Keeping body and soul together: why NHS teamwork is critical to patient outcomes

How care processes are managed within the NHS and what quality of care patients can and should expect within Britain’s hospitals is a recurrent concern, surfacing once again with the public inquiry into higher than expected death rates at the Mid-Staffordshire NHS Trust.

Just why such situations arise, and what measures can be taken to ensure better quality of care, is very much at the heart of the research agenda for Professor Michael West. Around 10 years ago West and his colleagues starting exploring the links between human resource management (HRM) practices and patient mortality.

Initially looking at HRM practices as reported by directors and senior managers in a sample of 61 UK hospitals, the research was subsequently expanded to cover staff experiences across the entire NHS in England and Wales. Since 2003 West and his team have been conducting the annual NHS staff survey on behalf of the Department of Health, and what they have found has emphatically corroborated their earlier findings.

"With this more extensive data," says West, "we have exactly the same findings: that what staff experience at work is a really good predictor of patient mortality."

Despite wide divergences between NHS trusts – for instance, in how staff view their leaders, whether staff have clear goals, their level of engagement and commitment, or the extent of positive feelings – the relationship between patient satisfaction and staff experience is, says West, strong across the board.

"If staff report high work pressure, patients then report they are being treated insensitively. If staff say there are lots of errors and near misses, patients report insufficient support, information, privacy and respect. When staff say they have got poor health and wellbeing and work-related stress, that then translates into lower levels of patient satisfaction."

Real versus pseudo teams 

One of the most striking findings to emerge from their latest analysis, he adds, is that the very best predictor of patient mortality is the percentage of staff working in well-structured teams. However, all is not what it seems.

"Although 90 per cent of NHS staff say that they work in teams, when we probe a little deeper we think the true figure is nearer 40 per cent – and that around half NHS staff are working not in real teams but in what we would term pseudo teams."

The distinction between these two is, he explains, relatively simple but nevertheless telling. "We ask questions about whether the team has clear objectives, whether they work closely together to meet those objectives, and whether they meet regularly to review performance and how it could be improved. We think those three simple elements are actually fundamental to any kind of team. So when people answer no to any of those areas, we define them as a pseudo team.

"What we find is that the more people who work in real teams, the lower the rates of injuries and errors at work – errors that could harm patients. Those teams experience less violence against staff by members of the public, and lower levels of patient mortality. Levels of staff wellbeing are also higher. The reverse is true for pseudo teams."

The teams that West and his colleagues have looked at cover all sectors of the NHS, involving both clinical and managerial staff. Yet once again, despite the differences in context, the findings are remarkably consistent: teams that have clear objectives and take time out to review their performance are far more effective, productive and innovative than those that don’t.

Team tensions

As might be expected, team dynamics are not always easily managed, and status issues can be particularly problematic. Here West and his colleagues are providing practical interventions for a variety of NHS organisations, designed to promote more effective teamworking:

"There is tension relating both to diversity of disciplinary background and to status inconsistencies in teams, so what we do is to help teams create an ethos where they value diversity, whether that be cultural diversity or disciplinary diversity. Because again the evidence we have is that where there’s a positive attitude to diversity – whether it’s professional, cultural or gender diversity – the teams with that diversity outperform more homogenous teams."

In this and other areas there is still much to do, concedes West. He is particularly concerned that the current emphasis on cuts is causing senior managers to focus on productivity at the expense of innovation – something borne out by his current research on the board minutes of NHS trusts. He would also like to see the innovative approaches already evident within the NHS being better exploited through better sharing of good practice.

Changes in practice

Nevertheless, many of the essential messages are getting through, and making discernible impact:

"I’ve been really encouraged over the last ten years by just how much senior policymakers have used our research and talk about the data when designing change in the NHS.

"For example, back in 2002 we published data showing the link between appraisals and mortality, and there has subsequently been a very big increase in the percentage of NHS staff receiving appraisals – up from around 50% to about 70%. There’s still a lot to do in terms of ensuring that those appraisals are actually useful and well structured but again those changes have taken place partly because of the data we produced.

"I think the really big challenge is to ensure that the messages we’ve been developing are put into practice by first-line managers within NHS trusts. It’s at the front line that these things really matter."

Where next? West plans to draw on Lancaster’s strengths to extend this research into the international arena. "My vision for the work we do at Lancaster is that we establish a centre focused on international health services, so that we no longer look simply at what’s going on in the English NHS but start to compare and contrast health service leadership across countries, exchanging knowledge and understanding from different kinds of health services and different cultures. I think that would be enormously exciting and beneficial, potentially paving the way for better delivered and safer health services around the world."

Work foundation

The Work Foundation

Professor Michael West is taking the lead in Lancaster's collaborative research with The Work Foundation, one of the UK's leading think tanks. 

In October 2010, Lancaster University acquired The Work Foundation, forming a new alliance that enables both organisations to further enhance their impact.