Ros Moore Chief Nursing Officers Team

October 2008

Next Step for the NHS

Next Steps for Matron

Provides care for nearly 60m people

It is third largest employer in the world

It is a officially a national institution valued across the social and political spectrum

BUT….

Ever higher

expectations

Advances in

treatments

Demand driven by

ageing

Changing NHS and

Social Care workplaces

Health in an information

ageChanging nature of disease

It faces challenges

Year of Birth

1927 – 1948

Age in 2008

60 - 79

Age in 2020

72 - 91

I Need Generation

Dominate today’s older patients

The longest living generation in history

I need generation

I want generation

Year of Birth

1949 – 1968

Age in 2008

40 - 59

Age in 2020

52 - 71

I Want Generation

The “New Old”

I can generation

Year of Birth

1969 – 1988

Age in 2008

20 - 39

Age in 2020

32 - 51

I Can Generation

The Change Makers

The now generation

Year of Birth

1989 – 2008

Age in 2008

0 - 19

Age in 2020

12 - 31

Now Generation

Tomorrow’s parents

and young clinicians

Ambition for public services is to be world class

The stages to our journey

Building capacity in the system

Introducing the reforms

High quality care for all

1

23

• NHS Plan saw greatest investment in the history of the NHS

• More doctors, more nurses, better facilities

• Patient choice and payment by results

• Foundation trusts• Stronger commissioning

• NHS Next Stage Review local clinical visions, national enabling report and NHS Constitution

NHS Next Stage Review

“ we know that nursing and midwifery are fundamental to high quality healthcare.

There is hardly an intervention, treatment or healthcare programme in which we do not play a significant part.

This means we are in a powerful position to improve the quality of care across the NHS and play a major role in improving health outcomes “

Dame Christine Beasley CNO (2008)

Nursing is PIVOTAL to quality ….

High quality care for patients and the publicOverview of proposals

• It is the quality of care that matters most to patients, public and staff

• Today, NHS is high quality in many aspects

• Next stage is to go to being high quality in all aspects

Context

Help people to stay healthy. Effective partnerships, more health promotion, better access to prevention services

What we will do

1

2

3

4

Empower patients. More choice and control to patients to promote quality

Provide the most effective treatments. Fair access to the best treatments for all

Keep patients as safe as possible. Patients in environments that are safe and clean, avoiding harm

High quality care for allNHS Next Stage Review Final Report

Quality at the heart of

the NHS

High quality care for

patients and the public

Freedom to focus on quality

High quality care for all

• Raising standards

• Stronger involvement of clinicians in decision making at every level of the NHS

• Fostering a pioneering NHS

• Empowering frontline staff to lead change that improves quality for patients

• Valuing the work of NHS staff

• Help to stay healthy

• Empowering patients

• Most effective treatments for all

• Keeping patients as safe as possible

Challenges for nursing

Variability in quality careVariability in quality care

Public confidence, image and identity Public confidence, image and identity 1

Access, choice and personalisationAccess, choice and personalisation

Focusing on health- transforming primary & community careFocusing on health- transforming primary & community care

2

3

4

“576 deaths that could be interpreted as potentially avoidable and relating to patient safety issues”

Variations in safety & quality

What are we doing ?

Creating a quality landscape

• Quality at the heart of PbR, commissioning & regulation • NHs Constitution• Care Quality Commission - new enforcement powers• National Quality Board setting priorities for NICE who will have an

extended role in quality standards• Quality accounts• Increase patients voice in measuring quality• Access to new evidence service• Quality boards locally • Quality observatories• Innovation rewarded • New partnerships with industries & education - HIECs

• New focus on health & inequalities

• Acute care out of hospital

• New relationships - a ‘meeting of experts’

• Multi disciplinary practice based commissioning

• Joined up services - integrated care pilots

• “Right to request” PCT Boards to consider the establishment of social enterprises, while retaining right to access the NHS pension scheme

• Clinical and leadership skills and resources for world class commissioning and effective high quality care

Where have we got to?

• Framing the Nursing and Midwifery Contribution (July 2008)

Role of the Nurse

• Nurses in Society – starting the debate • Expert Partner, Practitioner, Leader• Entrepreneurs • Leaders of service transformation• Champions of clinical quality

Role of the nurse

Modernising Nursing Careers

• Better recruitment

• Health focused careers

• Threefold increase in preceptorship

• A graduate registered nursing workforce

• Clinical academic and education careers

• Pathway based careers

• Standards for advanced and autonomous roles

• Regulation based on risk and proportionality

• Commitment to support CPD

Measurement & Management

Delivering care that is effective, safe and compassionate

• Metrics to define and measure clinical care

• State of the Art Metrics for Nursing: a rapid appraisal

• ‘Care line’ management - accountability framework that

spans delivery of care to the boardroom

• Extend the ‘Productive Series’ to community services

refreshing Essence of Care.

