Organising care at the NHS front line

The highly regulated and centralised nature of the NHS in England means that trust leaders are preoccupied with responding to external demands.

One of the consequences is that these leaders find it difficult to find sufficient time to work with clinical teams to improve how care is organised at the front line. This results in wide variations in how clinical teams deliver care on hospital wards and in clinics and reflects the absence of deep and sustained engagement in frontline care by leaders in most trusts.

Trust leaders must ‘go the gemba’ – the Japanese term for where the work is done – and spend time working alongside clinical teams where patients are cared for

Don Berwick and I have become increasingly aware of these issues in work we have been engaged in in recent months. Our work started on visits we made on separate occasions in 2016 to Worthing Hospital which is part of the Western Sussex Foundation Trust, rated as outstanding by the Care Quality Commission.

We took the opportunity during our visits to shadow one of the general physicians on his ward round and witnessed the frustrations he and his team experienced, even in a high performing trust with a strong commitment to quality improvement.

Growing workloads

These frustrations included staff working under constant pressure in the face of growing demand for care, lack of contact with GPs about their patients who were admitted as emergencies to hospital, and difficulties in communication between different teams in the hospital. We quickly realised that Worthing Hospital is not unusual in experiencing the difficulties we had observed.

We also realised that improving how care is organised at the front line should start with the teams providing care who often know what needs to be done but may lack the time and resources to do so in the face of growing workloads.

We know that this is happening in some trusts in England but it needs to be universalised. There ought to be a much stronger focus on how care is organised on hospital wards and in clinics, drawing on evidence from high performing healthcare systems. For this to happen, trust leaders must ‘go the gemba’ – the Japanese term for where the work is done – and spend time working alongside clinical teams where patients are cared for.

Serious commitment

The challenges we observed reflect longstanding divisions within medicine and between medicine and other clinical professions. They have become more acute as a result of rising demand from a growing and ageing population at a time when NHS funding has increased much more slowly than the long-term trend. Workforce shortages and changes to medical training have created new obstacles with increased reliance on agency staff and the loss of the medical ‘firm’ which have made it difficult to provide continuity of care to patients.

NHS trusts have adopted a variety of solutions to these problems. They include joining up disparate information systems, using board rounds alongside ward rounds to improve teamworking, strengthening handovers between nursing shifts to enhance continuity of care, and understanding how patients experience care.

More could be done by drawing on the experience of junior doctors who are able to compare and contrast practices in different hospitals through the rotations they undertake during training

Work to improve the flow of patients in hospital in and out of hospitals is also attracting interest. Some trusts have adopted organisation wide quality improvement programmes, although the number making a serious and sustained commitment to these programmes remains small.

More could be done by drawing 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 challenge the hierarchies and tribal divisions that are longstanding barriers to teamworking. For their part, national leaders must demonstrate that they understand the realities of care at the front line and show that they support staff in bringing about improvements in care.

Shadowing patients

As well as being workplaces for staff, hospitals are places of healing which become homes for patients during their stay. 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 have a responsibility to nurture these cultures by actively soliciting the views of patients and carers, observing care ‘at the gemba’, and by shadowing patients.

National bodies and regulators should change the way they relate to trusts by reducing the demands placed on the NHS. There should be much less reliance on external support provided by management consultants and greater emphasis on quality improvement that is led by trust leaders with a track record of delivering change. These leaders cannot look into their organisations and support staff in improving how care is provided if they are continually required to look up to regulators overseeing their performance.

Organising Care at the NHS front line by Chris Ham and Don Berwick was published today.