The annual report provides insights into the NHS workforce's opinions and experiences. While the survey provides a wealth of data, over the years two key metrics have emerged as headline indicators for many organisations: “I would recommend my organisation as a place to work” and “if a friend or relative required treatment I would be happy with the standard of care provided by my organisation”.
Unfortunately, both metrics have declined compared to last year, reflecting the level of discontent among NHS staff, as highlighted by recent industrial action. Interestingly, there appears to be a significant drop in these metrics when compared with the 2020 results, obtained during the height of the COVID-19 pandemic. This raises important questions around why the situation is getting worse and what are the lessons the NHS can learn from the challenges faced during the peak of the pandemic.
This year’s survey received responses from 46% of those invited to participate, a 2% decrease from the previous year. This means that over half of those asked to participate chose not to, raising the question of why. Most organisations actively run email, newsletter and poster campaigns to encourage participation, suggesting that awareness is not a problem.
Access may be a driver, with the questionnaire going out via email and frontline staff often sharing access to computers or accessing via joint logins and therefore not seeing their individual invites. While there is the opportunity to complete the survey on paper, only 7% of respondents opt for this option. Maybe the other 54% are satisfied in their roles and don’t feel any need to complete the survey. Maybe there’s apathy from providing feedback in the past without feeling meaningful change?
When considering the two key questions, both are worse this year compared to 2020. In terms of recommending their organisation as a place to work, the table below summarises the top five and bottom five acute providers in the 2022 survey, along with their historic positions.
| Top Five Acute Trusts in England 2022 | 2020 | 2021 | 2022 | Movement 2020 to 2022 |
| University College London Hospitals NHS FT | 78% | 74% | 75% | -3% |
| Northumbria Healthcare NHS FT | 84% | 78% | 74% | -10% |
| Sherwood Forrest Hospitals NHS FT | 81% | 75% | 72% | -9% |
| Guy's and Thomas' NHS FT | 73% | 71% | ||
| South Warwickshire University NHS FT | 79% | 70% | 71% | -8% |
| Bottom Five Acute Trusts in England 2022 | 2020 | 2021 | 2022 | Movement 2020 to 2022 |
| Norfolk and Norwich University Hospitals NHS FT | 62% | 48% | 41% | -21% |
| The Shrewsbury and Telford Hospital NHS FT | 48% | 40% | 41% | -7% |
| Mid and South Essex NHS FT | 58% | 47% | 42% | -16% |
| Gloucestershire Hospitals NHS FT | 0.64 | 52% | 43% | -21% |
| The Princess Alexandra Hospital NHS Trust | 54% | 45% | 43% | -11% |
Regarding happiness with the standard of care, this has decreased nationally from 74.2% in 2020 to 62.9%, an 11.3% drop. All trust types (acute, community, mental health and ambulance) have dropped during the period, but ambulance trusts have seen the biggest decrease, moving from 75% in 2020 to 56.7% in 2022.
The current scores are not necessarily a surprise given the well-publicised issues facing the NHS such as long ambulance waits, extended waits in accident and emergency, staff shortages, and extended planned care waiting times. But was there something special about 2020 compared with last year that has resulted in such large downward shifts in results?
The Staff Survey in 2020 was conducted during a particularly challenging time for the NHS. In October and November 2020, we saw the start of the second wave of COVID-19 and headed into the second national lockdown. Healthcare workers were facing unprecedented levels of stress and pressure - we all remember the scenes from the news of exhausted frontline staff, under layers of personal protective equipment (PPE), dealing with a new disease with (at this point) no known treatment or vaccination. PPE supplies were limited, central guidance changed daily, and staff faced significant mental and physical strain.
The graph below shows the timing of the survey and COVID hospitalisations.
Source: NHS
Despite these challenges, the results of the survey showed an increase in staff satisfaction compared to the previous year (recommend as a place to work 2019: 63.4%, 2020: 66.8%; standard of care 2019: 71.5%, 2020: 74.2%).
