The Friends and Family test in the NHS IPA Briefing

Transcription

1 The Friends and Family test in the NHS IPA Briefing This IPA Briefing examines the use of the friends and family test in the NHS. It examines the context of the test, why there is an increasing focus on such staff advocacy, and current levels of advocacy in the NHS. It then examines how advocacy might be improved drawing on background evidence, the staff survey itself and relevant case studies. Finally it makes recommendations on how advocacy might be improved. 1. Context Staff advocacy has been included in the NHS Staff Survey since As well as asking whether staff would recommend the trust as a place to work, the survey also asks whether they agree with the statement if a friend or relative needed treatment I would be happy with the standard of care provided by this organisation. This is sometimes known as the friends and family test. The friends and family test has been given greater prominence following the Francis Review into Mid Staffordshire which identified it as a key indicator. There is growing evidence that staff advocacy is a good predictor of other outcomes, including quality of care and mortality. NHS England wishes to increase the frequency of this measure, moving eventually to monthly reporting on a sample basis. From 2014, a small part of the financial allocation to organisations will be linked to performance on this measure in the previous NHS Staff Survey, based both on whether they are in the top or bottom quartile and on whether they are improving on this indicator. Alongside this, a similar question will be asked of patients. This briefing refers just to the question to staff. 2. Current performance The friends and family test is presented as a figure out of 5. Staff responses to the statement if a friend or relative needed treatment I would be happy with the standard of care provided by this organisation are given a rating out of 5 (1 = strongly disagree, 2 = disagree, = neither agree nor disagree, 4 = agree, 5 = strongly agree). These figures are presented as a weighted average. Higher scores indicate higher levels of staff advocacy. The figure for the friends and family test is reported in the staff survey findings as a combined score with the other staff advocacy question; I would recommend my organisation as a place to work. Figure 1, demonstrates the results by trust type on both the combined score (friends and family test and a place to work) and on the friends and family test alone from the 2012 results. It demonstrates significant variation across different types of trusts. Acute Specialist trusts (4.17) score far higher than the average (.64) on the friends and family test. Acute trusts (.61) score close to the average with Mental Health and Learning Figure 1: Reccomendation of the trust as a place to receive treatment Reccomendation of the trust as a place to receive treatment Reccomendation of the trust as a place to work or receive treatment (KF 1

2 Disability Trusts scoring a little lower (.54) and Ambulance Trusts coming some way behind (.46). The results for the combined advocacy score are similar, though with recommendation of the trust as a place to work being slightly lower than as a place to receive treatment. The notable differences come with Acute Specialist Trusts and Ambulance Trusts where this gap is much larger. Figure 2 shows how the figures for advocacy have changed over time. It shows the scores are relatively stable but with an increase from 2011 (.46) to 2012 (.57) Figure 2: Staff Advocacy (NHS Staff Survey) All Trusts Acute (Specialist) Trusts All Acute Trusts Acute Trusts All Mental Health/Learning Disability Trusts All Ambulance Trusts In addition to these differences between trust types, there are significant disparities in terms of employee advocacy among different staff groups. Managers and doctors tend to be more likely to advocate for their trust than nurses and ambulance staff who score particularly low. 1. Improving advocacy Background evidence There is extensive evidenceof the link between employee engagement and employee advocacy. Individually, engaged employees are more likely to advocate for their organisation. A study by Gallup found that 78% of engaged employees were happy to recommend their company s services or products, compared to2% of the not-engaged and a tiny1% of the actively disengaged. 2 This feeds through to a relationship at the organisational level; those with net employee engagement scores in the top quartile scored 12% higher in customer advocacy than those in the bottom quartile Figure : Staff Advocacy and Engagement by trust type (NHS Staff Survey 2012) Staff Reccomendation of their trust as a place to receive treatment Engagement 1 Are friends and family tests useful: agree, disagree, neither, don t know?, John Appleby, British Medical Journal,201; 46: f Great Britain s Workforce Lacks Inspiration, Peter Flade, Gallup Business Journal, December 200 Engaging for Success: Enhancing performance through employee engagement, David MacLeod and Nita Clarke

