'Trusts must cease looking upwards to the centre for instruction and instead look out to the demands of the local population they serve.'
Chairman of the Care Quality Commission
'What we need is to ensure that these values shape what we do each day and guide the systems within the NHS.'
Chief executive of the NHS Confederation
David Prior, the chairman of the Care Quality Commission (CQC), wrote a letter to The Telegraph on 1 February 2014 highlighting many of the ways that the NHS needs to change in order to restore it.
Independent Nurse was able to see a full copy of the letter with access to parts that were not printed in The Telegraph. In the letter, Mr Prior suggested the NHS could learn from the American healthcare system. He acknowledged that it was imperfect in many ways, but said it could teach the NHS a thing or two about leadership, encouraging clinicians to take on management roles and allowing hospitals to take over failing community services.
The main steps that Mr Prior thought would be required to prevent the NHS from 'going bust' are:
- Encouraging successful hospitals to take over failing hospitals and community services to ensure better care outside hospital.
- Integrating smaller hospitals with larger operations or community services so they are able to provide quality care 24 hours a day.
- Altering the relationship between NHS staff and management to enable them to affect the care of patients. Clinicians should be encouraged take a leading role in changing the culture of the NHS.
- When more than 100,000 NHS workers were asked about how they felt about their working environment, one in four reported bullying. This needs to change.
Mr Prior raised many valid points that have been circling the NHS for a while now. He writes that hospitals should be encouraged to integrate with community services to provide a seamless transition of care.
His point that there needs to be better relationships between managers and clinicians was a point raised in the Francis Report, this time last year. While these points have been raised and will be important in altering the way the NHS currently runs, what was missing from the letter was the 'how.' How will these changes be implemented to ensure an NHS viable for the future and how can nurses in primary care be part of that?
Hospitals taking over community trusts
Mr Prior suggested in his letter that in order to improve the quality of care offered to patients, hospitals could take over failing community services.
He also said that small hospitals should become a part of larger operations and change or integrate with community services in order for them to offer the quality of care that is required 24 hours a day.
Over the past few years, some hospital trusts have been integrating with community services in order to fully integrate care and ensure that patients can be seamlessly referred between services.
One such trust that integrated with community services in its area was Guys and St Thomas's Hospital Trust (GSTHT) in south London. Integration with community services began three years ago. Speaking at the Queen's Nursing Institute's (QNI's) Annual Conference in September 2013, Eileen Sills CBE, GSTHT's chief nurse and director of patient quality, said that patients had been initially concerned about the takeover.
'In order to alleviate patients concerns it was important for the acute trust to see this as a partnership and to show that the transfer of care will be seamless,' she said.
Ms Sills outlined the benefits of the takeover including better access to training and development for community nurses, a rotational programme for nurses to work across all sectors, regular road shows in the community and car parking permits so that the nurses could park anywhere in the borough of Lambeth to be able to work more efficiently.
Another hospital trust that has integrated secondary and community care is the George Eliot Hospital Trust in Warwickshire. In April 2013, the Trust decided to take over a number of community services, including four GP practices and community dental surgeries, in order to improve the quality of care that it provided and to create more robust pathways of care.
To carry out the transition, a community division was created within the hospital, which had the same clinical set-up as the other divisions in the hospital, including a lead nurse. The community division was made up of all the different community services, which were all required to report back to the division leaders. The transition was successfully completed in November of last year.
It took the Trust around five to six months to fully integrate the services and Julie Whittaker, the director of community services at the George Eliot Hospital Trust, said that it wasn't without it's challenges.
'Initially as we were working with nurses in four different organisations with four different HR policies, it was difficult to coordinate them all.
'Geography also posed a challenge as we also provide services in other locations such as Leicestershire and Coventry and so it was difficult to ensure good communication across the different sites.
'Also providing training for the nurses was quite difficult as it was all based in the hospital, so we set up mobile training schemes for the nurses, so that they could continue training in all of the locations.'
However, Ms Whittaker says that the takeover has provided the hospital and the community services with a number of benefits as well.
'We have a much better knowledge of primary care, now that we are working with GP-led services. We have nurses that work in joint roles, in both primary and secondary care and there is a rotational system so that the nurses can gain experience working in all of the different sectors. We also have a good bank of nurses that we can draw from and work with.'
Clinicians and managers
One of the other key differences between the US healthcare system and the NHS highlighted by Mr Prior is that more clinicians in the US take on management roles. He acknowledged that it is mainly nurses who go into management in the UK and they are branded as going over to the 'dark side' if they do.
'There are few serious clinicians in the NHS who will consider a career in management. This is true in primary and acute care,' he said. 'Clinicians need to recognise that an involvement in management enables them to affect the care of thousands of patients, not just those they see in their clinic,' he wrote.
