Executive summary

Purpose of this report

This report provides a summary of the evaluation and engagement work covering the first two years of health and wellbeing guardian policy implementation. Analysis of this work offers recommendations to help shape the future evolution of health and wellbeing guardians throughout the NHS.

To be consistent with the wider updated guidance document and appendices, the previous title of wellbeing guardian will be referred to here by the updated terminology of health and wellbeing guardian.

Background

Health and wellbeing guardians were established in 2021 as an ambition within the NHS people plan. They are senior leaders who act in an assurance capacity to hold organisations and board level leaders to account for growing a proactive and positive health and wellbeing culture for our NHS people and to deliver our NHS people promise.

Evaluation approach

NHS England have combined three main evaluation approaches to understand the early adoption and short-term impact of health and wellbeing guardians since launching in 2021, including:

1. Tracking adoption of health and wellbeing guardians in NHS organisations.
2. Engagement with health and wellbeing guardians through networks and community engagement events, peer support, a journaling platform and wider activities that provided experiential feedback.
3. Formal research exploring early impact of health and wellbeing guardians using an external evaluator during the first year of implementation.

Adoption of health and wellbeing guardians

• At the time of publishing this report, 96% of NHS provider organisations including acute, community, mental health and ambulance trusts report having a health and wellbeing guardian in their organisation.
  • Commissioning organisations were also engaged; however due to ongoing change, integrated care boards (ICB) – previously clinical commissioning groups (CCGs), reported difficulty in adopting and reporting on health and wellbeing guardians during this period.
• Adoption of health and wellbeing guardians in provider organisations was tracked periodically throughout the first two years of implementation. Since initial implementation this has maintained a figure of around 95%.
  • This figure has constantly varied due to changes of people in post (for example, health and wellbeing guardians retiring or changing roles).

Learning from engagement with the health and wellbeing guardian community

• The approach taken to create health and wellbeing guardian networks has resulted in their collective voice positively influencing the national health and wellbeing agenda.
• Health and wellbeing guardians have reported how they are acting as the strategic champions for improving the health and wellbeing of their employees.
• Health and wellbeing guardians have shared challenges associated with trying to influence strategic prioritisation of the health and wellbeing agenda, often due to competition with wider organisational performance, assurance, quality, and financial factors.
  • Limited health and wellbeing data has further compounded this and health and wellbeing guardians’ ability to effectively take forward the strategic assurance aspects of their function.
• There is an opportunity to broaden the framing of the function into employee health, to address a perceived imbalance where wellbeing is seen as prioritised, by rebranding as health and wellbeing guardian.
• Health and wellbeing guardians are mainly non-executive directors (NEDs), meaning that their time is limited to the assurance function.
  • While no organisation is the same, there is opportunity to support health and wellbeing guardians through better alignment and support from human resource organisational development and occupational health and wellbeing teams.
  • These teams have the potential to support the doing aspects, to free the health and wellbeing guardian and enable them to be a true strategic voice in championing health and wellbeing.
• The original nine principles applied from the NHS staff and learners mental wellbeing commission report (Pearson, 2019) require enhancement to ensure that they are truly enabling health and wellbeing guardians to improve employee health and wellbeing.

Learning from formal research

• Health and wellbeing guardians are becoming wider reaching by being incorporated into organisations governance arrangements and staff networks to enhance the voice of employee health and wellbeing beyond the board.
• Nine enhancements were identified through this research, including:

1. Access to high-quality evidence on how to improve health and wellbeing.
2. Access to resources, experts, and guidance.
3. Support and data to achieve the assurance function at board level.
4. More time and/or support to fulfil the function.
5. Navigating challenges related to COVID-19.
6. Collaborating with others.
7. Reviewing the scope of the health and wellbeing guardian.
8. Evidencing and sharing impact.
9. Shifting organisational focus to a wellbeing culture.

Recommendations

Based on this evaluation, the following recommendations are proposed to be considered in future updated editions of the health and wellbeing guardian guidelines.

