to day, to take account of the number of staff available for duty at the beginning of each shift.

• Every job advertised now has a recently reviewed job description and candidate specification, followed by careful recruitment and selection, to ensure ‘right person, right job’.

• The Trust promotes a warm, appreciative and participative management style. In particular the Trust expects managers to thank staff and this is measured by a question in the annual survey. The Trust’s comments on the 2005 survey result include “Whilst managers are approachable, the amount of positive praise and feedback has fallen – are we saying thank you enough?”

• The Trust expects that everyone will have a quality annual Performance Development Review meeting with his/her manager. Joint objective setting in the meeting generates SMART job targets and personal development plans, supported by routine one to one meetings over the year to track progress and identify problems.

• The Trust is working to ensure that appropriate work life balance options are available to everyone who needs them.

• The Trust has delivered a communication strategy to ensure that all employees are kept informed. This has three strands:

• The Chief Executive holds monthly ‘walkabout’ meetings, at which he addresses staff and discusses current issues. The time and location vary from month to month to improve staff access. The 2005 ‘Improving Working Lives Practice Plus’ report found that these ‘are highly valued by staff and promote good communications’.
• All managers hold monthly one-hour briefing group meetings with their staff, which have proved very successful and offer opportunities for staff to discuss issues and to input to decision making.
• The Trust publishes ‘Challenging Times’, a weekly staff newsletter with the brand “if it’s not in ‘Challenging Times’, it’s not true”, and its monthly staff magazine ‘Pulse’.

• Effective attendance management is now a requirement on all managers, to maximise staffing levels on the ground and to support staff. The Trust’s expects managers to:

• Pick up early signs.
• Encourage use of the Trust’s employee assistance programme, which provides a 24-hour telephone advice service plus face-to-face counselling.
• Refer to Occupational Health at the earliest opportunity. Occupational Health will meet with the member of staff to:
  • Identify any ongoing medical issues;
  • Explore the perceived causes of stress, using the HSE standards approach to identify the work related factors (i.e. role, demands etc) which are causing the problem. This has the additional benefit that it will often prevent other members of the same team suffering similar problems;
  • Advise the employee and manager to work through the HSE Standards and develop solutions;
  • Ensure that the member of staff is receiving appropriate treatment and support.
• Keep in regular touch with the member of staff whilst off sick, particularly in the case of long term absence.
• Manage the person’s return to work - as the Occupational Health Nurse Manager puts it, ‘think Walker’. The line manager should:
  • Meet with the person before their return to work to ensure that any workplace stressors are identified.
  • Discuss a rehabilitation plan with Occupational Health. It may be necessary to alter hours or duties for a short period on the person’s return to work.
  • Conduct a risk assessment by reviewing the job description, person specification and the member of staff’s skills and aptitudes, and review to identify whether any additional changes are needed (Demands, Control, Support, Relationships, Role, Change). Conduct a return to work interview.

Managers are supported by a booklet published by the organisation Mind Out for Mental Health, titled the ‘Line Managers’ Resource : A practical guide to managing and supporting mental health in the workplace’ www.mindfulemployer.net/Line%20Managers%20Resource.pdf. It provides practical advice on managing and supporting people who are experiencing stress, distress and mental health problems. The booklet, which Occupational Health describes as invaluable, is now unfortunately out of print.

• These initiatives require managers to take ownership of managing their staff, so the Trust is investing heavily in management development. As the Occupational Health Nurse Manager puts it, the key is ‘education, education, education’ in a five year effort to change the culture. The process started in 2003 with one day workshops on the use of transactional analysis to develop impact and influence. The Trust went on to introduce two courses, run in house but accredited by the Institute of Leadership and Management.

• The Core Management Skills programme is an introductory course, which runs over three days.
• The Essential Management Skills programme develops management skills further, operating as a five-day block with two subsequent days. The Trust’s 2005 ‘Improving Working Lives Practice Plus’ report found the programme “immensely popular and effective”. The course includes a half-day session on how to manage stress at work, covering the nature and causes of stress, national and local incidence, the Trust’s stress policy and how it is being implemented, and the role of Occupational Health.

Counselling and coaching help is also available for managers who need support.

