Employee owned NHS providers changing the face of healthcare through higher staff engagement

July 2014. Ministers, politicians and the media have been speaking of the "John Lewis economy" and the role that the employee ownership business model might play in the rebalancing and growth of the UK across all sectors, with the health sector a key part of this.

As more than 200 organisations up and down the country prepare to celebrate Employee Ownership Day (EO Day) on Friday 4th July, the health sector is increasingly accepting that staff engagement – one of the main benefits of the employee ownership model – has clear and important links to clinical quality, patient experience and outcomes.

It is therefore encouraging – as the health sector awaits the findings of the Ham Review into staff engagement in the NHS (due to be published in July) and the first results of the Q1 Staff FFT – to see employee ownership in the health sector increasing. Surrey is a prime example, where two out of its three community providers are now employee owned. And it’s reaping benefits for patients and staff.

Tricia McGregor, a Managing Director of CSH Surrey, says: “We firmly believe that being co-owned means our nurses and therapists are more engaged and care more about the services they are providing, and this means better quality care for our patients and families. 89% of our co-owners say they value working for an employee-owned organisation and 91% are happy to recommend CSH’s healthcare services to friends and family – far higher than the 65% of staff working in the NHS (source: CSH and NHS staff surveys, 2013). Importantly, patients are very positive about our services too, with an average 87% satisfaction rating in surveys over the last year, and an average Friends & Family Test (FFT) score of 94.” (sources: patient and FFT surveys 2013-14).

Nationally, there has been a 10% increase in the number of businesses converting to co-ownership in the last 12 months. Clinicians at First Community Health and Care, Surrey’s other co-owned NHS provider, took the plunge in 2011 when they chose an employee ownership model after devolving from the then PCT, NHS Surrey.

Philip Greenhill, Managing Director, agrees that co-ownership makes a difference to service quality. “We believe there is a strong correlation between our patient experience figures and staff wellbeing. We have been piloting the national Friends & Family Test survey with our community healthcare services for over a year, and our overall patient experience figures are above 4.8 out of 5 each month. We truly feel this is due to our excellent staff and the voice they have as shareholders in our company to make a difference in our local community. Our first results from the staff Friends & Family Test are 4.2 and 4.3 out of 5, which is an extremely encouraging foundation to build on.” (source: FCH&C surveys 2013 – 14).

Staff engagement, which has been measured through the annual NHS staff survey since 2009, is important in the light of the Francis Report. Amid its 1,700 pages and 290 recommendations, paragraph 1.118 says: “The patient must be first in everything that is done: [there must be no tolerance of substandard care]; frontline staff must be empowered with responsibility and freedom to act”.

CSH Surrey believes employee ownership provides it with a way of empowering, engaging and involving its clinicians to continually innovate and improve the quality of its healthcare services. And it appears to be working. Over the last three years its annual survey results have outstripped the equivalent NHS staff survey results in all key areas.

Key results from the 2013 CSH and NHS surveys are shown below. They are grouped into themes associated with staff engagement, which, according to The Institute for Employment Studies (IES), is defined as “a positive attitude held by the employee towards the organisation and its values. An engaged employee is aware of business context, and works with colleagues to improve performance within the job for the benefit of the organisation. The organisation must work to develop and nurture engagement, which requires a two-way relationship between employer and employee.”

Communication/team work

  • 99% of co-owners at CSH say they have a good working relationship with others in their team (NHS overall 79%)
  • 71% feel communication between managers and co-owners is good (NHS community trusts 35%)
  • 93% feel able to raise concerns (NHS 72%)
  • 95% feel part of a team (no equivalent NHS Survey question).


  • 97% of co-owners at CSH understand the contribution they are expected to make (NHS overall 74%)
  • 96% say they know what they are responsible for (NHS community trusts 81%)
  • 100% can see how their work relates to patient care (even if they don’t have direct patient contact) (NHS overall 82%)
  • 92% know what CSH’s strategy is (no equivalent NHS Survey question)
  • 94% understand the vision of CSH (no equivalent NHS Survey question)
  • 95% have a good understanding of the principles and values of CSH (no equivalent NHS Survey question).

Feeling valued

  • 51% of CSH co-owners believe they are fairly paid for what they do (NHS overall 39%, yet on the same Agenda for Change T&Cs)
  • 86% say they have opportunities to feed their ideas upwards (no equivalent NHS Survey question)
  • 74% say they receive regular feedback on their performance, up from 60% in 2011 (NHS community trusts 58%)
  • 96% say their immediate manager considers their ideas and suggestions (NHS overall 75%)
  • 95% say their immediate manager is supportive if they have a problem (NHS overall 67%).

Looking after co-owners’ wellbeing

  • 58% say they have an acceptable workload (NHS community trusts 26%)
  • 70% believe CSH is concerned about their health and well being (NHS overall 46%).
  • 78% are able to cope adequately with any stress they experience at work (NHS community trusts 57%).