3 A similar link is seen in the NHS Staff Survey. Figure (right) shows, that high engagement trusts are far more likely to also score highly on staff advocacy. But the quality of service provided by the organisation matters too. In part, this is just common sense. Staff will only be willing to recommend a service to friends and family if they genuinely believe it to be effective and high quality. There is evidence of the link between quality and advocacy. Analysis of the 2009 results has shown that advocacy was significantly higher in trusts rated as high performing in both service quality and value for money. Advocacy was significantly lower at trusts with higher mortality rates. Though it is difficult to identify causality, the author suggested that high advocacy could in part be a result of these three factors: staff who are aware of the Mortality rates of their trust, or have a general idea of the performance of the trust, are more likely to base their decision to advocate in favour or against their trust on their perception of performance. 4 Research by Ipsos Mori into local government also shows higher levels of advocacy at better performing councils. Those at authorities rated excellent (51%) and good (8%) were far more likely to speak positively of the organisation than employees in councils rated fair (25%), weak (25%) and poor (20%). 5 A similar concept lies behind the increasing use of the net promoter score in the private sector. This measure asks staff how likely they are to recommend the organisations products or services with 1 being least likely and 10 most likely. The percentage scoring 1-6 are subtracted from those scoring 9-10 (those scoring 7-8 are seen as passives ), giving the net promoter score. These scores have been found to correlate with staff perceptions of service quality. 4. Improving advocacy Evidence from the NHS staff survey In addition to the above, the NHS Staff Survey provides evidence of other potential factors influencing levels of advocacy. Appraisals The NHS Staff Survey shows a strong correlation between having a good quality appraisal and staff advocacy. Staff are more likely to display high advocacyif they had an appraisal in the last year, if the appraisal was well structured and if during the appraisal a personal development plan had been agreed upon. As Figure 7 shows, quality is important here. Those who 4 Advocacy of Treatment as a predictor of trust level outcomes, Anna Topakas Lul Admasachew, JeremyDawson, Aston Business School, AstonUniversity, 5 The reputation of Local Government, Ipsos Mori for the Local Government Association, September 2008

4 received a poor-quality appraisal (.4) scored lower than both those who had received no appraisal (.50) and significantly lower than those who had received a well-structured appraisal (.85). 6 This suggests that ensuring all staff have high quality appraisals could contribute to higher levels of advocacy. Job Satisfaction A number of measures related to job satisfaction are correlated with advocacy. The following measures indicate the strength of the correlation with higher figures indicating a stronger correlation: 7 Satisfied with quality of work Role makes a difference 0.49 Feel valued by colleagues Have interesting job 0.44 These areas are closely related to employee engagement. This suggests that improving engagement would help to drive up both scores on these indicators and advocacy itself. Health and wellbeing Healthy staff and those who do not feel under pressure at work are more likely to recommend their service. There is a strong negative correlation between work-related stress and presenteeism and advocacy. There is a weaker but positive correlation between general health and wellbeing and advocacy. 8 Supervisor Support There is also a correlation between staff advocacy and supervisor support. 9 This reflects the importance of engaging managers, one of the four enablers of employee engagement identified by the Macleod Report Improving advocacy Case Studies The following case studies highlight where organisations working in related areas have focused on improving staff advocacy. Case study 1 Local Government Staff advocacy has been seen as a priority in local government for a decade. There were two main reasons for this focus. First, there is a recognition that staff are important to council reputation. Having local staff willing to speak positively of the council is a potential asset in terms of reputation whereas staff speaking negatively of the council can undermine this. Second it is recognised that staff advocacy is linked to a variety of positive outcomes. Research by Ipsos Mori for the Local Government Association (LGA) for example showed that the willingness of staff to speak out positively was identified with the Audit Commission s rating of service quality, with value for money and with resident satisfaction. They also 6 Staff Advocacy of NHS Trusts and Related Variables Advocacy of Treatment, its antecedents and health related constructs, Jeremy Dawson, Anna Topakas, Lul Admasachew, Aston Business School 7 ibid 8 ibid 9 ibid 10 Engaging for Success: Enhancing performance through employee engagement, David MacLeod and Nita Clarke