• Enhance the health and wellbeing guardians’ guidelines based on learning from the first two years. Include better guidelines for ICBs and across primary care to encourage and track wider adoption.
• Evolve the name to health and wellbeing guardians to prompt equal weighting to both health and wellbeing aspects of the workforce at board level.
  • Also, begin to refer to the health and wellbeing guardian as a function rather than role, to emphasise that the responsibilities for organisational health and wellbeing do not sit with one person.
• Review and enhance the nine principles of the health and wellbeing guardian arising from the original Pearson review to ensure that they work better in practice, in particular the requirements around principle five in relation to suicide postvention.
• Expand the health and wellbeing guardian community support and networks to include other senior leaders who are responsible for the health and wellbeing of the workforce, such as human resource directors.
• Continue regional level support for health and wellbeing guardian networks and to encourage adoption of the function with a collective and influential voice.
• Continue to grow the health and wellbeing guardian supportive resources based on their needs, and to celebrate and share learning.

1. Early evaluation and recommendations to improve impact and reach

Covering the first two years of health and wellbeing guardian policy implementation, the background and implementation support offered to health and wellbeing guardians is detailed, followed by the evaluation insights and resulting recommendations.

Background and implementation support

The health and wellbeing guardian is a senior leadership function that seeks board level assurance that the health and wellbeing of the workforce is of high priority, being supported, and constantly improved.

It is a deliverable within the NHS people plan (2020) having arisen from recommendations within the NHS staff and learners’ mental wellbeing commissioners report (Pearson, 2019). Implementation of the health and wellbeing guardian has been supported with various publications including:

• Wellbeing guardian implementation guidance (2021) outlined the requirements of this new leadership function and how it can be applied in practice in NHS organisations.
• Enhanced board oversight – a new approach to non-executive directors (NED) champions role (2021) reinforcing the importance of health and wellbeing guardians, stating they should be one of five key NED roles.

Health and wellbeing guardian implementation support

The following information outlines wider support and resources that have enabled the implementation of the health and wellbeing guardian function in practice. Regular engagement, feedback and evaluation has ensured that health and wellbeing guardians are shaping and evolving the support they receive.

NHS England website

A formal NHS England website area designed to outline the health and wellbeing guardian policy guidelines.

Health and wellbeing guardian community website

A website designed to support the health and wellbeing guardian community, induct them into the function, offer a variety of supportive resources, and development opportunities.

Talking head videos and case studies

Videos (now available on NHS Futures) (login required) providing support and guidance, for example explaining what the function of a health and wellbeing guardian involves, how to get started, sharing insights, and best practice.

Regional networks

Providing a variety of regular local support and network spaces to health and wellbeing guardians in each of the seven NHS England regions

Journaling platform

A journaling platform that combines self-reflection and an impact/evaluation space for health and wellbeing guardians to anonymously share successes and challenges. Themes from the journal entries help to influence national wellbeing policy and direction.

National community conversation events

Quarterly community conversations events took place from August 2021 to March 2022, providing a space for peer support and for health and wellbeing guardians to influence national wellbeing policy. Data was combined from these conversations and the journalling platform using a sense maker evaluation approach to identify themes.

Health and wellbeing guardian newsletter

Quarterly newsletter distributed through regional networks highlighting key updates and supportive resources for health and wellbeing guardians.

Masterclasses and events

Masterclasses were run on various topic areas, as requested by the health and wellbeing guardian community, including for example:

• How to use your wellbeing data to know your people and your organisational context.
• Exploring the impact of COVID-19 on how to look after our NHS people. Looking at health and wellbeing insights and the future evolution of the wellbeing guardian function.
• Introducing the violence, prevention and reduction agenda and best practice examples of how health and wellbeing guardians can support this.

Health and wellbeing guardians were also invited to wider national and regional health and wellbeing events.

Look back, look forward, influencing the future event

This event enabled health and wellbeing guardians and those who support them to reflect on successes, the challenges, and co-design the actions to improve adoption and implementation of the health and wellbeing guardian function. It was held in March 2022 and had around 100 participants in attendance.

NHS health and wellbeing framework

Various supportive resources are within this NHS health and wellbeing framework toolkit to support health and wellbeing guardians and the people who support them. Helping them to understand the health and wellbeing needs of their workforce, to create an organisational strategy, and supportive resources – to create a culture of health and wellbeing for their workforce.

