Staff surveys, both past and current, have all shown degrees of disengagement between staff and the organisation. Media coverage of the NHS tends to highlight the shortcomings of staff in their care and attentiveness towards patients. Other coverage paints the doom and gloom scenario of the economic climate, with which we are all familiar.

The NHS doesn’t seem a happy place. Yet, it must be the case that the vast majority of staff and patients interact with each other in a way that restores the health of patients.

Now the Mid-Staffs review is about to be published. This review has arisen because of the use of data that highlighted a number of patients who may have died unnecessarily or prematurely. The work of Dr Foster, the organisation issuing information about how the NHS is functioning, has been brilliant. Earlier work by John Yates was also brilliant in highlighting variations in outcomes of care by clinicians. My own work in the 1980′s provided some standards and policy guidelines against which measurement was made; prior to this period there was virtually nothing other than standards issued by voluntary organisations with special interests, and the Colleges.

Now there is an industry built around accreditation, monitoring and validating what people do in the NHS. The NHS seems to have followed the developments in the USA, Canada and Australia where this type of industry pre-dated the developments in the NHS by some years. The question has to be – has any of this industry made any difference to the care and standards that govern the delivery of healthcare?

There are two aspects of the interest in measurement that I find particularly interesting personally. One is the setting of standards themselves – who does it, what are they and do they directly link to improved or positive outcomes for patients? In other words, if the standards, and their related protocols, were followed, would they inevitably result in improved patient care?

The second aspect is related directly to the self interest of staff, particularly clinical staff.

I make the assumption that these staff are highly skilled, motivated to achieve the best for their patients and other clients, and have a self interest that is related to their imperative to do the best for their patients. Obviously there are shades of interest. I remember well discussing how my father could tolerate seeing 50 to 60 patients in outpatients – what kept him going? I discussed the same with my brother. What motivated them? Apart from the overt gratitude and relieved faces at receiving attentiveness to their plight, which is warming, both were on the look out for the harder to diagnose cases. In a batch of patients there was nearly always one that required the use of their clinical intelligence, perception, and reservoir of experience. Both didn’t often refer their patients on to others, unless it was obvious the case was beyond their expertise. Both delivered their services in the context of clinically determined standards. The buck stopped with them.

Things are different now. The massive industry surrounding the setting and monitoring of standards may have the impact of diluting personal responsibility. It is part of the human condition to baulk at having to do something that we feel isn’t helpful. all forms of rules and regulations create an adverse response unless they are viewed by us as being helpful, sensible and worth applying. If the NHS produces better outcomes now than without the introduction of the standards industry then this would be testament  to the validity of overtly stated standards.  Alas, the NHS appears to have slipped down the international league table of improving outcomes across the board.

We are, no doubt, going to have more rules and regulations as a result of the Mid Staffs Enquiry. Will this improve the outcomes for patients? Probably, but from a low baseline that started to slide since the standards industry was established. In other words, be are piling another set of standards on a previous set that probably had the damning impact of dis-engaging staff from taking responsibility in the first place.

I personally like the approach on ‘comply or explain’ in relation to standards. My own Manager’s Code, developed to introduce a means of changing behaviour of managers to adopt those behaviours that provoke commitment, trust and engagement, was and is an enabling Code. One that requires managers to comply or explain; not one that condemns managers who deviate from the code, but one that seeks to engage managers in explaining why they do not follow the behaviours suggested.

I believe such an approach will produce a shift back to individuals taking personal responsibility for their actions, and be seen as enabling improvement rather than being seen as regulations that provoke a negative and possibly hostile reaction.

But there has to be more to it than a simple shift of emphasis.

The fundamental challenge in the NHS is the conflicting ideologies of the professional and the bureaucrat. The professional is concerned for the individual, whilst the bureaucrat is concerned for all individuals. Efforts over the years to blend the ideologies together within the umbrella of the NHS have had some success, but we know from the Mid Staffs situation that it is three professionals in a bureaucratic role who are selected to be interrogated further by their professional bodies. The initiatives often called clinicians in management have been seen to be a way of engaging clinicians in the management of services. It works elsewhere, notably in the USA where there has been a much longer lasting culture based on the commercial imperatives of the health services, something the NHS hasn’t had. It is time, I believe, to call a halt to this form of blending the ideologies and to think again.

My own belief is that people who are self employed have a very intense focus on personal responsibility, and are passionate about being custodians of professional standards within a professional framework often described as a Code of Conduct. We see this amongst independent social workers, independent psychologists, general practitioners and many others outside the healthcare industry. It’s not the answer to everything, of course, as there are thousands of employed staff who, also, keep their heads down and focus on delivering extremely high standards. But, there is an imperative that drives professional staff to deliver high standards when they stand on their own, and have to comply or explain their actions in relation to a Code of some kind, as opposed to following standards and protocols that diminish their capacity to exercise discretion.

