Doctors and nurses

 

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The quality of care depends on more than the sheer quantity of staff. Quality healthcare requires a quality workforce. Reforming the workforce will be essential to improve the quality of healthcare. Pioneers of healthcare excellence are already demonstrating how to effectively manage and motivate clinicians to deliver better quality services. Government now needs to ensure that all providers can adopt the lessons of high performing organisations. 

The best healthcare organisations in the world are the best employers because they understand the importance of human capital. In getting the best out of their doctors and nurses they exhibit shared behaviours or habits. Principally, they adopt modern management practices, such as rigorously selective recruitment processes; staff engagement; devolving clinical and often financial power and accountability to the frontline; encouraging flexible working and team-based care; investing in staff development, measuring performance and outcomes; celebrating and rewarding excellence, and identifying and dealing with mediocrity and failure. This report highlights the good practice of: 

>  Salford Royal NHS Foundation Trust. Salford Royal is one of England’s highest performing Trusts.  

Standardised mortality is in the top 10 per cent of hospitals in the country and 92 per cent of patients receive harm-free care.  Salford’s leadership has improved its workforce by innovative links between pay and performance and by new methods to measure nursing quality.  Staff satisfaction has been the highest in the NHS for two years running.  

 

>  The Mayo Clinic.  The Clinic has improved care by enabling doctors to work together in cooperative and multidisciplinary teams.  One reviewer found: “Mayo employs highly capable doctors and other caregivers, but so do other healthcare organisations. What distinguishes Mayo is effective medical staff team work.  The Clinic excels in pooling talent for the benefit of patients.”

>  Care management teams in Massachusetts and Illinois. These providers have used clinical staff in non-traditional roles. For example, nurses have been retrained in order to become care managers for caseloads of 50 patients, coordinating care by different clinicians and providers and encouraging self-management.

>  Healthcare providers in India. The greater scarcity of healthcare workers in the developing world is stimulating innovation in professional roles. At Narayana heart hospital, junior surgeons open and close surgical procedures while consultants complete only the most complex part of the operation.  This allows them to spend one hour on a six hour operation. At Aravind Eye Care System, ophthalmic assistants receive a two-year training programme enabling them to assist surgeons. At LifeSpring maternity hospital, all clinical and non-clinical tasks are standardised and able to be undertaken safely by less expensive nurses. 

The report also refers to good practice at University Hospitals Birmingham, UK, the Cleveland Clinic, the Geisinger Health System, Kaiser Permanente, all in the United States, the Coxa Hospital in Finland, and the Hospital de Manises in Valencia, Spain. 

Empowering the leaders 

Although NHS organisations have the flexibility to develop their own terms and conditions, they have often sought national action and reform to national contracts to manage workforce costs. Yet national policies to control costs, such as freezing pay, undermine the drive for a more productive workforce by preventing employers from using their discretion to change working practices or incentivise performance. To improve the quality of healthcare and get better value for money from the NHS workforce, employers need the motivation and freedom to be better leaders and employers. 

Dealing with financial and clinical failure is essential in order to protect patients and make NHS chief executives accountable for their organisations’ performance. In 2011-12, 34 Trusts ran up combined debts of £356 million and another 42 relied on handouts from local health authorities or the Department of Health to keep them going – almost 19 per cent of the 411 NHS organisations in total. Administrators appointed to oversee the crisis-hit South London NHS Healthcare Trust, which overspent by £65 million last year, have recommended that it be broken up and run by other NHS Trusts or private companies. However, according to the Public Accounts Committee, the Department of Health still does not have a proper failure regime. 

Protected from failure, most employers do not deal with workforce challenges within their own organisations, and instead call for action by central government to manage workforce change. NHS Employers, the organisation that represents the interests of employers during pay negotiations, has recently called for discretionary pay increments to be frozen and for the NHS pay freeze to be extended into a third year. Nearly all NHS providers are planning workforce reductions. Although acute Foundation Trusts had planned to reduce their workforce by 6 per cent between 2012 and 2014, in 2012 the workforce actually increased by 1 per cent. National efforts that seek to improve quality, such as greater regulation, often shift responsibility away from providers and crowd out local initiative. 

Before 2010, only one NHS Foundation Trust had used its freedoms to break from national contracts.  Now, as in other public services, financial pressure is proving a positive catalyst for new thinking.  In the South West, a consortium of 20 employers has announced plans to reform pay and conditions and reduce costs. The proposals, which will affect 60,000 staff, include ending overtime for nights, weekends and bank holidays, reducing paid leave and sick pay, making staff work longer shifts and cutting pay as much as 5 per cent. Despite evidence of the variations in quality and productivity, national contracts have preserved a virtual GP monopoly over primary care. Primary care largely remains a cottage industry with many small and often inefficient practices delivering highly variable care quality. To improve the quality and productivity of primary care, and also ensure that out of hospital care is more coordinated, it is essential to radically change primary care. This will mean moving from national GP contract negotiations to local contracting arrangements. Clinical Commissioning Groups should commission local primary care services through locally determined contracts. Local commissioning and local contracts will allow CCGs to change the shape of service provision and bring in alternative and more cost effective providers. 

Recommendations

>  The Government should establish a clear mandate for all NHS providers to innovate with terms and conditions and the skill mix of their workforce. It should support initiatives such as the South West Consortium which replace national terms and conditions with local arrangements.  Such initiatives are consistent with the best practice examples outlined in this report which have all been driven by local clinicians and managers.  

>  Ministers should take the same position on the NHS workforce as Ministers responsible for other public services.  Health Ministers, and indeed the Prime Minister, still defend the Government’s NHS policies by pointing to an increase in the number of doctors since 2010. Instead they should follow the approach set out by the Home Secretary who has rightly argued in relation to the police: “what matters is not the total number of officers employed, but the total number deployed, and how effectively they are deployed”.  

>  As in other public services, the financial pressure on the NHS should act as a catalyst for innovation.  For this to happen, Ministers will have to hold NHS leaders properly accountable for performance, including financial performance. The placing of the South London Healthcare NHS Trust into administration sends exactly the right signal to the rest of the Service.

>  The UK is heading towards a surplus of doctors. If existing pay structures were maintained it is estimated that the rise in consultants will cost the NHS an additional £2.2 billion. Yet the surplus creates an opportunity to drive down pay and review medical ranks. A number of organisations are exploring variations on the traditional medical career, ending the notion that when doctors become consultants their “Certificate of Completion of Training” is a grant of freedom and job for life. Ministers should welcome these developments. 

>  The Government should also relax immigration rules for doctors. In the past, workforce planning and medical training were concerned with avoiding medical unemployment. In the future all healthcare providers should have the freedom to decide how they will recruit and reward employees. Doctors and nurses are highly skilled professionals and they would be able to find work in other countries or elsewhere in the labour market. 

>  The primary care workforce needs urgent reform. Clinical Commissioning Groups should commission local primary care services through locally determined contracts.  CCGs need the ability to manage the performance of GPs and bring in new providers, including the private sector.

>  The Royal Colleges have focused on protecting the standing of the profession, such as maintaining boundaries between clinicians and traditional curricula, but they should lead reform of the profession to raise standards and back employers who seek to innovate with different working practices – especially team-based care. 

>  Health regulators should move away from regulating professional silos and protecting highly stratified professional hierarchies. They should create over-arching regulations to encourage greater role shift and team-based care.