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Why does this review deserve the spotlight?  

As part of the Health Foundation funded Efficiency Research programme, researchers from the University of Sheffield reviewed publications from 2004–2020 to explore what factors affect staff retention in adult mental health services. This caught my interest, as the factors included the vital but often overlooked issue of staff involvement in policy development.  

Back in the days of the Healthcare Commission’s Annual Health check, I worked as part of a mental health clinical governance team. We spent hours ensuring we not only had the right policies in place, but also the audits that told us whether practice followed policy. This experience taught me the value of involving staff in policy development. Not simply to tick a compliance box, but because of the difference it made to people’s levels of commitment, and to the improvements in care quality that followed. 

By chance, I also read this Efficiency Research programme synthesis within the same week as I read the recently published NHS Long Term Workforce Plan. I couldn’t help but wonder if the authors of the workforce plan had read this review. I concluded they hadn’t. Besides chiming with my own experience, unfortunately the synthesis underlined what was missing from the plan.  

Of course, the Long Term Workforce Plan covers a much wider range of staff groups. But mental health services potentially offer a useful case study. As the plan acknowledges, these services often have higher staff turnover and more vacancies. And staff face particularly challenging issues due to the nature of the care they provide (such as monitoring risk of suicide), and experience reportedly higher emotional exhaustion than colleagues in emergency settings.  

What did the researchers do? 

The researchers conducted a realist synthesis. This is a method that aims to use literature and people’s views to develop theories explaining why interventions work (or don’t), how they work and in what contexts. A realist synthesis aims to tell us that if we do something in such a way, then these actions will follow, which will lead to these outcomes.  

The researchers undertook the review in three ‘hybrid’ phases, combining more traditional methods of literature review with the collation of people’s views: 

  1. They carried out exploratory scoping of relevant literature, alongside workshops with staff from mental health teams. These were then used to develop preliminary theories. 
  2. They conducted a formal literature search and extracted relevant data. 
  3. They analysed and synthesised data, refining theories and developing a logic model. 

What did they find out? 

The review generated three interconnected theories, which tell us that successful staff retention starts with organisational culture and needs to consider:  

  • workload - if staff experience high workload, then they will feel they have to deliver lower quality care to manage time demands 
  • staff investment - if organisations invest in training, development and supervision, then staff will feel more confident to deliver higher quality care 
  • staff input - if staff shape the development of policies and practice, then they will feel valued and supported to work autonomously.  

All of these aspects impact on a person’s wellbeing, their sense of connection to an organisation and ultimately their job satisfaction.  

What’s valuable about this review, is not only that it enhances our understanding of retention, but it generates a whole systems perspective. A perspective missing from the workforce plan. 

What does this review tell us about the NHS Long Term Workforce Plan? 

The workforce plan does pick up some of the individual factors identified by the review. For example, one of the sections in the plan is entitled ‘train’. However, this section just focuses on growing overall numbers of staff. The importance of investing in people throughout their career, as emphasised in the review, is less apparent.  

Likewise, the plan acknowledges the significant workload issues for staff working in mental health settings. However, it fails to acknowledge the interconnectedness with quality of care, instead focusing on simplistic solutions such as increasing staff and creating new roles. The authors of the workforce plan seem to have missed the key point this review underlines: simply recruiting more staff is only one part of the picture. We need to keep hold of the staff we already have. 

When retention is discussed in the plan, it points to existing guidance. And yet, as others have pointed out, this doesn’t go far enough to tackle potential new issues caused by the disruption and burn out of the pandemic. 

The third factor for successful retention in the realist review, staff input in policy development doesn’t even get a mention. The nearest the plan gets is a section entitled ‘we have a voice that counts’, but the way to ensure those voices count is effective communication mechanisms, making ‘better use’ of national survey tools and a vague reference to ‘employee engagement metrics’.  

Unfortunately, the workforce plan seems to have missed the review’s central point, best summed up in realist terms:  

  • if workforce planning enabled a whole systems approach to tackling retention, starting with organisational culture, including staff input and investment and ensuring manageable workloads, 
  • then quality of care would increase and staff job satisfaction would improve, 
  • leading to better staff retention.  

There is much to be positive about in the NHS Long Term Workforce Plan, including the call for parity of esteem between physical and mental health.  

And yet not only does it seem that the authors haven’t read this realist review, it seems as if they have forgotten the lessons from the Healthcare Commission’s Annual Health Check, which established the interconnectedness of staff involvement, turnover and the impact on quality of care.  

This realist review not only makes me think of long hours spent on Healthcare Commission annual returns, but reminds us all that simply increasing staff won’t be enough, we need to give them a say to make sure they will want to stay. 

Justine Karpusheff (@JKsheff) is Assistant Director of Research at the Health Foundation.

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