So the NHS could be staffed in two ways. Staff who are inclined to work within defined protocols, and staff who are inclined to work under a Code or Codes of Conduct. The former group could be employed, as they can easily be held accountable for the delivery of protocols, whilst the latter group could be self employed, in constant danger of losing their income if they do not comply or explain their actions adequately under a Code. Enabling Codes facilitate the use of professional discretion, and provide the space for innovation, development and lateral thinking, so long as actions can be explained. This plays directly to self interest of professionals who are driven to do the very best they can for their patients and clients.

Currently I don’t see the NHS as facilitating professional self interest as part of its mainstream activities. It seems to be facilitating bureaucratic self interest. In this respect the NHS does seem to be letting its staff down.

My new strap line for wellbeing and performing organisations is ‘alert, animated and accomplished‘ - alert, being alert to opportunities by horizon scanning and being engaged with customers and clients; being alert to risks and threats and responding to them in advance of anything that becomes too detrimental. - animated – buzzing with innovation, inquisitiveness, attentiveness, and energy. – accomplished – doing things effectively and successfully; implementing actions in the best way to achieve the results being sought; building a track record of getting things right.

These are key features of a resilient organisation, one that is capable of  ’bracing themselves’ for shocks and challenges and dealing with them without diminution of their performance; one that is responsive to internal and external pressures for change, and is adaptive, capable of renewal, and experiences corporate efficacy – knowing they can achieve what they set out to do.

The strap line can be used to summarise what we are trying to achieve with organisations; we are trying to help them to be alert, alive and accomplished as the route to strong wellbeing and peak performance.

The Management is the controlling force in organisations, and managers are key to achieving peak performance from the workforce.

The Manager’s Code describes the behaviours that provoke commitment, trust and engagement between The Management and The Workforce.

The purpose of a Code is to provide a tool than enables all managers in an organisation to follow the same behaviour requirements. The Code may also be used to assess the behaviour of managers by testing their behaviour against each of the behaviour elements.

The Management Standards for Wellbeing and Performance (previously known as The Management Standards for a Healthy Organisation) amplifies The Charter for Wellbeing and Performance by providing greater detail on each of the elements that help organisations achieve high level psychological wellbeing for all staff, which, in turn, provokes peak performance to be achieved on a regular basis.

The Management Standards cover purpose, architecture, rules and behaviours – the ingredients for a peak performing culture.

The processes involved in transforming organisations from one state to that of being a high performing organisation based on the high level of psychological wellbeing of the workforce requires several stepping stones to be carefully placed along the pathway to change.

One of these is to agree between The Management and The Workforce a common understanding and common expectations of what the ‘new’ and transformed organisation looks like.

One way of doing this is to agree a Charter, or, as some organisations describe them, a Credo, Mission Statement or Corporate Values.

A Charter for Wellbeing and Performance contains the ingredients required to achieve high level psychological wellbeing and peak performance. Our Charter is on one side of A4 and can be displayed physically to remind everyone of the mutual expectations placed on both The Management and The Workforce. The Charter may be used as an agenda for every manager meeting, so that the cultural elements are routinely reinforced and embedded into the daily routine of the organisation.

Implementing actions within The Wellbeing and Performance Strategic Framework requires an agenda.

The Wellbeing and Performance Agenda is a step by step systemic approach to the primary prevention of psychological distress at work, which, at the same time produces high degrees of psychological wellbeing and provokes peak performance. Preventing the events that may cause stressful responses has the added value of improving performance, massively.

The agenda is constructed around the need to address:

• The culture
• The management
• The working environment
• The resilient person

The culture, The management and The working environment are all to do with the context within which people are expected to work, whilst The resilient person is about the individual who is working in that environment.

The approach to preventing stress and promoting psychological wellbeing and performance is systemic. All four of the ingredients to achieve wellbeing and performance need to be addressed; addressing one will result in limited impact.

A preliminary activity is to undertake an assessment of the workplace and the workforce. this is a process of Discovery – discovering the current state of play. This can be used as a benchmark to measure improvements arising from interventions to improve psychological wellbeing and performance.

The Wellbeing and Performance Group provides all the expertise required to implement The Wellbeing and Performance Agenda.

There’s a lot going on in the field of health and wellbeing. Government initiatives including The Responsibility Deal with its focus on public health; the British Standards Institute with the PAS 1010 with its focus on psycho-social risks at work; the numerous studies and reports that show more presenteeism and more psychological presenteeism; the studies that are focusing on manager behaviours and the triggers for strong workplace engagement. The question is – how does it all fit together and to what end are all these initiatives intended to achieve?

