The NHS’s current strategic goals place both significant and justifiable emphasis on improving the quality of patient care. Yet, while the way in which patients flow through the healthcare system has changed dramatically in recent years, ward structures and the approach to managing the workforce have not, remaining largely focused on job roles, descriptions and banding.
While the way in which patients flow through the healthcare system has changed dramatically in recent years, ward structures and the approach to managing the workforce have not
Effective service transformation must go hand-in-hand with a transformation in the way in which the workforce is aligned to new models of care. And arguably neither can be achieved without leveraging the knowledge, insight and, crucially, competencies of the NHS’s most-precious commodity: its people.
5 Boroughs Partnership NHS Foundation Trust has undertaken a significant exercise to both redesign the pathway for inpatient adult mental health services, as well as realign the existing workforce to the new model of care, using McKesson’s Critical for Quality tools and methodology. In doing so, the trust has not only given voice to its staff; it has also proven that a ‘skills management’ model for workforce sits at the heart of ‘quality first’ patient care.
5 Boroughs Partnership NHS Foundation Trust provides treatment, guidance and support for individuals with a wide range of health issues, including physical and mental ill-health issues and learning disabilities, living in the boroughs of Halton, Knowsley, St Helens, Warrington and Wigan and Leigh.
In 2012, the trust embarked on a project to move its inpatient adult mental health service to new accommodation. A great deal of time had been invested in the preparation for this new build, focusing on not just shaping the design of the new accommodation, but also redesigning the patient process which had complemented ideas to implement a recovery-focused admission pathway.
In addition, the trust recognised that this move was an opportunity to fundamentally re-evaluate the structure and skills of the staff involved in the provision of adult inpatient care. Responsibility for this exercise was given to Donna Robinson, who was then assistant director of adult services at 5 Boroughs Partnership NHS Foundation Trust.
“The move presented an opportunity to do something differently,” she said.
“Our patient groups have become very different. Healthcare is now far more dynamic than ever and we are coping with more co-morbidities around long-term conditions that are health related. Our existing structure was simply not geared up for this.
Healthcare is now far more dynamic than ever and we are coping with more co-morbidities around long-term conditions that are health related. Our existing structure was simply not geared up for this
“I had a vision of my team, with a shared vision of what they were there to do, with the right skills in the right place at the right time so that care delivery was consistently provided and the team had confidence in one another’s abilities. I was certain that I did not want to ‘lift and shift’ the current structure; staff needed to be exposed to the same level of scrutiny as the new patient process and the design of the new build.”
The question was how to achieve this?
A colleague introduced Robinson to Amanda Bassett, national lead for workforce innovation at McKesson. With a background in nursing herself, Amanda recognised that getting engagement from the whole team was both critical to success, and that it was of equal importance to provide quantitative and qualitative data to the trust’s board to underpin the significance of the exercise.
5 Boroughs started work with McKesson to implement a different approach to workforce change. Together, the team engaged the trust’s finance, HR and performance teams to collect and triangulate quantitative data from across the organisation around absence, sickness, temporary staffing levels, complaints, and pay. In parallel, a qualitative Critical for Quality workstream was launched, which collated intelligence around:
- The uptake of technology within the service
- The team’s appetite for change
- The number and reason for complaints and ‘never events’
- The team’s quality priorities
- What inspires team members to work differently
The Trust used virtual and face-to-face Critical for Quality tools to create common qualitative data sets which could be evaluated and compared as easily as quantitative data. A single half-day event was organised, to which a single representative from each type of health worker responsible for delivering the inpatient adult mental health service was invited - from the housekeeper to the consultant and everyone in between.
The three-hour event helped create a unified vision among the wider multi-professional team. The team also worked through the high-level patient contact points, considering what was needed by the patient to receive consistent care, and recorded the skills and competencies that were needed as the patient travelled through the service.
It’s given our staff a voice in a difficult environment, but, more than that, they know that they have been heard and are positively impacting their own working environment
This was the first time a cross section of the team had come together in such a way to look at patient care and what was needed in the form of skills and competencies to deliver the service. The process enabled the workforce to look at what was required to facilitate an individual’s recovery from a mental health crisis, rather than focus on what they delivered through the lens of their individual roles. Crucially, it supported the idea that other types of healthcare worker could adopt new skills, including bands 1-4, and that this would better meet the needs of the patients.
As a final exercise, Robinson asked both staff and inpatients to anonymously complete quality scorecards as to the elements of care that they felt contributed most to the quality of care within the patients’ pathway.
“The results were exactly the same and proved how aligned patients and staff were in their view of what quality care meant at 5BP,” she said.
In just three months McKesson delivered a Workforce Opportunity Report which clearly set out 21 opportunities, supported by qualitative and quantitative data. This provided 5 Boroughs with the baseline position showing clearly where they should invest efforts to make changes that would provide better care for patients. Staff agreed on five of these to work on in their wards aligned to the organisation’s strategic objectives.
They then downloaded a delivery plan with detailed tasks associated with operationalising each of the opportunity statements. Robinson’s team reviewed and finessed the plan, with individuals proactively asking to lead or involve themselves in the tasks.
The outputs have allowed 5 Borough’s inpatient mental health teams to:
- Reach a consensus on what skills and competencies are needed from the whole team as well as identify how they can use bands 1 – 4 differently aligned to the work
- Use temporary staffing differently
- Cross cover and focus on reducing sickness
- Make a start in influencing changed CPD and training needs using the skills and competency matrix as the evidence that today’s patients have different needs from those of the past
The case for change
“We now have the evidence for changing how we work in a language and a format that the whole team understands. In the short term the approach has meant that when using temporary workers we are not always replacing ‘like for like’; the ward leaders fully understand through the patients’ eyes what is needed at any contact point. Instead they are now plugging in the skills needed which can in some cases be supplemented by a different type of worker in order to have the same or better care delivered. We are actually positioning the right skills in the right place at the right time,” Robinson said.
This initiative has proven irrevocably to me that everything we need, both locally and at a national level, to transform care delivery to the benefit of patients and staff alike, is within reach of every care organisation
“Turnover has reduced from 14% to 1.9%. Overall our absence rates are coming down, and I have noticed that staff are more engaged in other projects. The outputs have helped staff share with me very simple things that inspire them to work differently and these outputs are being used to influence the development of an incentive and reward framework. It’s given our staff a voice in a difficult environment, but, more than that, they know that they have been heard and are positively impacting their own working environment – and crucially, the care of the patients for whom they are responsible.”
In December of last year, one of the wards involved in the project was recognised nationally for its work in developing a recovery-focused pathway for its patients. Meanwhile, the project has also kick-started a trustwide initiative for a re-evaluation of its career framework, as 5 Boroughs continues to prepare for the opening of its new accommodation.
Robinson said: “This initiative has proven irrevocably to me that everything we need, both locally and at a national level, to transform care delivery to the benefit of patients and staff alike, is within reach of every care organisation; the skills, knowledge and passion are in the staff who provide care every day. The challenge is putting the framework in place to harness this. But I am now also convinced that those organisations who do invest will actually be better placed to balance the seemingly divergent ‘quality’ and ‘efficiency’ targets. And that has got to be the call to action.”