NHS growing occupational health and wellbeing together strategy

This national NHS Growing occupational health and wellbeing together strategy sets out how the NHS can grow occupational health and wellbeing services, practice, and the united multiprofessional family of people within these services improve the health and wellbeing of the NHS workforce, and result in improve patient care.

Health and wellbeing guardians form part of this united multiprofessional family, acting as the strategic voice of employee health and wellbeing, as articulated within the vision of this strategy.

Health and wellbeing guardians on the board guides

The wellbeing guardian on the board and wellbeing guardian poster documents were developed in partnership with NHS Employers and the NHS Health and Wellbeing Guardian Network, human resource directors, and NHS health and wellbeing leads. They detail how board members can work collaboratively and with health and wellbeing guardian to create a culture of wellbeing for their workforce.

Wellbeing compartment to the model health system

The model health system is a data-driven improvement tool to support health and care systems.

A new wellbeing compartment of the dashboard was developed to provide health and wellbeing guardians and boards with insights to help establish a baseline and an indication of priority areas.

Further work was undertaken to create six lead and lag indicators and incorporated into this system, including:

Leading indicators:

1. Psychological safety climate

Data source: National staff survey – ‘my immediate manager takes a positive interest in my health and wellbeing’.

2. Health work environment

Data source: National staff survey – ‘my manager values my work’.

3. Positive health and wellbeing/engagement

Data source: National staff survey – ‘I look forward to going to work’.

4. Job resources

Data source: National staff survey – ‘I am able to make improvements happen in my area of work’.

5. Job demands

Data source: Organisational data: vacancy rate as a predictor of increased workload.

Lag indicators:

1. Stress/burnout symptoms

Data source: Organisational data: sickness absence rate.

Formal research report into implementation

A formal report outlining the research conducted by the What Works Centre for Wellbeing, in collaboration with NHS England, to impartially examine the implementation of the new health and wellbeing guardian function within NHS provider organisations.

2. Evaluation

Three main evaluation mechanisms were used, including:

1. Tracking the adoption of health and wellbeing guardians in NHS trusts.
2. Community conversations and engagement.
3. Formal research into early implementation.

2.1 Tracking the adoption of health and wellbeing guardians

NHS England regional teams worked with NHS provider organisations to track adoption of the health and wellbeing guardian function since initial launch in January 2021.

At the time of writing this report, 96% of provider trusts report have a health and wellbeing guardian in post, or report that they are actively recruiting a replacement due to a change in postholder. The remaining 4% are yet to appoint a health and wellbeing guardian.

Figure 1 breaks this data down by NHS England regions as a percentage:

Figure 1: Adoption of health and wellbeing guardians in NHS provider trusts by region as a percentage (December 2022) 

Figure 1 is a bar chart image showing the percentage of NHS provider trusts by region which have adopted a health and wellbeing guardian as of December 2022. From left to right North East and Yorkshire (97%), South East (100%), South West (100%), East of England (100%), London (91%), Midlands (88%), North West (100%); total average for all regions combined (96%).

Commissioning organisations were also engaged; however due to ongoing change at the time across clinical commissioning groups (CCGs)/integrated care systems (ICSs)/ integrated care board (ICBs), they reported difficulty in adopting and reporting on this and have therefore been excluded from this report.

Most of the health and wellbeing guardians are reported to be non-executive directors (NEDs), who follow recommendations within the national health and wellbeing guardian implementation guidelines.

While other appointee variations do exist, such as human resources directors for example, NEDs are the preferred option due to the nature of their role being able to independently challenge and hold the board to account for improving health and wellbeing of the workforce.

2.2 Community conversations engagement and analysis

An ongoing opportunity to confidentially journal personal lived experiences of being a health and wellbeing guardian was offered.

Themes were taken from these journal entries to inform various ongoing health and wellbeing guardian national community conversation events, designed to explore hot topics, offer peer support, and encourage a collective voice.

Outputs indicated that this collaborative space has helped health and wellbeing guardians to reflect on the conditions required to create effective cultural change to improve health and wellbeing of the workforce.