As the founder of The Wellbeing and Performance Group I have been making clear the links between psychological wellbeing and performance, and the need to focus on issues of health, wellbeing and their impact on performance – that health and wellbeing without a purpose other than to improve health and wellbeing is unlikely to have the impact on the workplace that we know can be achieved if the message was a little different.

Psychological wellbeing is about feeling well. Performance at its best is achieved when we can concentrate on thinking and performing tasks. The workplace is a controlled environment that can help both the psychological wellbeing of individuals and the creation of the context that provokes concentration.

So where do the HSE Management Standards, PAS 1010, The Responsibility Deal, the studies on manager behaviour and a host of other studies, fit?

The Wellbeing and Performance Strategic Framework has its origins in 1990 as a strategic framework developed by me to help health authorities in the Republic of Ireland work out how they could develop health services. The framework has been used constantly since then, and appears in print in the appendix to New Ways of Working for Applied Psychologists, as the framework for applying psychology.

I now use it to help all types of organisations assimilate their own initiatives with national initiatives with what they should be focusing on – the improvement in psychological wellbeing to achieve peak performance in individuals as well as their organisation.

The improvement of psychological wellbeing requires the prevention of stress having a disruptive and diverting influence on individuals. This is made possible by addressing the prevention of stress from two ends – the context within which people work, and the degree of personal resilience to adverse and challenging events.

The Wellbeing and Performance Strategic Framework, therefore, has, at its core, the prevention of psychological distress at work – this means preventing the events that trigger possible stressful responses.

However, we all experience degrees of stress, some being the stimulating end of the spectrum, others at the disabling end. A strategy needs to prevent individuals from deteriorating once they experience the beginnings of strain and stress. A strategy that intervenes immediately anyone begins to experience strain and stress will enable the person to regain personal control and revert to performing at their best. Almost all stress management programmes have the prevention of deterioration as their aim, as almost all stress management programmes start with the assumption that people in the workforce will suffer stress. The Wellbeing and Performance Strategic Framework places an emphasis on preventing the events that may trigger stress, and, therefore, is founded on the assumption that stress can and is preventable at work. There is a massive cost in waiting for people to become stressed. Surely it is better to prevent people waiting to become stressed and turn that time into activities that provoke high level psychological wellbeing producing peak performance?

Not all people who begin to experience the symptoms of strain and stress can be prevented from deteriorating. The support networks may be inadequate or the individual may, simply, be continuously exposed to the trigger for their stress response. Whatever the reason, people who deteriorate often find themselves needing to escape from the context of their stress, and to find the time and mental space to regain personal control so they can return to work in the future. The processes involved in helping someone back to work are not straightforward. The restoration process requires adaptation and flexibility on the part of the organisation as much as the individual.

Sometimes those who deteriorate and escape from work cannot recover personal control. They need to be cared for outside the workplace. However, work, of any kind, is known to enhance psychological wellbeing, and it is important for people in this situation to undertake meaningful activity, if only to bring meaning back into their own lives and strengthen their psychological wellbeing. Organisations that have been a party to someone’s chronic stress condition need to provide the means to enable the person regain personal control even if that control prevents them from returning to their original place of work. The person needs some form of purposeful activity.

The final aspect of the framework is a return to the primary prevention element. Once an organisation has implemented the requirements for preventing the events that may cause stress in people there is a need to sustain the culture, manager behaviours and working environment that prevent events from occurring. For reasons, probably associated with selfish self interest, being concerned for the psychological wellbeing of others as a means to achieving peak performance for everyone can easily become eroded by changes in managers and leaders. Therefore, it is essential that the positive cultures, behaviour and environment that achieves great performance with high levels of psychological wellbeing is sustained purposefully.

So the Wellbeing and Performance Strategic Framework is:

• Prevention
• Prevent deterioration
• Restoration
• Palliation
• The next generation

I live in the company of two blondes. On a good day they are Golden Retrievers; on bad days they resemble dirty Black Labs. I spend a lot of time walking them. This morning it occurred to me that there is some connection between walking my dogs and leadership. At its simplest, leadership is taking a lead. Slightly more complex is leadership being a process that inspires someone to do great things, who, in turn, inspires others to do great things.

The connection between dog walking and leadership seems to me to be in the use of a lead. For unruly dogs the lead is used tightly to keep the dog under control. The shorter the distance between the walker and dog the more control is being exercised. For dogs who are reasonably well controlled the distance between walker and dog may be lengthened, although the dog may still be on a lead, just in case the dog decides to do something inspirational. Under some circumstances the lead may be replaced with these long extension leads, for use when the walker isn’t quite certain that the dog is controllable, but the circumstances of the walk suggest the dog should be able to roam, be inquisitive, innovative, exploratory, but only when the walker allows this to happen. A sharp tug on the lead can rapidly draw the dog back to being next to ‘Master’.

