Chris Ham: Views from the front line - how can we improve hospital care?

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Speaking at a breakfast event on 3 May 2017, Chris Ham shares key findings from our report, Organising care at the NHS front line.

This presentation was recorded at our event View from the front line: how can we improve hospital care? on 3 May 2017.

Transcript

Let me start by saying a bit about the work. This as you can see is Mike reflecting on the outstanding rating given by the Care Quality Commission to Western Sussex Hospitals NHS Foundation Trust.  This slide is important because the journey that led to this report started with visits that I made and also Don Berwick, who is the co-editor of our report, to Worthing Hospital which is part of Western Sussex Hospitals Foundation Trust.  We were intrigued by the work that Marianne Griffiths and the executive team have been doing to lead the Trust down this journey of quality improvement.  We wanted to go and see for ourselves what was involved, what progress had been made and we were both genuinely impressed on separate occasions by what we saw, what we heard not just from the executive team but by talking to clinicians within the Trust.  A great example and I think Mike will attest to this in his contribution of how quality improvement really can improve quality, it doesn’t always do so.

But equally on those two separate visits Don and I had the privilege of shadowing Gordon Caldwell, Gordon is with us in the room today, one of the general physicians who’s worked in Worthing for 25 years or thereabouts now and Gordon had invited us to shadow him on his morning ward round, which we did and we saw a very different experience; the frustrations of a general physician with his team of accessing information about patients, knowing who their GPs were, internal communication within the Trust as well as communication with hospitals from which some of the patients had been transferred. We were therefore puzzled by this and interested to understand how could we explain the awarding of the outstanding status to Western Sussex by CQC and yet front line clinical experience which felt and was rather different at least in one part of Worthing Hospital, which is in turn one part of Western Sussex Hospitals Foundation Trust. 

So that’s really the starting point for the work. The report today I’m grateful to all of the contributors to the report.  We brought together several perspectives on these issues some from Worthing many from other parts of the NHS wanting to draw on examples where the issues we observed on that morning in the general medical ward are being tackled elsewhere, national perspectives alongside local perspectives, views from patients and views from others.  I think apart from Don and myself there are 19 fellow contributors to a series of essays and perspectives where we can see and listen to the views, the voices of front line clinical staff of medical and nursing as well as patient perspectives.  So I would encourage you to dip into the report, I think it makes fascinating reading, it shines a light of aspects of health care that are often hidden from view.

The four questions we explored were the ones that you can see here and I’m going to use my brief time this morning just to give you a summary of what we concluded. So starting with was Worthing Hospital unusual and of course the answer is no.  The care for acutely ill medical patients we observed on the ward round is a challenge everywhere.  How the care is delivered varies both within individual hospitals and between hospitals but many of the challenges around information systems, the physical environment, the lack of privacy and sometimes a lack of dignity for patients, the challenges that presented for staff are very familiar and they are common across the NHS, and as Mike reminded us when we were doing this work no Trust is perfect.  You can be outstanding but within every outstanding Trust there will be areas of care that could be better.  This is a concern because the ultimate worry here is patient care is being compromised.  Care may be unsafe, care may not be of the right standard if these frustrations are as common and as familiar as they seem to be.

So how do we explain this? Well it’s a combination we think of the growing intensity of clinical work in acute hospitals.  We know that caring for acutely ill medical patients is a very big part of that, those patients present with needs that are complex but also difficult to diagnose and difficult to treat.  There are some longstanding challenges as well as the growing intensity - divisions between GPs and specialists and the poor communication that we observed but also divisions in the clinical professions themselves.  Caring for these patients clearly requires excellent team working, it requires coordination and both of those are difficult given the intensity of the work and given the divisions between doctors, nurses, therapists and others. 

So those are some of the explanations but there are of course many others besides and these are documented in some detail in our report. There are well known staff shortages and a reliance therefore on agency staff which sometimes compromised continuity of care.  The changes in medical training have very publicly affected the working conditions of junior doctors.  IT systems I referred to aren’t joined up, they vary between hospitals, they’re often slow and they’re clunky and there’s a very powerful essay by one of the contributors which illustrates that and the physical environments of care don’t always allow the privacy and the dignity needed both for staff and for patients and many other factors besides. 

