What the NHS staff survey tells us about the state of improvement in England

Published the same day news broke of NHS England’s abolition in March, it’s no surprise the results of the 2024 NHS staff survey received scant coverage. Given what the survey can tell us about the state of the NHS, this is a shame. According to one highly experienced trust leader, the survey ​‘is the best lead indicator for everything’. Especially revealing, in his view, is a trust’s staff engagement score. If this is high, he told us, chances are most other major performance metrics will also be high. The right culture ​‘will deliver everything else’. 

There is now a strong evidence base to back his claim. As Michael West and others have shown, higher staff engagement is associated with a host of benefits, including better care quality, staff retention, patient satisfaction and resource use. Research elsewhere has concluded that overall staff engagement scores predict provider organisations’ Care Quality Commission ratings. 

With the fieldwork for the 2025 staff survey set to begin, it’s important to reflect on what we can learn from the latest results. In the 2024 survey, the overall staff engagement score was slightly lower than in the previous survey and some way short of in the last pre-pandemic survey. This shows NHS trusts still have plenty of work ahead of them when it comes to staff engagement. 

Yet, this score tells only part of the story. As the 10-Year Health Plan for England acknowledges, there is significant variation between organisations in terms of their survey participation rates and results. Our analysis of one of the survey’s most important staff engagement questions – whether staff feel they are able to make improvements happen in their area of work – bears this out. The gap between the highest and lowest performing acute hospital trusts on this question is nearly 20%, up from 16% in the previous survey. 

For the NHS to deliver on the ambitions set out in the 10-year plan and drive improvement at scale, closing this gap needs to be a priority. So, what can be done? The 10-year plan points to a range of practical measures employers can take to boost staff engagement. These include more flexible working options, health and wellbeing initiatives and better career development. These are important steps, but they are not enough to deliver the cultural shift required. Staff need to feel they have the permission, confidence and motivation to engage in improvement. 

The reasons people may feel reluctant or unable to make improvements are complex and wide-ranging. In some cases, staff may have the technical skills and professional experience to lead improvement but lack the confidence to do so, not least for fear of a negative impact on patients. In one intervention, staff underreported their own improvement expertise due to anxiety about taking on decision-making roles. 

Mentoring arrangements and open dialogue within teams about managing clinical risks can help. But these concerns may be a consequence of deeper-rooted unease among certain professions about the extent to which their organisation values and trusts them, or how it would react if something went wrong. Hierarchies within professions may also create barriers. In one setting, newly qualified clinicians who had been exposed to improvement methods during training were prevented from using these skills by a presumption that improvement would only be led and delivered by more senior colleagues. 

Equally, some staff may not be emotionally ready to engage in improvement. Stress, fatigue and work overload are likely to limit willingness and ability to initiate or contribute to improvement. ​‘Moral injury’ due to, among other things, an inability to deliver care that aligns with intrinsic professional motivations, also may lead to burnout and a disinclination to participate in improvement. This can prevent change in precisely the areas where it is most needed. Practical obstacles also abound, not least difficulties getting permission to undertake improvement training or take time away from core duties to work on improvement. 

The first step is to acknowledge their existence. Giving people the opportunity to discuss issues affecting their emotional and cognitive readiness for improvement is critical. Change management models such as that developed by Annette Chowthi-Williams and colleagues, whose piloting has been supported by the Health Foundation, can help identify these issues. This diagnostic work should be used to inform organisation-wide efforts to address the practical and cultural challenges it unearths. 

Other important considerations for overcoming barriers to improvement include: 

• Leadership behaviours. Visible, nurturing, empathetic leaders who go out of their way to show how much they value each professional group set the standard for middle and front-line managers to follow. 
• Establishing the right cultural norms. Encouraging and normalising deference to expertise rather than hierarchy, collegial behaviours and intellectual curiosity can help to erode people’s reluctance to act as improvement practitioners. 
• Strong social networks within and between organisations, coupled with access to people with improvement expertise. These have been shown to galvanise change and ensure timely peer support is available when required. 
• Having a compelling vision for improving productivity and quality that is aligned to the 10-year plan. 
• Clear processes and pathways for enacting change, with a presumption that promising proposals will be seriously considered if consistent with strategic priorities. 

Embedding cultural change takes time. But it is possible, even during the most difficult of times. Our NHS staff survey analysis shows that at 1 in every 10 acute hospital trusts, over 60% of staff feel they can make improvement happen. This provides grounds for hope. The challenge now is to ensure all trusts have the support and guidance to build workplace cultures conducive to improvement. That the staff engagement metric has been included in the data underpinning the new NHS trust performance league table may provide the impetus necessary for this to happen.