Eight years ago, the NHS Executive and the Department of Health recognised a number of important truths about our healthcare system in the UK:
- The Service needed to be transformed to be fit for purpose for the 21st century
- The re-engagement and re-empowerment of its frontline staff was key to this transformation, particularly the doctors, nurses and other healthcare professionals who deliver services to patients
- The people who know best how to deliver excellent healthcare should be freed up to do what they need to do to make this happen - free from central dictat, political intervention and constant re-structuring – being encouraged ‘to look out [to patients and the local community], not up’ [to Government departments and politicians].
Eight years on, it is worth checking in on how things stand, if only to give us a reality check on the likely success of the latest set of plans, or the next ones in the pipeline.
Since 2006 we have seen a lot of coming and going: one government going, a new coalition government coming to the end of its first administration; an old set of NHS principles and promises out, a new NHS Constitution refreshing the values and vision of the Service after sixty years; an old set of systems structures designed to manage the Service out, a new set of commissioning and provider structures wrestling with the system complexities; the end to the goal of world class commissioning, and the advent of clinical commissioning groups; and a white paper focused on Care Closer to Home overtaken by the latest white paper ‘Liberating the NHS’. At the time of writing, the next iteration of 'What Next?' has been produced by Simon Stevens, the new CEO of the NHSE, in his 5 Year Forward View.
So, how has all this shifted the aspirations in 2006 to transform the Service, re-engage and re-empower frontline staff, and free them up from interference from above to deliver the quality and safety of care they all want to deliver and that we all hope they can deliver for us, our relatives and friends?
I suspect the answer for most readers is somewhere between a somewhat sceptical ‘not a lot’, to a downright caustic ‘you’re having a laugh’. Unfortunately for all of us, as taxpayers, NHS staff, patients or relatives of patients/staff, neither end of that response spectrum - nor anything in between - is of any comfort.
Quite the reverse, in fact.
Were the truths of 2006 valid then and are they valid now?
Yes to both.
Does the Service need to be transformed to be fit for purpose in the 21st century?
This article isn’t orientated to the financial or political options available and relevant to the NHS for the next 50 years or more, nor is it bothered about whose politics is right and whose isn’t. It is just a matter of simple fact that the current and emerging healthcare needs of a fundamentally shifting population and demographic in this country demand we transform our healthcare system from where it is today to something more appropriate, sustainable and relevant. A bit like technology, the only thing that is certain in future, is that the scale and pace of change will increase, and it will be harder to cope with these influences unless we change what we do, and we change the way we do it, soon.
Do we need to engage and involve the frontline teams who deliver our healthcare services in helping make this shift? Yes. Why would you – how can you - transform the health service without involving the frontline staff who deliver it?
Look no further than the last decade of disasters in technology in the NHS to see the sense and value in ignoring the input of doctors and nurses in making change happen and stick.
On the third important goal of not interfering with the frontline teams and letting them get on with it, is that still a valid aspiration too?
Yes. Any survey of NHS staff – and there are enough of them! – highlights the challenges, barriers, and obstacles NHS staff feel the system (which is meant to enable them to do their jobs) puts in their way of looking after their patients. Indeed, fewer and fewer frontline staff are spending less and less time focused on patient care.
So eight years ago, the aims and goals were laudable and relevant, and they are still today. It’s just the progress – or lack of it – against them that should be a huge cause for concern.
And in truth, the same could be said of another dozen occasions over the last 20 to 30 years in the NHS when a room of incredibly bright men and women sat down to decide the transformational agenda for our NHS, all without a single doctor or nurse or healthcare professional in the room. Well-intended, undoubtedly; misguided, certainly; and prone to ‘slow-motion-car-crash-outcomes’, absolutely.
But it’s not that difficult really and the solutions are at our fingertips.
The NHS needs a fundamental shift in how it is organised and run, putting frontline staff back at the centre of change.
It is long past time to adopt a more collaborative approach to deciding what to do and how to do it. The NHS needs a fundamental shift in how it is organised and run, putting frontline staff back at the centre of change. We know from Pulse Checking over 120,000 NHS staff in the past 4 years that over three quarters of staff don’t feel valued, encounter day-to-day frustrations that could be easily resolved (but aren’t), say communication between their senior managers/leader and themselves is poor, and don’t believe existing structures, processes, systems or their work environment help them do their day jobs.
