Despite current concerns about the NHS, the Care Quality Commission’s State of Care report for 2016/17 shows that 98% of community trusts, 97% of NHS mental health services, and 97% of NHS acute hospitals were rated ‘good’ or ‘outstanding’ for Caring.

Frontline staff can only deliver such consistently high-quality care for patients if motivated and engaged. The most recent NHS Staff Survey, conducted between September and December 2016 across 316 NHS organisations, shows motivation in the NHS is higher than other public services. Staff motivation scored 3.92 out of 5, staff satisfaction with the work and care they are able to deliver 3.93, and 74% of staff feel enthusiastic about their job. The survey also recorded a small increase in staff engagement score rising to 3.79 from 3.78.

Yet, despite these high levels of engagement, motivation and enthusiasm, staff retention is the biggest workforce challenge facing the health service today. Between 2016 and 2017, 20% more people left the nursing and midwifery register than joined it, according to November 2017 data from the Nursing and Midwifery Council.

According to Ian Cumming, Health Education England chief executive, his organisation’s figures show the main reason for nurses leaving the NHS is “insufficient flexibility” in working patterns. This could be explained by the fact work-life balance is the top factor contributing to lack of satisfaction for doctors and nurses in the UK, Germany, Ireland, Netherlands, Norway and Spain.

Secretary of State for Health Jeremy Hunt has also acknowledged big challenges in retaining NHS staff, stating that inflexible contracts, particularly in nursing, act as barriers as NHS workers now expect flexible working practices.8

Addressing the NHS Confederation conference in June 2017, Hunt said: “One of the areas where we have started to make real progress – but where there is much more to do – is in responding to the changing demands of a modern workforce for flexible working.

“I’ve actually seen some great software and heard from NHS Professionals about the work that they’re doing to make it easy for people to roster themselves flexibly using modern software on their phones. [These are] all the things that people expect in a modern workplace these days.”


Dr Darren Kilroy


A key focus at East Cheshire has been the need to harmonise rostering across all departments.Previously, our e-rostering platform had been in place simply for the nursing staff. It has since spread across all medical disciplines and staffing areas.

We have brought all medical staff together on one system and it’s much more efficient. The system is popular with doctors, but there is still work to do in terms of its wider operational impact in the hospital. That’s the key engagement challenge that involves time and tenacity.

Flexibility versus predictability

There’s an interesting question as to whether flexibility in working patterns is valuable to staff or not. In my experience, many want predictability rather than flexibility.

Flexibility is great if you are a member of bank staff, but the majority of the staff we roster aren’t bank staff and want predictability around which they can plan their lives. You need some fixed points.

The key principle of an e-rostering system should be that it puts doctors in front of the right patients at the right time. There will be variation but you need some predictability in demand.

This ‘care needs first’ principle dictates that you should organise your workforce around predictable demand. That is the essence of our e-rostering platform for nursing.

A high-quality rostering system that accommodates the right staff in a planned way benefits care.

For example, it can help ensure that clinics start on time, and to minimise the number of cancelled clinics. You don’t have to cancel if you can see the relevant staff members are on site and you can redeploy them.

Consistently effective roster implementation demands culture change at scale as well as a fit-for-purpose administrative and technology platform infrastructure.

Dr Darren Kilroy is Deputy Medical Director of East Cheshire NHS Trust as well as the Divisional Medical Director for Planned Care at the Countess of Chester NHS Foundation Trust.

Multi-disciplinary working

For many within the health service, the future of workforce deployment lies in greater use of multi-disciplinary teams to treat increasingly complex, long-term conditions. A view is also emerging about the desire to create employment that gives staff flexibility in terms of the work performed.

Dr Chris Streather, Chief Executive of the Royal Free Hospital, says: “In the long-term we need to look at innovation both in medical careers and creating new roles – having jobs that are traditionally done by doctors done by other people. If we don’t do that we will get into difficulties.

“The elective environments are those where it is safer to try new things in terms of organising the workforce. For instance, we can bring in people who are the surgical equivalents of physician associates. A lot of urgent primary care provided in A&E can be delivered by pharmacists.”


