Sunday, 24 February 2013

How to fix the NHS? Let’s start at the very beginning..

How do you fix the NHS? A $64,000 question – or more accurately a £100 billion problem. Out of bad comes good – we hope – and the Mid Staffs scandal must surely be the turning point for change. The avoidable deaths of over 1,000 patients and the maltreatment of many, many more has got to be the trigger for improved care, accountable management driving ownership and responsibility among every employee of any care facility. We are all hoping that this must be where the line is drawn – yet there are still examples of poor, even bad, care happening now, today, this moment, in hospitals and care homes throughout the UK.

How do we bring about change? The NHS has often been compared to the Titanic, both in size and mortality, but the major issue is neither, it’s the speed at which it can change direction that’s the problem.

With a nod to change management experts worldwide – where should the NHS start to bring about this crucial evolution to balance technical expertise, cutting edge medical treatment and good old fashioned basic care?

Adopt a clear vision and strategy:
In theory – the Health and Social Care Bill should provide both. Andrew Lansley, the former Health Secretary may have had a clear vision in his mind of how his perfect NHS would look but he failed to translate this into a tangible and workable strategy. It is now down to the new Health Secretary, the Department of Health, Clinical Commissioning Groups, Hospital Executives and Monitor and other organisations too many to mention, to make some sort of sense of a Bill we are now stuck with. Clear goals (and forgive me, but maybe the odd target) are called for.

Start at the top:
No-one can now argue that the culture of the NHS needs serious attention. How do you change culture? No apologies for repeating my favourite mantra – you start at the top. David Nicholson must go. What a shame he hasn’t had the decency to fall on his sword. You have had plenty of time to make things better Sir David, and the 1 million plus NHS employees need to understand that performance management is a vital element of a successful organisation. Nicholson has not achieved what he is paid to do so he must go. Forget scapegoats – if someone doesn’t perform well they either need additional training and guidance or they move on. This shouldn’t just apply to the Chief Executive of the NHS – among the multi-layered beaurocracy, especially in hospital trusts and PCT’s – there are underperforming senior personnel who have been flying under the radar for far too long. The NHS desperately needs good leaders – not just managers – leaders.

Involve every layer and create ownership:
This is where responsibility and accountability comes in. Every act of negligence, cruelty or just plain incompetence is down the perpetrator. Every individual involved in the delivery of care, whether as a porter, surgeon, nurse, healthcare assistant or even ward clerk, makes a decision to be exceptional or ordinary, kind or cruel, diligent or lazy, competent or incompetent. I am not so naïve to believe that it is so simple. Toxic culture can turn good people bad. A caring person can have an off day and let their standards slip. But they must realise that blaming the boss, colleagues, economic environment, pressure or even ‘time of the month’ is absolutely no excuse for lack of care. Badges noting name and job title for ALL patient facing staff is a good place to start.

A care facility must make it absolutely plain to patients and staff which standards are acceptable and how these standards will be measured. As changes start, employee engagement is essential and it is only through ‘stakeholder buy-in’ that real change can take place.

Reward good behaviour and punish bad behaviour:
Effective change management is like good parenting.

Provide support, mentoring and guidance for all staff:
Effective management is like good parenting! And leaders – don’t forget that managers need support, mentoring and guidance too. This is appropriate at ward level and board level.

Create measurable goals:
What does good care look like? The 6 c’s created by the Royal College of Nursing (Care, Compassion, Commitment, Courage, Communication and Competence.) are all very well but what do they actually mean? Goals should follow the SMART principle - Specific, Measurable, Attainable, Realistic and Timely. No more sound bites but tangible monitoring. Patient and carer questionnaires, regular performance appraisals, and ongoing training at the very least.

Empower all stakeholders:
'Nothing about me without me’ was one of Lansley’s favourite phrases. Yes – it is jargon but the principle behind it is sound. Don’t just say we are giving patients and carers a voice. Make it happen – at every stage of the care pathway. One of the most shocking elements of the Mid Staffs debacle is the way that Julie Bailey, whose mother, Bella died in the hospital, and many other relatives of members of Cure The NHS were treated. Unforgivable. ‘Whistleblowing’ doesn’t just apply to staff, it should be a given for all. But it should also be a last resort. We cannot rely on whistleblowing to fix the NHS, but it must be an acceptable route for all those with a conscience to follow. I hope that this will be one of the lasting legacies of the Francis report following his enquiry into this hospital’s maltreatment of so many patients.  I long for the day when whistleblowing is rare – not because it’s discouraged, but because it’s no longer need. What a Utopian vision!

And finally..

Make sure that the change is sustainable:
No quick fixes – quick wins yes, but supported by long term, realistic plans. The majority of care in the NHS is good, sometimes exceptionally so. But sadly, bad care is more common than it should be and even worse, in some areas, accepted as a tolerated norm. The process of change needs to ensure that we look on the first decade of the 21st century as the bad old days of state managed care, never to be repeated.


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