• Innovations and Incentives

The profession has some internal issues to resolve

• inward looking outward looking

• Giving care overseeing care

• Non-graduate Graduate

• Generalist practice Specialist practice

• Patients as recipients Patients as leaders

• Employees Social Entrepreneurs

• Exclusive profession Extensive workforce

• Eat our own love & nurture our fledglings

Priorities for Matrons?

Quality

Quality

Quality

We have achieved a great deal already … so lets celebrate & thank you

There are islands of innovation everywhere with creative local solutions

In many cases we have the evidence, we have the measures & we know what works

But we don’t yet have the results

Variations in performance remain Quality remains stubbornly short of where we want it to be & where it could beWe are still slow & sporadic in making improvementWe are still not achieving sustained improvementOften initiative led

Patients don’t ask for a lot..

– Get the basics right - don’t leave it to chance• Ensure staff are competent, • Don’t lose my notes• Keep the place clean

– Fit into my life - not force me to fit in to yours• Make the service easy to access• Give me convenient options• Don’t waste my time

– Treat me as a person - not a symptom• Listen to me and take me seriously• Understand the wider context of my condition• Treat me with respect and dignity

– Work with me as a partner in my health - not just a recipient of care• Encourage me to keep control of the process, • Equip me to look after my own health• Give me the support I need

• harm• indignity• hunger and thirst • being de-humanised• being de-personalised

with protection from…

NHS Care has improved significantly in some important respects and most

patients are highly appreciative of the care they receive, but despite pockets of excellent practice the service as whole is

far from patient-centred.

Picker institute 2008

A really user led service?

Patient centeredness

• Not just focussing on what we see as the patient needs• Reaching beyond our knowledge • Listening to what the patient see as quality • Their priorities may not always be clinical

Patients see things differently

STAFF comments: “I think it’s fun. Whimsical. I’d like

to have it in my home.”

“Funny little talking apple cores. Maybe some are sweating.”

PATIENT comments: “Charred skulls. Drops of blood are flying.” “Wounded people. They’re in pain and crying out.”

Emotional Congruence Theory Reflected in Responses to Art in a Psychiatric Ward (Ulrich, 1986)…

Care is embedded in the environment, culture & history of the organisation ward and team, as well as in the actions and working practices of staff.

You cannot know, comprehend or predict actions and effects that are operating without considering the system as a whole

(after Holden 2005).

Patients said

• They watch & witness everything

• Five minute window• Part of community/solution• Appearance is important• Visible leadership,

management & discipline • Contact after 2pm• Case management • Failures in cultural &

interpersonal competence

Hearts & minds

• Refocus on patient

care/experience• Learning organisation• A celebrated

organisation

OLD NHS

THE NEW REALITY

• Meaningful targets• Clear route maps• Relevant initiatives

A confident, efficient,caring organisation

STAFF AND MANAGEMENT

WORKING TOGETHER IN MUTUAL

RESPECT

ETHOS

RECENT NHS

What staff said

• Clinical priorities dominate• Ambivalence to relatives• Cultural competence• Intergenerational workforce • First amongst equals• Lack supervisory &

management skills • Patient ‘focused’ not ‘patient

led’• Assume interpersonal

competence but not technical • Want to be ‘cared for’ as well

The system

• Routine & rituals ( the key dance) • Creative workarounds • No systems to monitor ‘caring’ • Enforced compliance • Playing in the sandpit• Targets, single issue or

departmental initiative driven activity – don’t see the interdependencies

• Single cause – single interventions (usually targeted at staff)

• No methods to match ‘care demand & capacity in real time

• Outdated communications• Does not take longer to be caring

Organisational imperatives

• Right climate & good structures• Senior leadership• Good performance criteria• Good performance management• Use the talents of your intergenerational workforce • Use IT solutions• Evidence based policies & procedures• Access to research• Access to education & development• Authority to change practice• Partnerships across the organisation• External links to expertise• Communities of learning - inside & outside

Quality is a matter of professional pride

The Five ‘C’s

• Candour is the starting point acknowledging what need improving

• Comparison what athlete ever broke a record with knowing what the record was?

• Consequences knowing the ‘costs’ to patients; to staff; organisation; NHS

• Courage without which the rest is impossible • Cooperation national frameworks for local

action Clancy (2005)

People are often unreasonable illogical & self centred

- Forgive them and work with them anyway

If you are driving forward, people may accuse you of ambition, or of selfish ulterior motives

- Drive forward anyway

If you are successful you may win false friends & true enemies

- Be successful anyway

If you are honest and frank , people may use you

- Be honest and frank anyway

What you spend years building, someone else could destroy overnight

- Build anyway

The good you do today, people may forget tomorrow

- Do good anyway

You see in the final analysis It never was about you and them anyway - its about you and the people you serve