Community Health Innovators

Transforming health through frontline innovators


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Blocks, barriers and doorstops! Innovation in the NHS

If anyone needs a reason to innovate in the NHS, then they need look no further than the Francis Report into the deaths at Mid Staffordshire. This was published this February and painted a picture of a health service under pressure, constrained by money and targets and managed by people out of touch with the frontline. In the advent of one of the largest healthcare scandals in recent memory, there is a real focus on both improving the standards of care and about driving clinical innovation.

The culture change Francis asked for in order to make sure that patients never went through this again, was enabling fresh ideas from the ground up to be actually put into practice.

So what stops this from happening?

Nurse First recently surveyed NHS clinicians find out what were the major barriers stopping local innovation. We also wanted to know what had worked in order to help others create sustainable local innovation. We were really surprised that the top answer was not money in either case.

The most important factors that helped create clinical innovation (in order) were:
• The attitude of senior and middle managers in their organisation
• Being given skills and knowledge around in innovation
• Being given protected time for innovation
• Being given access to senior managers in their organisation

Access to start up funding was mentioned but was not even in the top 5 factors that actually helped people create innovation.

We were surprised by these findings as we had expected to find money the main issue. Yet in reality it may be liberating because anyone really wanting to create an innovative and safe organisation in the NHS doesn’t have to worry about money first and foremost but should focus on changing the attitudes of management and giving staff the skills and knowledge to put their ideas into practice. If an organisation wants to create more clinical innovation, the answers are less about finance and more about attitude and access of its management team, combined with skills, knowledge and time to encourage innovation.

The issue of getting access to senior managers was a theme that emerged elsewhere in the study. Our survey found that 38% of clinicians found it difficult or impossible to meet their own Chief Executive and some people may find this surprising. One of the things we ask participants on our innovation programme to do is get a meeting with their Chief Executive. This turns out to be a very interesting indicator of the culture within healthcare organisations. In some cases we have seen staff being threatened with disciplinary action simply for trying to contact and meet their own Chief Executive. In these cases Chief Executives were often completely unaware of the gatekeepers in their own organisations who prevent them from talking to frontline staff.

We know that we cannot keep delivering healthcare in the way we have been doing it for decades, pouring more and more money into hospitals and ignoring the demographic time bombs around diabetes, heart disease and dementia. We also know that innovation in healthcare is much more likely to come from the clinical staff who provide care and the management challenge going forward is how to help these innovative ideas flourish and help make them sustainable and scale quickly across the whole NHS.

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Why the reintroduction of the Named Nurse could be a terrible idea

Bradford22 lo resAnother week and another initiative comes from the Secretary of State for Health. Recently Mr Hunt is launching the idea of a “named nurse” for every patient which is obviously a radically new solution that has never been tried before …. Unless you count that time in the 1990s when it was last tried. For those readers who perhaps weren’t in nursing in the 1990s, this was the “named nurse” initiative which was closely linked with the development of “primary nursing”. The problem wasn’t so much the idea itself which was mainly about giving the patient, their family and friends, etc a single named individual to approach about issues with care. The problem (as it often is) was wrapped up in the devil of the implementation. Without redesigning the staff rotas, what inevitably happened was that the “named nurse” could end up being someone the patient had never seen and was never on duty between the patient’s admission and discharge. In some places, the ward sister or charge nurse was allocated as the “named nurse” for every patient in an area which made the whole exercise pointless.

As with many issues, the key is to understand what the real problem is that the solution is trying to address. Many of the advocates of the approach use the justification of accountability, arguing that it is important that the patient knows who is accountable for their care. Unfortunately this is a very simplistic understanding of how accountability operates and wrongly assumes that there can be a single accountable individual who “the buck stops with”.

Every nurse is personally and professionally accountable for the care that they deliver. The nurse’s manager is also accountable for the care that is delivered, as is their manager, the Director of Nursing, the Chief Executive, the Chair of the Board and a myriad of commissioners, regulators and inspectors. All of them are accountable for the care that is delivered and they discharge this through varying schemes of delegation and monitoring. So there are a whole number of people who are accountable for the care that is derived and not a single individual. There is certainly no single place along this chain of accountability where “the Buck” stops and goes no further. Chief Executives are paid a huge amount of money to ensure that quality care is delivered across their organisation every day and they cannot duck this by pointing at less senior nurses deep in the grains atonal hierarchy.

The concept of responsibility is probably more helpful. The essence of responsibility is the ability to respond, in other words, the capacity and the capability to address problems and issues that arise. What I believe patients, family members, carers, etc mainly want is to know who to go to to find out key information about the care being deliver and who to go to to sort out problems or issues. For a single named individual to be able to be responsible, they have to have the authority to sort out problems and issues. There is no point going to this person with a complaint about cleanliness, food standards, the organisation of care, etc unless this person has the ability to do something about it.

If an organisation creates a culture where nurses are able to control the environment of care and organises staff rotas so that there is continuity between nurses and specific patients, then there will genuinely be “responsible nurses”. In this type of environment, then letting patients know who their “responsible nurse” is could be really valuable. Adding it as a form of window dressing applied uniformly across the NHS without fundamentally addressing these issues will just lead to an irritating time-wasting fiasco. Exactly as happened the last time this was introduced.