As a result, CSH Surrey benefits from highly motivated and engaged co-owners:

  • 94% say they enjoy the work they do for CSH (NHS overall 69%)
  • 89% say they value working for an employee-owned organisation
  • 79% believe CSH is a great place to work (NHS community trusts 53%)
  • 95% believe CSH is genuinely committed to delivering high quality services (NHS community trusts 64%)
  • 91% are happy to recommend CSH’s healthcare services to friends and family (NHS 65%).

Iain Hasdell, Chief Executive of the Employee Ownership Association, says: “Engagement results like this could be replicated across the NHS – as it is in other sectors of the economy – through employee ownership. Proven benefits of the model include increased employee health and well-being, productivity and innovation.

“Nationally, employee owned companies now account for over £30 billion in total annual turnover and 4% of GDP. Importantly, by 2020 we expect employee owned businesses to be delivering £10bn of public services, up from less than £2bn today.”

This is good news for patients and their families, particularly as employee engagement emerges as “the best predictor of NHS trust outcomes”, according to Professor Michael West, Senior Fellow at The King's Fund and Professor of Work and Organisational Psychology at Lancaster University.

The Point of Care Foundation report, Staff Care: How to engage NHS staff and why it matters (2014), expands on this. It states that ‘high-quality, patient-centred care depends on managing staff well, allowing staff to exercise control over their work, listening to what they have to say, involving them in decisions, training and developing them and paying attention to the physical and emotional consequences of caring for patients’.

Dr Jocelyn Cornwell, Director of the Point of Care Foundation says: “It’s the experiences of healthcare staff that shape patients’ experiences of care, for good or ill, not the other way round. Caring about the people who work in healthcare is the key to developing a caring and empathetic health service. More than that, it is the key to finding innovative solutions to the challenges that face the services on which we all depend in these financially straitened times. The evidence is simple: patient-centred organisations pay attention to their staff.”

The Staff Care report follows research from global management consultancy, the Hay Group, into attitudes among public sector workers. Its latest survey in January 2014 revealed that health sector staff do not feel as empowered to do their jobs as those in other areas and say there is a lack of flexibility in their jobs. 

John Howarth, associate director at Hay Group, says: “Both of these may be a consequence of getting leaders and managers to articulate a greater sense of direction to staff and provide them with more clarity on how their roles fit with this and this spilling over into ‘telling people what to do’.”

CSH Surrey Physiotherapist, Nicola Kelly, has worked at CSH Surrey since its then 650 nurses and therapists chose to spin out of the NHS in 2006 and says it definitely feels different being co-owned. “We feel more involved and have more control over our services. This means if we see a problem we have more influence over solving it, so we feel less frustrated and there’s less waste now. It also means clinicians on the frontline can be more creative and have ideas that we can apply effectively to improve our services. I definitely feel more empowered and I think co-ownership has also made people feel more accountability and responsibility. Communications are also a lot better and there’s more transparency.”

Bill Deighton, a patient of CSH Surrey, also feels the difference: “I have received outstanding treatment from CSH over a number of years, and I am extremely grateful and appreciative for the care and professionalism they consistently provide. This is without doubt a unique and first class service.”

First Community Health and Care’s patients agree they offer something different. “Caterham Dene should be used as a model for all other NHS outlets of care and service.  I have visited the centre for various reasons and always been treated with excellence.”

The reason behind the difference in co-ownership companies is nicely summed up in the words of Waitrose’s first media campaign promoting the benefits of employee ownership, which it launched in May this year: “Everyone who works for Waitrose, owns Waitrose. And when you own something, you care a little more.” Rupert Thomas, Marketing Director of Waitrose, the UK’s most well-known employee owned business, says: “The care and service that are the hallmarks of our brand are inextricably linked to our co-owned structure. Because our partners own the business, they are motivated to go that little bit further for customers.”

On Thursday 3rd July, research sponsored by John Lewis and conducted by the think tank Centre for London, will reveal how the UK can promote greater growth of employee owned business locally and regionally. The report, Local Owners, is being launched by Business Secretary Vince Cable and John Lewis Chairman Sir Charlie Mayfield at a special event in London. It argues that policy needs to shift to promoting employee ownership locally and regionally in the wake of important national tax reforms to support the sector. The report includes a challenging set of recommendations which go to the heart of business culture in the UK.

Iain Hasdell of the Employee Ownership Association concludes: “CSH Surrey and First Community Health and Care are great examples of the success and engagement that can be achieved with employee ownership in the health sector. They back up existing evidence that employee owners have higher levels of job satisfaction, feel a greater sense of achievement and job security and are more likely to recommend their workplace than employees in non-employee owned businesses.

“The employee owned sector is growing because co-owned companies tend to be successful, competitive, good to work for and sustainable. Successive governments have promoted employee ownership because they recognise its potential contribution to the economy. As a result, we expect 10% of UK GDP to be delivered by employee owned businesses by 2020.”

On Employee Ownership Day (Friday 4th July), the EOA (Employee Ownership Association) and its 200+ members, including CSH Surrey, will celebrate with over 100 events across the country as they showcase how this innovative business structure is benefiting a new generation of businesses large and small, and is changing the shape of the health sector and the UK economy.