It also acted as a mechanism for health and wellbeing guardians to have a shared voice and influence the nation health and wellbeing agenda. Three key themes were identified from this feedback, which were:

Theme 1: Prioritising health and wellbeing activity alongside workforce, demand and capacity considerations

• Staff health and wellbeing is yet to become an equal priority.
• Recruitment and retention being a common issue faced by organisations.

Theme 2: Enhancing the contribution of data and metrics

• Corporate data is currently not as helpful as stories, insights and observations.
• Authentic voices from staff were more effective in enabling rapid innovation.

Theme 3: Sustaining energy for the health and wellbeing guardian function for the long term

• Time is a critical factor for health and wellbeing guardians.
• Time constraints limit guardian’s ability to share their knowledge and to influence.
• Duties often mistakenly interpreted by their organisation as a going role.

Community conversations, regional network conversations and wider engagement activity including a look back, look forward workshop also identified wider challenges and opportunities to enhance the health and wellbeing guardian function, including:

• Doing vs assurance: health and wellbeing guardians feel pressurised into doing roles, while the function is one of assurance and leadership to improve health and wellbeing. They also feel anxiety from not being (or needing to be) experts in health and wellbeing. Enhancing their supportive team of organisational development, occupational health and wellbeing experts and alignment to the human resource team and director will help to address this.
• Nine principles application in practice: The health and wellbeing guardian principles were experienced as ambiguous and in need of enhancement to effectively work in practice. Principle five around suicide postvention also caused confusion and anxiety due to lack of clarity. Feedback was captured on how to enhance these.
• Adoption in integrated care boards (ICBs) and primary care: The health and wellbeing guardian guidance is currently well placed to support large provider trusts. However, the guidance requires further enhancements to make it suited to wider NHS environments, such as ICBs and primary care.
• Wellbeing vs health: The aspect of health was sometimes overlooked by both guardians and organisational leads, with a conversational focus on wellbeing. Health and wellbeing guardians need to be empowered to champion both at board level.

These themes offer learning to support enhancement of the wider health and wellbeing agenda in the NHS, and ways that the health and wellbeing guardian guidance and support can be enhanced to improve implementation and impact.

2.3 Formal research into early implementation

During year one of implementation, an external evaluation was undertaken by the What Works Centre for Wellbeing and explored the following two main sources of data:

1. Desktop review: A document analysis of NHS provider trust board papers to assess the presence of health and wellbeing guardian input and early impact within senior board level discussions.
2. Experiential and observation: Qualitative data from health and wellbeing guardian personal experiences, collected during observations at four regional health and wellbeing guardian network meetings.

2.3.1 Desktop review of board papers

A total of 200 board meeting papers across 31 NHS provider trusts were analysed during the first year of health and wellbeing guardians being launched (2021). Nine trusts had no mention of health and wellbeing guardians, and seven referred to them only once. Where health and wellbeing guardians were referenced, it was found that:

• Integration of the function in existing governance: Trusts are incorporating the health and wellbeing guardians into existing committee structures and assurance processes, often aligning it to specific directorates, most commonly human resource and organisational development.
• Limited evidence of challenge/seeking assurance: There were limited examples of health and wellbeing guardians seeking assurance on staff health and wellbeing. This may be a result of health and wellbeing guardians still embedding into their position at the time of the data analysis.
• Peer, regional, and national support welcomed: New to post health and wellbeing guardians articulated that they had secured support from regional and national networks and events. Examples of good practice were also evident, for example in the sample of trusts drawn from the North West where the development of a staff wellbeing programme provided a focus for peer support and collaboration.

2.3.2 Experiences and observations

Observation and analysis across several regional health and wellbeing guardian networks took place to gain experiential feedback. Analysis of these observations resulted in the identification of nine themes that outline common areas of enhancement, as follows:

