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Organising care at the NHS front line

who is responsible?

This report looks at the reality of caring for acutely ill medical patients at the NHS front line and asks how care in hospitals can be improved.

It comprises a series of essays by frontline clinicians, managers, quality improvement champions and patients, and provides vivid and frank detail about how clinical care is currently provided and how it could be improved. The essays are introduced and summarised by Chris Ham and Don Berwick and the report serves as the starting point of an ongoing appreciative inquiry into improving care processes, particularly for acutely ill medical patients.

Key findings

  • Providing safe and high-quality care for acutely ill medical patients has always been challenging but has become more so as the volume and complexity of work has increased.

  • Most of these patients are old and frail with complex physical and mental health needs that may be difficult to diagnose and treat.

  • Many clinicians are involved in their care and this requires a high degree of collaboration and co-ordination to deliver the best possible outcomes.

  • Clinical teams experience frustrations in providing care including the intensity of work, lack of contact with GPs, difficulties in communication within hospitals and ineffective information systems.

  • Despite the best efforts of staff, patients may sometimes be harmed by weaknesses in communication and information systems, staff shortages and lack of continuity of care.

  • Frontline teams, who often know what needs to be done to improve care, need to be supported by trust leaders who have a key role in signalling, through their words and actions, that the needs of patients come first.

  • More could be done to draw on the experience of junior doctors who are able to compare and contrast practices in different hospitals through the rotations they undertake during training. This requires trust leaders to genuinely value junior doctors’ insights and to challenge the hierarchies and tribal divisions that are longstanding barriers to teamworking.

  • A continuing effort must be made to avoid the desensitisation of staff that can harm patients, however inadvertently, and to develop cultures in which the needs of patients always come first. Trust leaders can nurture these cultures by actively demonstrating their commitment to developing patient-centred care.

  • Some trusts have found solutions to some of these frontline challenges, but solutions to others – such as the need for care environments that provide space for staff to work or patients to be treated with dignity, and for information systems that provide rapid access to patients’ records and test results – require action across the NHS.

Policy implications

  • There should be a much stronger focus on how care is organised on hospital wards and in clinics throughout the NHS and greater standardisation of care processes.

  • Trust leaders should spend more time working alongside clinical teams where patients are cared for and provide the time and resources needed by these teams.

  • National leaders must demonstrate that they understand the realities of care at the front line and that they support staff in bringing about improvements in care.

  • There should be less reliance on external support provided by management consultants and greater emphasis on quality improvement led by trust leaders with a track record of delivering change.

  • Quality improvement should be taken forward systematically across the NHS as part of a coherent national strategy and move beyond pockets of innovation.

  • National bodies and regulators must change the way in which they relate to trusts by reducing the demands placed on leaders within the NHS to enable them to focus on improving care.

  • Government has a responsibility to provide sufficient and sustainable funding to meet rising patient demand safely and effectively.

  • Everyone has a part to play in improving care for acutely ill medical patients and no stakeholder ought to be a bystander.