5 identified a correlation between the willingness of staff to speak up for their employer and the willingness of the customers of the organisation to do so. 11 Given this evidence, there was an increasing focus in local government on improving staff advocacy. Part of the approach was to ensure robust monitoring of staff advocacy in annual employee surveys. ORC International, one of the main staff survey providers for local government, have an engagement index made up of six questions focused on say, stay and strive. One of the two indicators for the say measure is on advocacy ( I am happy to speak positively about the Council with my family, friends and others outside of work ). Ipsos Mori also include advocacy in their local government staff surveys. In addition to just monitoring staff advocacy, the Local Government Association s (LGA)set out how it could be improved as part of their Reputation Project. 12 The LGA emphasised two main factors driving staff advocacy: Management styles they argued that councils should look to learn from the management styles of the most effective performers in order to boost staff advocacy. They highlighted the key elements for success as being listening managers who set clear goals and give good feedback on individual and collective performance. 1 Internal communication advocacy depends on effective internal communications in which the senior leadership are able to express a clear vision and describe how staff can fit in to this. Case study 2 Kaiser Permanente Kaiser Permanente is aprivate healthcare provider based in America. Employees are seen as one of their most crucial audiences in terms of strengthening the organisation s reputation. As Diane Gage Lofgren, Senior VP at Kaiser explained, a strong brand depends on a strong internal culture. They therefore prioritised encouraging employees to be brand advocates for the organisation. 14 Again, the focus on driving staff advocacy at Kaiser was on internal communication. First, they aimed to ensure leaders and managers had a shared and consistent message that could be communicated to and understood by employees and physicians across the organisation. Second, they identified the importance of using a variety of communication channels to reach staff. This included standard channels such as regular s and newsletters and meetings from team huddles to bigger town hall meetings. They also made use of social media both external sites such as Twitter and Facebook and an internal collaboration platform called IdeaBook with more than 27,000 users. One of the key lessons from Kaiser is to give employees the facts whether they are good or bad. They recognise that being open and honest with employees is important and arming them with the facts both supports trust and better enables them to advocate for the organisation. 6. Recommendations Employee Engagement Improving advocacy cannot be done without improving overall staff engagement. This is already a priority for most trusts and it is easier said than done. Trustsneed to confront their central 11 The reputation of Local Government, the Local Government Association, September ibid 1 The Business Case for the Reputation Rroject, Local Government Association, Inside Out: Employees as Our Best Brand Advocates, Diane Gage Lofgren, APR, Fellow PRSA, is senior vice president, brand strategy, communications and public relations, at Kaiser Permanente, The Public Relations Strategist, Winter

6 engagement challenges, come to a whole-organisation view about the specific enablers for improving engagement, and prioritise those which can make the biggest impact. Many trusts have found using the four enablers of engagement identified in the Macleod Review as lenses to review existing practice useful; a strategic narrative that is clearly and consistently articulated and understood by all; engaging managers who are effectively trained and able to support and coach staff, a strong sense of employee voice that permeates the organisation; and integrity, ensuring there is no gap between values and actions. Trusts should consider making advocacy a key aim of their engagement strategies. Service quality Although engagement and other factors can drive advocacy and performance, it is clear that service quality matters too. Staff will only be willing to recommend a service that they believe to genuinely be of high quality. Ensuring high quality service and addressing performance issues will improve advocacy scores. Obviously, improving service quality is already a top priority for trusts and it is incredibly tough in the current context. Appraisals There is a clear link between appraisals and advocacy. Staff must be given a high-quality appraisals, at least annually, that celebrate achievements, identify areas for improvement and lay out a personal development plan. Appraisals must demonstrate how individual tasks/objectives fit in to the goals of the team and the organisation as a whole. There should be support for line managers in conducting effective appraisals such as training and best practice guides. Internal communications organisations should celebrate achievements and improvement but also acknowledge areas for development and actions to be taken. Organisational goals and values should be consistently and clearly articulated in internal messaging. A variety of channels should be used to reach all staff. Healthy working environment there is a strong correlation between work-related stress and low advocacy. Minimising stress and ensuring staff are fully supported in their roles could help increase advocacy as well as other positive outcomes. This will represent a key challengein the NHS as demand grows and budgets tighten. Based on this analysis, the graph below demonstrates the factors that could help improve staff advocacy in NHS Trusts. It shows that the factors likely to have the biggest impact on advocacy are also the hardest to deliver. 6