1. Access to high-quality evidence on how to improve health and wellbeing: A gap was identified in terms a lack of access to evidence-based and practical research to draw on as part of their function to improve health and wellbeing.
2. Access to useful resources, expertise, and guidance: Having quick access to easily digestible, relevant guidance and resources as well as health and wellbeing experts is crucial and supports health and wellbeing guardians in discharging their duties, as they are not subject matter experts.
3. Support and data to achieve the assurance function at board level: Limited localised workforce health and wellbeing data, inconsistencies with who operationally supports the health and wellbeing guardian, and lack of standardised reporting mechanisms has reduced health and wellbeing guardians’ ability to act in their assurance function.
4. More time and/or support to fulfil the function: As predominantly NEDs, health and wellbeing guardians have limited time/capacity to fulfil the function and increasing demands on them.
5. Navigating challenges related to COVID-19: While COVID-19 has positively increased focus on health and wellbeing, this also brough additional challenge when implementing the function due to the need for urgent action, meaning less time to grow the function organically.
6. Collaborating with others: Collaboration with others in similar roles and combining efforts has the greatest impact, for example with other board members, other wellbeing related roles in the organisation (for example, wellbeing champions, human resource directors, occupational health and wellbeing leads, human resource and organisational development, freedom to speak up guardian) and other networks in the local system.
7. Reviewing the scope of the health and wellbeing guardian: There is variance in understanding the scope and remit of the health and wellbeing guardian function, partly due to this being a new and because the function needs to be adapted to fit a variety of local contexts.
8. Evidencing and sharing impact: Health and wellbeing guardians need tools and/or support to evidence the impact of their health and wellbeing work, both personally and within their organisation. There is demand for better ways of measuring activity and impact through wellbeing metrics and key performance indicators, yet lack of guidance on what this should be or how to create such data matched to the local workforce.
9. Shifting organisational focus to a health and wellbeing culture: Health and wellbeing guardians report focusing on how to tackle systemic issues (for example turnover of staff and high sickness absence rates) rather than where they perceive they have added value, in improving wellbeing through culture change. This may be due to the impact of the COVID-19 pandemic and focus on sustaining workforce wellbeing during this period of severe adversity.

These combined themes offer both gaps and opportunities for further work to enhance the NHS employee health and wellbeing agenda, and further ways to support and enhance the health and wellbeing guardian function.

2.4 Summary analysis of all three evaluation areas

The summary analysis across all three evaluation areas is detailed as follows.

Adoption of health and wellbeing guardians

• 96% of provider trusts have adopted a health and wellbeing guardian.
• Health and wellbeing guardians are being integrated into NHS trust organisational governance structures, to increase reach and strategic engagement.
• Integrated care boards (ICBs) and primary care are yet to adopt health and wellbeing guardians, due to the function requiring some adaptation to ensure fit.

Early impact of health and wellbeing guardians

• Early signs indicate that the function of the health and wellbeing guardian is strengthening the strategic voice of employee health and wellbeing at NHS trust board level.
• The peer support and regional/national networking has provided the health and wellbeing guardians a collective voice to influence the national health and wellbeing agenda. For example, improvements to national suicide prevention/postvention resources, and influencing the incorporation of health and wellbeing into assurance mechanisms such as the Care Quality Commission inspections.

National and regional support

• The variety of national resources, support and guidelines has helped to ensure the health and wellbeing guardian function is adopted and recognised within organisations.
• Regional and national communities of health and wellbeing guardians have started to provide wider peer support and sharing of learning. Regional support activities have been beneficial in building relationships to help embed, develop, and evolve the impact that this function plays within organisations.

Organisational support

• Health and wellbeing guardians reported a more effective experience and ability to have impact when there is alignment of purpose and proactive support from key organisational leaders such as, the human resource director and wider occupational health and wellbeing and human resource and organisational development teams.
• However, there is an inequity of organisational support for health and wellbeing guardians. Some report being expected to operate as a wellbeing operational lead, rather than in an assurance capacity. This is compounded by most health and wellbeing guardians being non-executive directors and having little time to discharge their duties.

Lack of health and wellbeing data

• Lack of standardised and easily accessible workforce health and wellbeing data, and the localised challenges of varying data systems, limits the ability for health and wellbeing to be given equal status and priority at board and limits the ability of health and wellbeing guardians to undertake their assurance function.

Growing the health and wellbeing function

• With the new NHS architecture taking effect, it is essential that health and wellbeing guardians are supported in wider healthcare environments, such as ICBs and consideration given to their ability to operate across primary care.
• It is essential that the health needs of the workforce are considered equally alongside wider wellbeing needs, as both aspects need to be considered simultaneously. Therefore, the name of the wellbeing guardian may need to evolve to reflect this (ie health and wellbeing guardian).
• The nine priority areas of the health and wellbeing guardian require further enhancement to ensure they work in practice and truly improve the health and wellbeing of the NHS workforce.

