On 4 May Airedale trust chief executive Robert Allen called all the senior managers into the board room to tell them about the national consultation exercise on the NHS national plan. He gave a presentation outlining the seven questions and asked that the managers do the same for their staff over the following week, and provide him with a written report from each clinical division by 15 May. He expected every member of staff to be consulted.
This was not a simple task. Airedale trust in West Yorkshire is a combined community, mental health and acute trust with 3,000 employees based in 82 locations within 650 square miles.
As physiotherapy services manager, I gave four presentations to 60 physiotherapists in the trust, and wrote up the findings from all nine departments in the clinical services division: pathology, pharmacy, healthcare psychology, optometry, nutrition and dietetics, mobility services, speech and language therapy, occupational therapy and physiotherapy.
The first question discussed was whether we can ensure that all parts of the health and social care system work better together, with the right emphasis at each level of care.
The consensus within the division was the need to improve communication and the mutual understanding of different professional roles and services. Suggestions for doing this included: integrating information technology systems; forming one organisation to include health and social services and housing, education and voluntary agencies; forming multi-agency teams with a single access point for assessment and intervention; pooling budgets;
resolving means-testing and charging problems; shared training; simplifying referrals between professionals and agencies; more beds for rehabilitation and convalescence.
Down with hierarchy
Strong feelings emerged over the question of how we can ensure that the NHS has the right workforce to deliver modern, flexible patient-centred services.
Staff felt it was time to recognise that the NHS was more than doctors and nurses. Comments included: 'We need more of everything - not just doctors and nurses'; 'Too hierarchical - power should not just be with the consultant medical staff '; 'We need the same terms and conditions for everyone.'
Staff saw inequities in access to training and stated that 'all staff should have protected professional development time on a par with the doctors'. They wanted funding to replace staff who were sick or away on training courses, or maternity leave. They also proposed improved training packages, better terms and conditions to improve recruitment and retention, increased pay, incentives such as bonuses, equity with the private sector, flexible working, and nursery facilities.
Some professions were concerned about managers.
Comments included: 'Managers need to go back to the shop floor to increase understanding of today's work practice and pressures'; 'We have too many managers'; 'We don't have enough managers with appropriate health centred skills.'
There was a feeling that therapy professionals were under-represented in the top jobs and that career structures should change to retain high-calibre staff.
Concern was raised about the role of specialist nurses as they 'tend to be inefficient in terms of delivering service', and the need to look at appropriately trained professionals.
'Clinical psychologists and counsellors are also skilled in change management and this is largely an untapped source, ' commented one staff member.
There was also a discussion around the question of how to deliver the organisation and clinical performance and productivity required to modernise the NHS (see box).
Staff were asked how we could deliver fast and convenient access to all services, in line with the patients' clinical need. Ideas suggested were:
flexible appointment times, including evenings and weekends; clinics provided near to people's homes and a one-stop shop approach ensuring that patients can be seen by the appropriate professionals, have their tests, and receive the results on the same day; beds close to the patient's home for rehabilitation;
develop NHS Direct further, and make it the first point of access to all health services.
Empowerment and information
We also discussed how staff can empower and inform patients so that they can be more involved in their care.
Most staff felt patients should take more responsibility for their care. But for them to do so they would need more easy- to-understand information. Also, professionals, particularly consultants, should give more time to patients to allow them to check on their understanding of their condition.
Other ideas included: helplines for patients between appointments;
ensuring patients see the same professionals on each visit.
Staff were asked to discuss how we can promote health, prevent disease, reduce health inequalities and focus the health system on its contribution to tackling the causes of avoidable ill-health.
Staff believed that prevention must start by tackling problems in society, including poverty, housing and education. Most departments also mentioned that government policy should support health promotion.
Examples included: banning alcohol and tobacco advertising; increasing the use of speed cameras in urban areas; working with the food industry to produce healthy food; encouraging positive health advertising messages - targeting schoolchildren in particular.
Suggestions for the NHS included: reducing prescription charges; improving access for patients to specialist healthcare; improving screening and back-up facilities; regular health and lifestyle checks and advice for the general population.
Staff were asked to consider how we can make the modernisation agenda resonate more powerfully with the day-to-day experiences on the front line.
This was an important question because unless they see some positive change, the whole exercise will have been a waste of time. Answers included:
see our ideas and suggestions implemented;
continue dialogue and feedback about developments from the exercise;
reduce work-related stress throughout the NHS;
improve morale through job satisfaction;
recognise that the NHS is not just doctors and nurses;
remove politics from healthcare so the service does not change every time there is an election;
make everyone feel part of the agenda;
increase staffing levels and not just pay;
give frontline staff a sensible time period in which to respond to a consultation period for such a major investment. A week is not enough.
The consultation showed that staff believed that radical change would be impossible without additional staff. They felt they were already working at capacity.
There was also concern about the speed of the consultation process and how the information would be filtered as it was passed from one level to another. Good ideas could easily be lost. The issue about the power base of doctors and nurses was also worrying, as the smaller professions may once again find it difficult to be heard.
Therapists consulted over the national plan in one trust expressed the need for recognition that the NHS was more than nurses and doctors.
They proposed the introduction of consultant therapist posts to allow them to take on some of the work of doctors.
They thought therapists were under-represented in the top jobs.
Most felt they were working at maximum capacity and that increasing productivity would be difficult.
Increasing productivity How can we deliver the organisational and clinical performance and productivity required to modernise the NHS? This was a difficult question for most professions because they felt they were working at maximum capacity already.
As one said: 'Many health organisations have increased productivity year on year to the point where all other activity, such as continued professional development, has been relegated to weekends and evenings.'
The solution was seen as properly funding increases in activity.
Some questioned the relevance of productivity for healthcare and voiced the need to concentrate on quality. Staff felt that there should be 'valid performance indicators which reflect all professions', rather than the current counting of consultant episodes.
Despite misgivings, they identified the following ways to increase productivity:
better equipment to take advantage of new technology ;
funded flexible working to provide services at evenings and weekends;
reducing paperwork and the number of meetings because they took time away from patient care;
more support staff to decrease the burden of bureaucracy, and better technical support to assist with increased clinical workloads;
introducing therapy consultant grades to do some of the work of doctors.