Only when dog is compliant, well trained, well behaved and amenable to command will a lead be dispensed with. The dog will walk at heal, be allowed to roam at large, but on command returns instantly to ‘Master’ – a good, compliant and and obedient dog. The reward is freedom from the lead.

Now, let’s see if any of this rings bells for human leaders and human followers, especially, but not exclusively, in the public sector.

We had a hugely successful mini-workshop last week on Measuring Wellbeing and Performance with an audience of nearly 80 on  Thursday afternoon in London. Bridget Juniper led us through how to cost health, cost presenteeism and establish the return on investment of interventions. I chatted about the steps to be taken to introduce and sustain wellbeing and performance at work. We’ve had some excellent comments and feedback that makes us feel great – in fact, makes us feel psychologically well!

I have now put together a revised paper on The Wellbeing and Performance Agenda, setting out the problems we confront in changing the attitudes and culture in favour of an environment that provokes people to feel well. The biggest problem as I see it is organisational amnesia – a condition that forgets that organisations are made up of people, and therefore forgets to place at the front of any queue the requirements for the workforce to function at peak performance levels. Next is the problem of selecting the strategies of change that dis-engage people rather than engaging them. Next is the problem of all the impediments to performance that managers’ have a hand in – such as poor computing where people have to wait a long time for the wretched thing to boot up, or you need endless passwords that never seem to work, or a help desk that doesn’t help. All these problems deflect the mind away from concentrating on work, and produce under-performance, and the phenomenon call psychological presenteeism – being present but mentally absent from concentrating on work.

The solutions have to be systemic in approach. Fixing one aspect of the organisation cannot compensate for not fixing the others; they all have to be fixed.

The culture needs to be one that provokes commitment and trust between everyone, as this raises the levels of psychological wellbeing in people. The culture has to be focused on peak performance as well. The combination of feeling well and being focused on peak performance creates a buzz that is infectious. This is a ‘will do’ culture, but having particular regard to the triggers that make people feel psychologically well, so no boasting, no aggressive talk, no humiliation,no domination, no oligarchy,  no bullying, no targets that drive, but loads of encouragement, challenges, feedback, discussion of the un-discussable, mutual expectations, important and strong relationships, celebrations, individual support and development , polyarchy, and everyone having joint responsibility for success.

Leader and manager behaviour should be persuasive without causing distress – seductive in other words. These guys are the controllers of everything, they hold the authority to spend money. They need to share responsibility for success and are pivotal in sustaining a culture of positiveness and encouragement. It takes special people to be brilliant leaders and managers, not everyone can do it, so care in recruitment is vital.

Getting rid of the impediments to performance. There are groups of impediments – nutrition, exercise, ergonomics, IT, and manager processes. Each need to be focused on making it impossible for the workforce not to concentrate on their work. The nudge principles of Thaler and Sunstein come to mind; nudging everyone to peak performance.

The last part of the wellbeing and performance jigsaw is personal resilience, the contribution the individual makes to peak performance. Aside from being appropriately skilled and with the knowledge and experience to do the work that is expected, there is a need to have a robust attitude towards oneself, events and other people so that when challenges arise they can be dealt with without any diminution in peak performance.

Each element of The Wellbeing and Performance Agenda needs to be applied to every organisation everywhere. I can help!

Measuring the Impact of Well-Being on Performance at Work

Do you know how the well-being of your workforce is affecting the performance of your organisation?

Are you struggling with how to measure the well-being of your employees?

Do you have the right data to guide your thinking?

Can you confidently justify your programme?

Are you clear about the results you want to deliver?

Our unique, half day, low cost workshop in central London entitled Measuring the Impact of Well-Being on Performance at Work will give you the tried and tested, practical basics to build the case for employee well-being.

Divided into three sessions, the workshop will enable you to:

1. Calculate the real costs of impaired health in your organisation; we will show you how to get to a number that is accurate and gets the attention it deserves.
2. Pull together existing information on health and wellness in your organisation to help quantify well-being levels that will inform your plans going forward
3. Review your current approach; learn about the key elements of an effective employee well-being programme so you can take an objective view on existing activity, hold on to the good stuff and can set about adjusting the rest.

You will learn how to combine measurement, costs and outcomes in one practical session so you can really get the most out of happy and healthy staff.

The session will be led by Professor Derek Mowbray of MAS and Dr Bridget Juniper of Work and Wellbeing.   Frustrated with existing approaches, they have designed this exclusive workshop based on their research, best practice and hands-on experience of well-being programmes that really work.

Details for the workshop are as follows:

Visit our website to book your place and for further information about the workshop. To discuss running the session in house, contact Barbara Leigh at barbara.leigh@mas.org.uk or call on 01242 241882.

You will find a number of articles by Dr Bridget Juniper around the topic of employee wellbeing in the section headed Leading and Managing for Wellbeing and Performance in our article library.

Hope to see you there.

The MAS Team