This unexpected upswing is likely to have multiple factors. Many frontline colleagues we know describe a sense of camaraderie and solidarity, fostering a wartime spirit in the NHS, a “we are all in this together” mentality. Decision-making was streamlined with increased autonomy, reducing layers of bureaucracy and red tape. The significant reduction in elective work allowed many staff (both frontline and back office) to be redeployed to support COVID-19 areas and staff returning from retirement often improved patient facing staff levels. The public’s shift in approach to how they accessed health services meant hospitals were able to create patient flow, emergency departments were not overcrowded, and bed pressures lessened.
Many trusts stepped up their support to staff during COVID including free staff drinks, free parking, improved health and wellbeing offers, and increased staff counselling services. Alongside this, the population at large showed an outpouring of support for the NHS through priority shopping, free goods from third parties and the weekly clap for NHS workers.
Although times were exceptionally hard, staff felt appreciated and recognised by both their organisations and the public. Frontline staff endured uncomfortable and demanding conditions to provide the best possible patient care. Support services were aligned to providing support to the front line, and the public were grateful for the NHS’s efforts, dedication and resilience. At the time the survey was taken, most working in the NHS recognised that there would be a winter peak to get through, but with the promise of a vaccine on the way, staff were ready to give one last push to get through to the new year.
The 2022 survey took place in a markedly different context. The nation had faced multiple additional waves of COVID-19, while less severe than those in 2020, the situation facing the NHS had changed. The focus was now on the recovery of elective waiting times, a major priority for NHS England. This impacted patient flow as elective capacity needed to be ring fenced and protected. Staff who had been redeployed to COVID wards were back on their base wards, often understaffed, reflecting a pre-COVID issue but amplified by many of retirement age choosing to leave at that time after such an intense period.
Patients presenting to emergency departments had more progressed or complex pathology because they avoided accessing healthcare during the pandemic. Emergency department flow started to deteriorate as flow into the wider trust became worse, and as a result ambulances started queuing for extended periods outside emergency departments. Flow out of the hospital has also been impacted as care homes became understandably cautious about accepting patients from acute trusts without proof of COVID status. As a result of more entering the system and less leaving at the back end, corridor care (which is hugely unpopular with staff and patients, alike) inevitably returned.
The NHS landscape in 2022 was a very different place to 2020, with systems openly planning to exceed budgets and progress on elective and urgent and emergency care recovery being slow. NHS England has been unsurprisingly taking a more prescriptive approach. However, this has resulted in additional bureaucracy, and removed some of the autonomy generated during COVID-19. A lot of the benefits staff experienced during 2020 have ended (eg, free parking) and recent pay deals have been viewed as disappointing. Public sentiment has slowly shifted from the NHS as saviours and angels to dissatisfaction about waiting times in both planned and unplanned care. The sense of camaraderie and national pride in the NHS has disappeared. Unsurprisingly, this has led to poor survey results and latterly, industrial action.
The staff survey results paint a concerning picture, with declining scores across most NHS trusts and a widening gap between the top and bottom performers. This shows that issues are not confined to a few organisations and points to a systemic problem that requires a collective effort at the local, regional, and national levels. It's time for a shift in focus from local solutions to an integrated approach that reflects on how to rebuild and maintain the sense of pride and purpose that emerged during the pandemic.
Looking at 2020, how does the NHS re-build the “we are all in this together” mentality and sense of purpose all year round? What are the opportunities to rethink how corporate back-office functions can streamline processes to create sufficient capacity to provide frontline teams with information to manage their services while complying with regulatory reporting requirements? How does the NHS consistently demonstrate to staff they are truly valued all year round and not just when there is a crisis? How are more staff effectively recruited and retained?
The forthcoming ‘people plan’ promised by the Chancellor in the recent Spring Budget may offer some solutions. However, the NHS needs to take a multifaceted, long-term view of how to address the workforce issues, developing a plan that places the patient firmly at the centre, and recognises and values the staff as its core asset. By working collaboratively across the NHS, we can build a sustainable and resilient healthcare system that benefits both patients and staff.