Imagine having 80% of your staff demoralised, disillusioned and dispirited every day, and consider what sort of service they can deliver when they feel this way.
So many staff in the NHS are too busy, too often, and are in constant danger of falling over with the effort (look at the sickness and absenteeism trends amongst frontline staff in the NHS for the size of the problem). The system is ‘running hot’ and it is not sustainable going forward. And yet the solutions to many of the challenges are within our grasp.
How much of the current effort is centred on the only thing that matters: delivering safe, high quality care and a good patient experience? Staff tell us that they spend a huge amount of time fire-fighting - focusing on the urgent over the important – and are tied up with administration and bureaucracy that stops them from doing the jobs they want to do. On top of this, a whole army of corporate service functions offer services to their frontline colleagues that many of them don’t seem to want, need or value.
So it’s time to invert the pyramid.
It’s time to look at radical ways to change the way we do change ensuring that those who know most about looking after patients and excelling in healthcare provision are given the lead on how we organise and run these services, supported by their current operational and organisational masters.
We need to connect the right people to address the challenges they face. We need to give them the opportunity to collaborate on patient priorities and to agree a common set of simple, pragmatic goals; and we need to empower them to own the changes they want to make to deliver the service we all want to see. They must be supported in doing this by their non-frontline colleagues who are perfectly positioned to help 'unblock the way' and ensure they have what they need. One CEO put it succinctly when he said: "If you’re not a frontline member of staff, you had better make sure you are working for someone who is".
We need something radical, brave and life-changing.
The only thing that stands in our way is an appetite to challenge convention, the courage to confront vested interests, and the mind-trap of 'that’s just the way we do things around here'. If what we are doing today was working, we wouldn’t be where we are. Moreover, if we want to see a fundamental shift, then doing more of the same – or a slight variation on that – is not going to get us there. We need something radical, brave and life-changing.
The encouraging thing is that it doesn’t take much to re-connect with doctors, nurses and other health professionals and give them hope again. Scratch the surface, empower them to get on with it, and watch the results follow. Staff who spend years training for their vocation and who joined the service to care for patients don’t need much to encourage them to contribute to improvements in their workplace when the opportunity presents itself.
So engaging and empowering front-line staff makes sense.
But not just for the sake of it, and not just because it seems like the right thing to do. We’re not talking about the sort of ‘staff engagement programme’ that morphs into a series of road-shows where a number of senior managers present the latest merger plans for the local health economy. Nor is it about the HR Director pulling out the folder entitled ‘Staff Engagement’ from the filing cabinet and seeing what it says about plans to improve staff survey results. It’s not even about meeting up with staff every quarter for a CEO breakfast briefing where staff are asked to share what’s on their minds. None of this will make the slightest difference to the transformation of the Service.
If you ask, listen, and then take action together, a world of possibilities and potential is unlocked.
What has, what does and what will continue to make a difference, is to engage staff – frontline and support staff together – around what matters to them and what gets in the way of them doing their day job, and to support and enable them to take ownership of the changes that will make the biggest difference, in a way that makes them feel proud.
If you ask, listen, and then take action together, a world of possibilities and potential is unlocked. They won’t believe it for a while, and that while might last months or even years, but it is the first step towards reversing a 30-plus year trend and culture in the NHS that needs to be fixed. Once the small things that have stopped our doctors and nurses and other healthcare professional doing their jobs are resolved, the time to focus on the big stuff coming down the line grows. As does morale, motivation, energy, resilience and commitment to want to get involved and tackle bigger challenges and issues around patient care, and the future for the Service.
And ‘you’ in the previous paragraph is not pejorative. It’s not ‘you, the executive’, it’s not ‘you, the senior manager’, and it’s not ‘you, the politician'. It’s ‘you, the individual who works in or has an interest in our health service and its future’ - because the engagement and empowerment of staff is the responsibility of everyone in the NHS today, whatever they do and whoever they are.
But it starts with the leaders of the NHS – the executives and the politicians - to have the courage to ask the staff the question, listen to what they say, and let them get on with it.
And the question to the doctors, nurses, healthcare workers, and managers in the same room is: ‘If you were in charge of delivering a better, safer, quality service for your patients, your colleagues and your Trusts, what would that look like, and what would you do about it?’.
The ‘What’ is easy, the ‘How’ and the ‘Why’ slightly harder, but it is a lot easier with the right people in the same room, always, with the professionals leading the way.