The Impact of Covid on Employee Morale in NHS England
NHS England recently published the annual staff survey results for 2023. This post provides an overview of trends in employee morale and its contributing factors.
Introduction
Every autumn, all NHS employees in England are encouraged to participate in the NHS Staff Survey. The survey offers a snapshot in time of how people experience their working lives, gathered at the same time each year. Since 2021, the survey questions have been aligned with the NHS People Promise in order to monitor progress towards the goal of collectively enhancing the working experience within the NHS.
Between September and November 2023, over 1.4 million NHS employees in England were invited to take part in the survey, with 707,000 employees providing responses. The most represented occupation group was Registered Nurses and Midwives who contributing 196,000 responses. It should be noted that primary care is not included in this survey so General Practitioners and their staff are not covered in this article.
The staff survey asks 87 questions, the responses to which are compiled to yield seven summary indicators known as the 'People Promise,' as depicted in the subsequent graphic.
The survey results are also aggregated to provide insights into two further key areas: Staff Engagement and Employee Morale.
The remainder of this article will focus on Employee Morale but further analysis of the survey can be found at either of the following two links:
Summary
Covid has had a significant impact on employee morale in the following ways:
Morale was on the rise before the onset of Covid in 2020, when it reached its peak.
In the two years following the onset of Covid, morale declined and hit its lowest level in 2022.
Employee morale improved in 2023, reaching levels comparable to those of 2019, yet it still did not reach the heights achieved in 2020.
The primary factors influencing employee morale trends were the sub-themes of ‘Work Pressure’ and ‘Thinking of Leaving’, which were significantly affected by Covid.
The question which most significantly influenced the 'Work Pressure' sub-theme was 'Did you have enough staff to do your job?', while the question that had the greatest impact on the 'Thinking of Leaving' sub-theme was 'How often have you thought of leaving the organisation?'
Employee Morale
Employee morale is an aggregate measure based on the response to thirteen questions. These questions cover three broad areas which are 'thinking of leaving’, ‘work pressure’, and ‘work stressors’.
The following chart shows the trend in the aggregate measure of employee morale from 2018 to 2023.
Interestingly, morale reached its peak in 2020 as the NHS rose to the challenge of Covid's emergence, bolstered by strong public support. However, over the subsequent two years morale levels fell. Given the tough economic environment, the lingering impact of Covid on hospitals, and the relentless effort needed to tackle care backlogs, a decline in staff morale during this time was likely to happen. In 2023, employee morale improved and is now the same as it was in 2019.
The next chart shows the performance trend between 2017 and 2023 for the three areas that contribute to overall morale. To maintain consistency with the morale score, the higher the value the better the performance.
With the advent of Covid in 2020, the scores for 'work pressure' and 'thinking of leaving' reached unprecedented highs, while the score for workplace 'stressors' remained relatively unchanged.
At first glance, the improvement in the 'work pressure' score for 2020 seems paradoxical. After 2020, both 'work pressure' and 'thinking of leaving' scores deteriorated, reaching all-time lows by 2022 before recovering in 2023. In the following sections, we will delve into the specific survey questions that shaped these trends.
What is shaping the ‘Work Pressure’ trend?
Three questions are used to determine the 'work pressure' score. They summarize whether staff have adequate supplies to perform their duties (represented by the blue line), if they can reconcile conflicting demands (indicated by the green line), and whether there is sufficient staffing (shown as the red line).
The chart shows that the main reason for the improvement in the ‘work pressure’ score during the first year of Covid was that more employees (38.4%) reported there was enough staff for them to do their job properly. This probably reflects the positive effects of flexible work arrangements and redeployment during the pandemic, the reinforcement from returning professionals and expedited student involvement in the COVID response, and reductions in elective and emergency attendees.
In the two years after the on-set of Covid, the percent of employees who said there were enough staff dropped significantly to there lowest levels ever. This almost certainly reflects the pressure to catch-up on the backlog, the on-going burden of Covid, and higher levels of staff absence exacerbated by Covid.
In 2023, the percent of employees reporting that there were enough staff showed an improvement and is now at a similar level to 2019. Perceptions of adequate staffing levels improved across all types of trust, while the proportion of staff working in Ambulance Trusts who feel that there are enough staff at their organisation is now 9 percent higher than in 2021. This suggests that the investment initiatives to support NHS recruitment are beginning to take effect.
