The Gatehouse Blog

Twitter’s impact on engagement within the NHS

Chris Horner had worked in NHS Communications for almost two decades when social media emerged as a fully-fledged tool for internal communication. Intrigued by the possibilities these platforms offered for engagement, he undertook a dissertation study for the NHS Leadership Academy Elizabeth Garret Anderson Programme/University of Birmingham MSc in Healthcare Leadership. In this article, he summarises the results of his research seeking evidence around the impact of Twitter on employee engagement.

There is clear evidence that good engagement with staff is linked to better patient care in the NHS (Dawson, 2009; Macleod and Clarke, 2009; West, 2012). But achieving employee engagement is a challenge in geographically dispersed organisations, such as NHS Community Trusts.

These engagement challenges are likely to become more common over the next five years, with the arrival of accountable care organisations, hospital chains and regional footprints in the NHS. Organisations are likely to become larger, operating across greater geographical areas with dispersed leadership. These expanded organisations will bring together more staff from different divisions and professions, with different day-to-day priorities – so reaching diverse audiences and making messages stick will be key.

According to the King’s Fund: “If there were a silver bullet for securing high staff engagement, it would probably already have been found” (Ham, 2014). As a communications lead in the NHS, my experience is that there is a need for a revolver with several different bullets and the use of social media could be one of those bullets.

Context and methodology

At organisational level, social media use in the NHS is now the norm. Nine out of ten organisations are using social media – with Twitter by far the most used of the available platforms (McCrae, 2017). Guidance from bodies such as NHS Employers (2013) has actively encouraged Twitter as a tool for employee use and engagement, providing a new way of working for leaders; flattening the traditional hierarchy and supporting engagement. Despite high levels of usage, many studies around NHS engagement predate the recent growth in social media use so do not measure its impact.

My aim in conducting this study for the NHS Leadership Academy’s Elizabeth Garratt Anderson Programme was to assess that impact. The research focused on middle managers (often seen as the conduit/barrier to good communications) in a geographically dispersed NHS Community Trust in which the communications team had led a programme to encourage take-up of Twitter amongst this group.

“The research focused on middle managers in a geographically dispersed NHS Community Trust in which the communications team had led a programme to encourage take-up of Twitter amongst this group.”

54 middle managers, half of whom used Twitter, responded to a survey to share their views on engagement and social media use in the organisation. Interviews with Twitter users also provided further views and opinions. Six standout conclusions show that Twitter can boost engagement in geographically dispersed organisations, but also a word of caution to IC professionals hoping to use social media platforms in their organisations.

1. Twitter users are more engaged than non-users

One of the first things respondents were asked in the survey was to rate their level of engagement in three areas: engagement with the organisation; with the executive team (who were also encouraged to use Twitter); and with their colleagues. The results showed that there is a statistically significant positive (higher) engagement score among Twitter users compared to non-users across all three categories.


2. Three quarters of Twitter users say the platform has had a definite impact on their perception of engagement

You could assume that those who use Twitter are just more engaged with the trust, and more willing to test new platforms – however, middle managers’ perceptions differ. An average of 74% of users stated that their use of Twitter has improved their engagement at the trust.

3. Twitter’s impact on engagement is significant compared to other forms of communication

In addition to the previous findings, Twitter has the second highest impact on engagement when compared to other forms of engagement. For both Twitter users and non-users, faceto-face communication with senior managers, not surprisingly, rates highest. However, face-to-face communication has a near identical score to Twitter use for users, suggesting


Twitter can provide an effective alternative to face-to-face when it comes to engaging staff.


4. Twitter has a direct impact on improving care – even in relatively small ways

As well as positively impacting engagement, Twitter had a direct impact on improving care, patient experience and / or equality and diversity in the organisation (the three golden threads of the NHS Leadership Academy’s Anderson Programme).

Interviewed managers gave specific examples of something they had shared or implemented – or a connection that was made – as a direct result of their Twitter use that they felt could have an impact, although it was difficult to quantify the impact at present.

These included finding out about and encouraging other managers to take part in (and receiving funding for) humancentred design programmes; linking directly with service users on Twitter to improve services; taking on elements of a service model from another community service seen on Twitter; and developing an integrated working programme with a neighbouring mental health trust that directly came about because of a manager’s Twitter story being shared by an executive.

One manager said, “Twitter has allowed us to do some of those things that will impact on patient care and I’m not sure it would have happened without it. It wouldn’t have happened as quickly certainly.”

“Twitter has allowed us to do some of those things that will impact on patient care and I’m not sure it would have happened without it.”

5. Lack of time and confidence and an unclear value proposition limit Twitter’s take-up

Given Twitter’s impact on engagement, it was important to also assess the barriers that prevented non-Twitter users from adopting the platform. 37% of non-users said that they still don’t see the value in its use, and 29% stated that they:

a) faced time constraints

b) had never considered using it or

c) didn’t feel confident with the technology/needed training.

Some of the managers I interviewed voiced additional concerns around staff being uncertain about tweeting during working hours. This is a reminder that change in practice requires embedding, and for those informal permissions to be
formally granted.

Leadership teams can play a key role in this, as one manager highlighted: “It needs leadership from team leaders in their teams to take it to the next level and let staff know it’s ok and beneficial to use.”

Overall, there is still more work to do to encourage a wider body of staff to adopt social media use and show its value and that the investment in time is worth it.

6. NHS leaders, particularly executives, need to be true to their vision and real-life persona

All managers talked about the use of Twitter by executives. Although it was viewed positively, there was a feeling among participants that executives were tweeting ‘safely’ with simple messages. Managers wanted to learn more about them as people, and what they stood for. One clinical manager stated, “What I would like is to see what makes them tick as they get more confident and tell us what they agree with, what they don’t and what they’d like to see, their awareness and insights.”

Conclusions and lessons learnt

Overall, the results point towards the added value Twitter can bring to an organisation, and in fact has brought to the NHS Community Trust. The use of Twitter has led to a statistically significant improvement in staff engagement, and staff report that using Twitter is leading to real service improvements. The findings give credibility to the push by NHS Employers that leaders in organisations adopt social media as part of their leadership repertoire. As such, it should be considered a key tool for use in employee engagement activities by managers and communications teams.

Senior leaders, particularly at executive level, need to use Twitter in a way that reflects their own personal vision and values to ensure that middle managers remain engaged and do not see their Twitter use as tokenistic and false. Executive teams, as well as communications teams, also have a key role to encourage the use of Twitter across the organisations, formally granting users the permission to use the platform in the workplace so it becomes the norm and they feel confident using it at work and talking about the positive impacts on patient care, so other staff understand the return on the investment of time.

Saying that, staff still rate face-to-face communications highly in terms of impacting on their overall engagement. Twitter does not necessarily replace other forms of communication, but this study shows it has a key role to play in supporting better engagement in a dispersed NHS organisation, where face-to-face communication with leaders is difficult.

“Twitter does not necessarily replace other forms of communication, but this study shows it has a key role to play in supporting better engagement in a dispersed NHS organisation where face-to-face communication with leaders is difficult.”


BIOGRAPHY – Chris Horner

Chris Horner is based in Manchester and has been an NHS Communications lead for over 17 years, working at national and local level – mainly in hospital trusts, including Sheffield Teaching Hospitals and Warrington and Halton Hospitals. He is currently working as strategic communications consultant with Bridgewater Community Healthcare NHS Foundation Trust in the North West of England and has a particular interest in use of social media as an employee engagement tool. Chris was awarded the NHS Leadership Academy award in senior healthcare leadership and MSc in Healthcare Leadership this year.

Find him on Twitter: @chrishorner1974