3. Recommendations

There has been rapid adoption of health and wellbeing guardians across NHS provider trusts, which is contributing to a stronger voice on NHS boards to champion the health and wellbeing needs of the healthcare workforce.

However, this evaluation activity has identified further enhancements to fully realise the benefits of the health and wellbeing guardian function in creating a consistent culture of health and wellbeing across our NHS system.

The combined intelligence from all evaluation activities has helped to develop several recommendations and potential action areas to help expand the adoption and growth of the health and wellbeing guardian community and their impact (see section 3.1 below).

We will work with health and wellbeing guardians and the human resource and organisational development, occupational health and wellbeing community who support them, to consider how these recommendations can be taken forward.

This will ensure that health and wellbeing guardians can continue to deliver a positive impact on improving the health and wellbeing of NHS employees, to enable them to pass good care onto patients.

3.1 Recommendations and potential action areas

1. Widen the adoption of the health and wellbeing guardians across all NHS trusts and integrated care boards (ICBs)

• NHS England to continue to support the remaining four percent of provider trusts who report not having a health and wellbeing guardian in place to understand why/close this gap.
• Now that ICBs are established, provide further support to ensure that all ICBs have a health and wellbeing guardian in place.
• Explore opportunities to adopt the function across primary care, appreciating that this landscape is more complex.

2. Enhance the health and wellbeing guardian implementation guidelines

• Use the learning from this report and wider engagement with health and wellbeing guardians and those who support them to enhance, evolve and simplify the health and wellbeing guardian implementation guidelines.
• Review and enhance the nine principles to ensure they are fit for purpose and will result in positive impact. Ensure the identified complexities around principle five (suicide postvention) are positively addressed.
• Ensure that the guidelines are also suitable for wider healthcare environments, including ICBs and primary care.
• Consider reframing the health and wellbeing guardian away from a role, and into a function to better represent that these responsibilities cannot rely on one person in an organisation and that health and wellbeing guardians need to work alongside their human resource director/equivalent, with wider occupational health and wellbeing/human resource and organisational development teams to support them.
• Consider updating/reframing the name to be health and wellbeing guardian to outline that the guardian must equally champion both the health and wellbeing aspects of the workforce.

3. Harness the collective voice of health and wellbeing guardians and links with those who can support them

• Based on the learning that the collective voices of health and wellbeing guardians can have a positive national impact on the employee health and wellbeing agenda, find more formal ways to enhance the combined power of this voice to steer national policy and strategy.
• Encourage health and wellbeing guardians to build local networks with their organisations including links to freedom to speak up guardians, staff networks, and to connect with local health and wellbeing champions who are able to provide the first-hand experiences of employees.

4. Continue to support the health and wellbeing guardian community

• NHS England national and regional teams to continue to support health and wellbeing guardian networks and peer support activities.
• Consider broadening out the health and wellbeing guardian community networks to include human resources director (or similar very senior leadership roles) to encourage working together on the strategic employee health and wellbeing agenda in these peer support forums.
• Based on need, continue to identify, capture, and share best practice to inspire health and wellbeing guardians to adopt good practice in their organisations.
• Continue to provide strategy, resources, and toolkits to support health and wellbeing guardians. This includes enabling health and wellbeing guardians to understand and champion the adoption of the NHS growing occupational health and wellbeing together strategy and NHS health and wellbeing framework as key resources to help health and wellbeing guardians and board leaders to create a culture of wellbeing for their workforce.
• Review and enhance the national health and wellbeing guardian community hub/website and newsletter to improve how these supportive resources meet the needs of health and wellbeing guardians.

5. Health and wellbeing data

• Explore ways to support health and wellbeing guardians, and the wider occupational health and wellbeing community, to improve the use of employee health and wellbeing data.
• Consider both operational and strategic use of data, to ensure that day to day the organisation is improving the health and wellbeing of the workforce, and that strategically the board and health and wellbeing guardian have assurances that workforce health and wellbeing are improving.