Finally, a separate question that relates to ‘work pressure’ asks employees if they feel burnt out because of their work. This question was added in 2021 to assess the impact of Covid on the workforce. The next chart shows the percent of employees for the main staff groups who say they always or often felt burnt out because of their work.
In 2021, the year that followed the emergence of Covid, 35 percent of employees reported always or often experiencing burnout. This figure decreased slightly to 34 percent in 2022 and further declined to 30 percent in 2023. Ambulance workers have consistently reported higher than average levels of burnout; however, this group has seen a notable reduction of 7 percent this year. Moreover, improvements have been observed this year among other staff groups, including registered nurses, midwives, and nursing and healthcare assistants.
Despite these improvements, Saffron Cordery, deputy chief executive at NHS Providers remarked in response to the survey findings that …
“Work-related stress also continues to impact a significant proportion of staff. The cut to national funding for staff wellbeing hubs is hugely disappointing as it takes away vital mental health support.”
The questions driving the ‘Thinking of Leaving’ trend.
Previously, we saw a significant improvement in the 'thinking of leaving' score in 2020 coinciding with the onset of Covid, followed by a decrease over the next two years. In 2023, the score improved yet remained slightly below the pre-Covid figures.
Three questions drive the trend behind the ‘thinking of leaving’ score. They ask if staff are thinking of leaving, looking for a new job, or will leave as soon as they can find another job. The following chart shows the percent responding negatively to these three questions between 2018 and 2023,
The chart illustrates a steady improvement in the responses to all three questions, culminating in the best performance in 2020, the year Covid started. The improvement in these responses is most likely due to the public’s acknowledgment of the crucial role NHS staff played during the first year of Covid. Additionally, the scarcity of alternative employment opportunities due to the economic downturn likely contributed to this trend.
Worryingly, the trend took a negative turn in 2021, with responses to all three questions worsening, culminating in 2022 with the poorest responses on record. This issue was especially pronounced among ambulance trusts, where 48 percent of staff reported they often thought about leaving in 2022. The factors contributing to the increased consideration of leaving among staff are many, but burnout and the perception of inadequate pay in the face of escalating living costs are likely significant contributors.
There is good news with signs of progress showing in 2023, indicated by a 3 percent reduction in the number of employees often thinking of leaving. Nevertheless, these figures are still high and exceed the pre-Covid levels.
As previously mentioned, satisfaction with pay has been a prominent issue over the last 18 months, with NHS personnel striking for better pay, often for the first time. The following panel chart shows how satisfaction with pay has changed from 2018 to 2023 for the main staff jobs.
Before the Covid pandemic, the general satisfaction with pay was consistently low, except for the medical and dental staff (primarily consisting of doctors), who expressed higher satisfaction. However, in the two years after the emergence of Covid, there was a noticeable decrease in pay satisfaction, with doctors experiencing the most significant drop. The failure to reach pay agreements in 2022 led to unprecedented industrial action in 2023 from ambulance staff, nurses, and doctors. In 2023, pay agreements were successfully established with ambulance staff and nurses; however, at the time of writing, the dispute over doctors' pay continues.
In 2023, there was a slight improvement in overall pay satisfaction, yet it remained low and did not reach the levels of 2019. The only exception was doctors, whose satisfaction with pay continued to decline due to their ongoing pay dispute.
In Conclusion
The initial impact of Covid on employee morale was positive, reaching a peak in 2020. However, morale sharply declined in the two years following Covid's onset, driven by high levels of 'Work Pressure' and an increase in staff 'Thinking of Leaving'. In 2023, these two factors saw improvement leading to better morale, but it has not yet returned to pre-Covid levels.
I’ll leave the last word to Saffron Cordery, deputy chief executive at NHS Providers, who concludes ….
"Given the context of a challenging economic environment, severe staff shortages, ongoing pressures to tackle care backlogs and widespread industrial action, it is worrying, but unsurprising, that staff morale and wellbeing remain low. It is positive to see areas of improvement, such as an increase in staff reporting that their organisation takes positive action on health and wellbeing but it is important for further progress to be made.”