Changing rostering and culture in East and North Hertfordshire NHS Trust


East and North Hertfordshire NHS Trust undertook a flexible working project in an effort to empower frontline staff to take ownership of e-rostering, as the trust believed this would lead to more effective workforce deployment, improved staff work-life balance, and increased productivity. The trust decided to make several changes to its rostering processes during the project, which included:

  • Enabling and encouraging staff to access rosters online via the mobile app
  • Opening rosters to allow 100% of contracted hours to be requested (often referred to as self-rostering)
  • Running educational workshops on how to make the most out of requests – not just requesting days off, but more positively requesting shifts they can work
  • Promoting shared governance and self-ownership of rosters
  • Creating fixed working patterns when this worked for the service and individual.

The trust saw great results from the changes implemented as part of a wider workforce optimisation piece the trust was undertaking. For example, in the medicine division:

  • Online rostering login requests increased by 9%
  • Roster approval lead time improved by over 20 days
  • Temporary staffing usage reduced by 14%
  • Agency usage reduced by 12%
  • Sickness decreased by 3%
  • Care hours per patient day for substantive staff increased, which meant there was a reduction in the need for temporary staff, without compromising patient care.

Prior to this project, most conversations about rostering happened at a strategic level, because of the need to control approval lead-time and look at annual leave management. But by engaging matrons and ward managers, where most of the interaction about staffing occurs, the trust was able to get frontline staff to own rostering. This has introduced a shared governance approach to the way the trust rosters. To support this change, roster approval is possible at eight weeks and staff can now request all of contracted hours, resulting in an increase in employee online usage.

  • Changing the rostering process also brought about culture change, which has helped create an environment for sustained organisational learning in relation to rostering. A recent independent audit of the service noted the collegiate nature of staffing meetings.

    The trust’s advice on creating a cultural change in rostering is:

    • Find a story to focus all effort on that everyone can buy into, such as improved care quality and productivity
    • Highlight the fact that e-rostering is an integral clinical tool and is a support service, so the data and processes should be clinically owned and driven
    • Engage frontline staff through coaching, to ensure staff understand how to get the best out of the system
    • Ensure the roster team understand the challenges the organisation face
    • Operationalise rostering and reduce the administrative burden on clinical staff, as this can make a real difference in delivering patient care by freeing up time
    • Make e-roster play a key role in staffing meetings – put it first on the agenda
    • Empower the front line; create ownership of work-life balance and service delivery.


Alan Duffell


A key point to understand when implementing an e-rostering system is the need to prepare for the unusual customs and practice that almost inevitably emerge from the woodwork.

While the system upgrade at Leicestershire Partnership brought increased fairness, openness and transparency to the way in which the workforce was organised, it also raised staff concerns as a result of that transparency.

An example – one individual would always leave at 3pm because they had childcare commitments. As far as people could remember, this individual had always made sure they finished at 3pm and was always rostered to leave then to look after their child.

After some digging, it was identified that the young child was now well into their twenty’s and in full employment. So, managers clearly haven’t kept things up to date. Therefore, one of the areas we had to focus on is that managers need to be up-to-date with workforce arrangements.

So, while it is possible to adjust to individuals’ working arrangements, there will always be a need to review them at regular intervals.

Interestingly, we didn’t encounter any real push back at all from staff-side trade unions throughout the process of shifting towards e-rostering. This was because these changes were presented to the unions on the basis that everybody would be treated fairly and equally. The system does not discriminate – it splits work around fairly.

Many of managers argued that the ‘give and take’ when it comes to arranging staff working patterns isn’t there because the system doesn’t allow it to be built in. But the system will do whatever you tell it to do. We just need to manage it.

A chief nurse had the ability to run a report to check who gets more school holidays off than anyone else, who’s always worked Christmas, and who hasn’t. Some work patterns may be choice – but moving to the software did throw up a whole range of anomalies that we just hadn’t foreseen.

So, the technical information is one thing, but it’s important to get systems and processes working. It’s changing the cultural element but also looking at the leadership element.

As a worker, if you give me the opportunity to change my hours for nine months because I want certain personal leave arrangements, you have to review the situation after nine months. Nine months shouldn’t become 19 months, nine years or longer, without any review.

Alan Duffell joined Royal Wolverhampton NHS Trust as Director of Workforce in April 2017.

Prior to this Mr Duffell was Director of Human Resources and Organisational Development at Leicestershire Partnership NHS Trust for five years