Crystal Oldman, the chief executive of the QNI, agrees that clinicians should be encouraged to take on more leadership roles. 'The QNI have, for the last three years, been campaigning for stronger leadership of the district nursing services, through the appointment of appropriately qualified district nurses to lead their nursing teams and set the culture for the delivery of high-quality care in peoples' homes,'she says. 'We are wholly supportive of clinical leaders becoming the managers of NHS services - but they do need to be appropriately selected, developed and supported to deliver on a role which is very different from the clinical role of hands on care delivery. Being an excellent clinician is no indication of being an excellent manager and we must also recognise that not every good clinician will make a good manager of services.'
Lou Patten, the chief officer of NHS Aylesbury Vale CCG and a former district nurse, says that to encourage nurses into management roles, they need to be shown examples of good relationships between nurses and managers.
'Nurses can shadow managers and vice versa so that there is a better understanding between the two different roles,' she said.
| An excerpt from David Prior's letter |
'If you want to change the behaviour of medical staff, to change the culture of the organisation, it takes time. In the UK we expect overnight results so we often get superficial change facilitated by expensive consultants parachuted in at great cost. When a hospital goes into 'special measures' we should not always expect it to come out quickly. We should expect its trajectory to change but fundamental, sustainable change takes time.
I am absolutely convinced that great management teams do add significant value and we must use the relatively few that we have to a greater extent. Foundation Trusts are a vehicle for this, so are the AHSN's and so are the established teaching hospitals. But we have not yet found a way to set our highly performing hospitals free, free to takeover other hospitals, free to deliver more care outside the hospital. The concept of 'buddying up' with other local, poorly performing trusts does not go far enough, there is not enough skin in the game. We have to back success and accept the risks that go with that freedom. We need more innovation and less national frameworks. The alternative is that the current system atrophies. Trusts must cease looking upwards to the centre for instruction and instead look out to the demands of the local population they serve.'
David Prior, The Telegraph, February 2014.
Transparency of culture
As well as encouraging clinicians to take on management roles, Mr Prior also wrote that a higher level of transparency was required to support clinicians.
His letter consistently referred to the need for a culture change in the NHS. 'Parts of the NHS have developed a culture that doesn't listen - or worse, that stigmatises and ostracises those who raise concerns or complaints.
'Too often it delights in the ritual humiliation of those deemed to fail, tolerates and institutionalises outdated working practices and old-fashioned hierarchies, and can almost encourage 'managers' and 'clinicians' to occupy opposing camps,' the letter said.
Ms Patten agrees with Mr Prior that nurses need support to speak out against organisations.
'Managers must nurture a culture of transparency. Nurses are good at getting to grips with clinical problems and we have to nurture [nurses] so that they can comfortably bring up problems with managers.
'The US example of constant learning is a good one and empowers people to raise issues,' she says. 'We have to accept that encouraging clinicians to raise concerns will lead to a perceived increase in the rise of complaints, but then it will level out.'
A complex system
Rob Webster, chief executive of the NHS Confederation, believes that it is important to recognise that the NHS is not a single organisation with a single culture.
'The NHS is a system not a single organisation, with commissioners, different providers, people that work in public and private sectors and medical, managerial, nursing and therapeutic staff. There are different cultures within each part that people feel connected to. Sometimes the view about the culture is quite simplistic. We should think about it in terms of various cultures instead of a single NHS culture.
'What does unite us is a shared set of values, and a clear commitment to the NHS. What we need is to ensure that these values shape what we do each day and guide the systems within the NHS.'
Mr Webster also believes the nurses he works alongside are passionate about delivering the best possible care. 'The aims of nurses fit together with the values of the wider NHS. We need to support them to do so.'
He also acknowledges that there are bad things happening in the NHS that rightly receive focus and attention. He also stresses that there are good things happening every day, which need to be publicised for the benefit of staff and patients. 'We need to strike the right balance of tackling both poor care and celebrating excellence.'
No quick fix
The letter coincides with the year's anniversary of the Francis Report on 6 February, which recommended that a culture of putting patients first was required in the NHS to ensure openness throughout the NHS system.
While it appears that there has been some change following the Francis Report, there is still a long way to go before a culture change is fully embedded into the NHS.
Jocelyn Cornwell, director of The Point of Care Foundation, commenting on the publication of the Nuffield Trust's report The Francis Report: One Year On says: 'The Francis Inquiry has made a difference and inspired positive change in the NHS. This is shown both by the research published today and by anecdotal evidence circulating throughout the NHS.
'True culture change takes time and is not easy. But national organisations, including the Department of Health, NHS England, the CQC and Monitor, are making the job more difficult by placing increasing demands on the NHS.
'Culture change has to be led from the top - with new values and behaviours clearly demonstrated-and it has to be system wide. So much of the focus has been on hospital trusts, but national bodies, community, mental health and social care organisations are all equally important in establishing an NHS that puts patients at the heart of the system.'
There is no denying that Mr Prior's letter raises some important points about what changes are needed to preserve the NHS. However, it is now time for opinion leaders and senior members of the NHS to illustrate practical steps that will result in these changes and for primary care nurses to play their part in making change happen on the ground.