The management development programme is a requirement for new managers and for managers on promotion, and other managers who volunteer to participate are found places. The Trust’s next step will be to identify the management development needs of all existing managers, within the appraisal process and in the context of the NHS Key Skills Framework, and to deliver appropriate management development for everyone.

Outcomes

The results for Hinchingbrooke are:

• Staff sickness absence down from 6% (October 2003) to 3.8% (October 2005), giving the Hospital one of the lowest NHS absence rates in the UK. Karen Charman estimates that this has reduced the cost of agency cover by £500,000 each year.
• The Trust repeated the survey in July 2005 (Appendix A). The repeat survey showed huge improvement in terms of Demands and progress on Control. The Support score had slipped back, reflecting a need for managers to be more attentive to the support needs of staff.
• In September 2005 the Trust was awarded ‘Improving Working Lives Practice Plus’ status, the highest level of award in the NHS for HR.
• In the 2003 national (Aston) NHS staff survey, Hinchinbrooke was in the 20% of trusts with the highest degree of work pressure felt by staff. The Hospital is now in the lowest 20%. The same survey finds that the number of staff with intention to leave has fallen.
• Patient satisfaction is up in all areas.
• The Hospital’s employer brand has improved, evidenced by movement from a range of unfilled Health Care Assistant vacancies in 2003 to a waiting list in 2005 of applicants who have passed the Trust’s selection system.
• The number of reports to OH of stress has gone up, reflecting greater awareness of the issue and willingness to seek help.
• Productivity has substantially increased, including reductions in waiting times, the opening of a major new facility for diagnostic work and day surgery, and increasing patient numbers.

Hinchingbrooke’s achievement is particularly strong given a background in 2005 of ward closures to save money. In March 2006 the Trust announced a further planned 10% saving in staff costs, and this will be a major test of the Hospital’s ability to manage its people successfully through major turbulence.

Cost benefit

Significant investments in the initiative have been in management development and in half the time of the Occupational Health Nurse Manager for the first six months whilst she developed and launched the programme. The external provider’s audit tool is low cost, and the expense of additional internal communications was absorbed by existing budgets.

The ongoing cost is expected to be the cost of management development, and a quarter of the time of an Occupational Health nurse for case management and participation in delivering management development.

These investments delivered a saving of £500,000 per annum in agency cover, together with increasing productivity. The effort put into the stress management initiative also went a long way towards enabling the Trust to achieve a range of other objectives, including:

• Meeting NHS Key Performance Indicator targets for acute trusts, including managing demand particularly in Accident and Emergency;
• Achieving the standards set in the NHS Trust Performance Management Framework or ‘annual health check’ launched in Spring 2005, particularly in relation to Safety and Governance;
• Earning the award of ‘Improving Working Lives Practice Plus’ status.

Evaluation of the initiative

Managers at the Trust reflected that:

• Management commitment and skill, workforce participation and excellent communications are all key to success.
• A one to two year set of initiatives does not finish the job. It’s a five year programme to achieve cultural change to deliver:
• The right people with the right skills in the right place at the right time.
• Skilled management, which enacts the style and people management policies of the Trust successfully and deals promptly with problems of performance.
• There could have been greater monitoring of Associate Directors’ areas to ensure that each one generated an action plan in discussion with staff after each survey, and that the actions were delivered. Perhaps this might have involved HR presenting the action plans to the Board, together with six monthly progress reports covering both corporate and Directorate actions.
• There might have been more work to educate managers and staff in depth from the outset, using ‘guest spots’ in existing forums.
• Planned sessions on stress could usefully be incorporated in the annual training and development calendar.

Appendix A

Survey results for Hinchingbrooke Healthcare NHS Trust

HSE Standard (with HSE Benchmark)	July 2004 Survey	July 2005 Survey	Comments
Demands (85%)	20%	60%	Huge improvement. Particularly strong improvement in feelings of having to work long hours and deadlines being unachievable.
Control (85%)	65%	72%	Step in right direction – links with demands
Support (85%)	85%	76%	Issues on support from manager rather than peer group
Relationships (65%)	75%	76%	Improvement
Role (65%)	70%	84%	Superb
Change (65%)	70%	64%	Scale of change going on