We didn’t just want to do the diagnosis we wanted to understand how is care being improved and how can it be improved still further by drawing on experience in other parts of the NHS and we invited colleagues to come and join us at a couple of roundtables we held here at the Fund, we also accessed evidence and examples from other places. You’ll see there are contributions from David Evans from Northumbria, who is with us today, from Tom Downes form Sheffield about the really good work they’re doing to try and deal with the frustrations I've described to join up information systems, to improve patient flow just to give two examples.  In addition there are some Trust wide quality improvement programs that are helping in some places.  Western Sussex indeed is an example of that but there are a small but growing number of other examples.  The work that Jane and colleagues are doing at the College on the Future Hospital program is contributing, work in several hospitals around the country looking specifically at the care of acutely ill medical patients, looking at for example rapid assessment at the front door, looking at patient flow, looking at how information systems can contribute.  Work in the New Care Models program that  Sam Jones and others have been leading that work is helping to build more effective links between GPs and specialists to improve communication to make it easier for each to talk to the other.

A big point I want to emphasise is given the complexity of this particular patient cohort and the difficulty of agreeing a clear diagnosis and a treatment plan it’s really important that the clinical teams involved, general physicians, geriatricians and other specialists have the time in the working week, the time to talk to each other to collaborate and to coordinate care because if that time doesn’t exist that is one of the factors that will compromise safety and quality of care.

So the last question, who’s responsible? And of course the obvious and correct answer is everybody, but we would very much emphasise the need to start with the front line clinical teams.  Those teams know what the problems are and often if they have the time and the resources and the support they know what the solutions are, that’s what we’ve highlighted in examples from Northumbria, Sheffield, Birmingham and elsewhere, but for that to happen Trust leaders have to engage actively and give their support to clinical teams.  National bodies have a role too.  Not all of the challenges can be dealt with locally, the challenges around IT systems or indeed the physical environments, the old buildings, the open wards, the lack of privacy require an investment of resources beyond the capability of individual Trusts and organisations. 

One of the factors that Marianne Griffiths highlighted in her work and her contribution to our report was the challenge in doing this work for executive teams really focusing on front line care when there are so many demands coming in from the national regulators or only so many hours in the day, days in the week,. If you’re feeding the beast, if I can put it very simply, it takes times away from improvement work alongside the teams delivering the care and we also argue that regulators should rely less on management consultants when it comes to supporting organisations that are experiencing difficulty and rely much more on NHS leaders who have got experience of quality improvement and transformations of care.  Government clearly must provide sufficient funding to enable all of this to happen.

So finally where next? Well organising care at the front line we don’t believe has had sufficient attention and certainly it hasn’t recently had sufficient attention in the work of the King’s Fund.  Everybody needs to be more focused on the basic issues around how care gets delivered on hospital wards, in clinics and in other health care settings.  Trust leaders need to go to the Gemba, the Japanese word for where the work is done, at the front line, not spend their time solely in the executive suite in the executive offices but to be visible and to signal through their behaviours the way they spend their time that this really is what matters.  Care on general medical wards needs to be standardised where the evidence tells us what good looks like and Sam Pannick, who is with us today another contributor, has written about this based on his review of the academic and other evidence that might help us understand what good indeed does look like.  A lot of this is about cultures not structures so Trusts have to develop cultures centred on patients and their needs and Jocelyn Cornwell, who is with us today, has written a really valuable contribution on what that might mean and how it can be done.  Of course back to junior doctors they have incredibly valuable insights through their rotations bringing fresh pairs of eyes but often they don’t feel empowered to use their insights and to suggest what needs to be improved and how that can be done.

Quality improvement is being taken forward in a growing number of NHS Trusts but not enough and it needs to be taken forward in our view much more systematically across the NHS. This is the report that Don and I wrote with Jennifer Dixon about a year or so ago where we set out the arguments for this to happen. 

Finally Marianne talks about the need for strategic patience in improving care. It cannot be done through a quick fix, it takes time, it is about the aggregation of marginal gains, lots of small improvements taken together.  Clinical teams if they have the major responsibility they simply need the time, simply skills and support and support from their own Trust leaders.  We need to move away from a firefighting culture, a word that’s used several times by different contributors to our report, to plan and specify how clinical work is done on wards, in clinics, in surgeries and elsewhere.  This is not glamorous work but actually it’s essential if we’re going to deal with the pressures facing hospitals and I’ll end with a paraphrase of what Sam Pannick says in his contribution that we’ve got to be much, much tougher on the systems through which care is delivered at the front line if we’re going to be much kinder to the people who are delivering that care.  If we fail to do so we’ll carry on repeating the challenges and the frustrations that I’ve referred to.

So that is a very rapid run through the report, there’s much more in it besides, but I hope that gives you a flavour of what we’ve said and why we think these issues are really very important indeed.

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