Changing NHS culture
Thank you. It is a great pleasure to be here at Guy’s and St Thomas’.
Not just to thank you for looking after my daughter in your A&E department and the Evelina in November, where I remember the wonderful care given by staff as my daughter nearly caused the roof to fall in with her screaming.
But also because you have been leading the way in the change of culture we are beginning to see in the NHS, where in the wake of Mid Staffs we are making sure compassionate care is properly restored as one of our main priorities.
In particular I would like to congratulate Eileen Sills and everyone involved in the “Barbara’s Story” project which started here and is helping to transform attitudes across the NHS to people living with dementia. I know that you are rolling out the project internationally, which can only serve to strengthen your reputation as an internationally-renowned hospital with world-class staff who are leading the way in setting high standards of care.
It is that culture change I want to talk about today.
Some people say that being honest and transparent about the challenges we face is ‘running down the NHS.’
The reverse is true.
If you believe in the NHS, if you support its commitment to giving everyone the best healthcare regardless of income…
If you share the compassionate values that attract doctors and nurses into their noble profession, then you are even more angry when things go wrong and even more determined to remove the obstacles that stop people on the frontline doing their job in the way they would want.
If you truly believe in the principles of fairness and equality on which the NHS was founded, then you have to speak up for the most vulnerable in society – the frail elderly, those with mental health problems, those living alone with complex conditions. They are without a voice and we betray them if we fail to confront the issues when the system lets them down.
According a recent Harris poll, the majority of GPs say there are meaningful differences in the quality of care in their locality. But only a minority of the public reported being aware of them.
That is a “transparency gap” we need to address.
Not just because it is wrong for the “system” to know about problems that the public who pay for the NHS do not.
But because in the end the most effective pressure to sort out poor care does not come from Ministers, nor from NHS bosses, nor from local councillors - all of whom have vested interests of one sort or another.
It comes from the people who actually use the NHS as patients and pay for it through their taxes.
But if you ignore those problems, if you sweep them under the carpet, if you fail to expose and deal with poor care and poor safety wherever it exists, then you are not just betraying the patients who suffer as a result, you are compromising the very future of the NHS – in the eyes of the public and also in the eyes of every single doctor or nurse who has given their life to our greatest national institution.
This government will not make that compromise.
It can never be right to sit on poor care in the interests of “maintaining morale” in the service, or for any other reason. Because the best way to maintain morale is, quite simply, to give the best care. That’s what patients want – and what doctors and nurses want as well.
Nearly a year on from the Francis Report, I am pleased to say that change is starting to happen. And I am proud that we are straining every sinew to turn the tragedy of Mid Staffs into the moment the NHS resolved to become a global beacon for the highest quality, safest and most compassionate care in the world.
Fragmented care for patients
But to do this, we need to be better at listening to patients.
Every day the first thing I do when I arrive at work at the Department of Health is to read and reply to a letter from someone whose NHS care has gone wrong. Of course I know that for every mistake there are many, many instances of superb care. But as Health Secretary I want to know where the problems are because I want to sort them out.
Let me tell you about a couple of letters I have received.
One letter I was sent last March was from a lady whose husband sadly passed away after what can only be described as 2 years of chaotic care. Her husband was passed around the system from clinician to clinician, with no one appearing to know anything of his needs or history. One example of this was his severe diarrhoea: it started in January, but it wasn’t until November that he finally got the operation he needed to sort it out.
When you look into why that was, it was not about the doctors or hospital ever ignoring the problem - far from it.
He was sent for tests and asked to wait a month for the results. Then more tests by a different doctor, and again asked to wait. Then a consultation with yet another doctor – with no one at any stage stopping the conveyor belt and saying “wait, this person has been waiting for several months without us resolving the problem, we need to get to the crux of this and sort it out now”.
Another letter I received last November was from a man diagnosed with throat cancer, but also suspected secondary cancer of the kidney. Kidneys weren’t the consultant’s field of expertise, so investigations and treatment were delayed and confused. Surgery required dental extractions beforehand, but on the day of the dental work the surgeon knew nothing of his patient’s cancer.
This gentleman ended his letter to me by saying that he had lost confidence in the care team’s ability to communicate effectively with each other, and had significant worries about his future cancer treatment.
In neither case were the problems caused by a lack of compassion by doctors. They were caused by poor continuity of care, by a system where no one took responsibility for sorting out the problem or looking after the person rather than just a part of the body where things had gone wrong. And time and time again we see this happen when dealing with patients with complex needs or multiple long-term conditions.
Loss of teamwork
A Royal College of Physicians survey found that nearly a quarter of consultant physicians rated their hospital’s ability to deliver continuity of care as either poor or very poor. And when I met a few weeks ago with a group of senior frontline doctors to discuss this, they made it clear that these incidents were not isolated.
One doctor told me that “hospital care today has become a series of brief encounters”. Another spoke of the real problem of “episodic care”. Yet another said there has been a “loss of long-term relationships” because the way rotas worked meant you often never saw the same patient twice. I was also told that “stable teams have been undermined by shift work” and the European Working Time Directive. Someone else spoke of “a ping pong of referrals”.
All agreed on the need to rediscover teamwork. Continuity of teams matters as much as continuity of care – in fact they are one and the same thing.
Every patient is a person
But this is not just about structures. It is also about culture.
So often when considering the appalling suffering at Mid-Staffs, things came back to a culture – as Robert Francis described - “focused on doing the system’s business – not that of the patients”.
And getting the right culture means reasserting a simple truth: every patient is a person.
A person with a name. A person with a family. Not just a body harbouring a pathology; not a diagnostic puzzle; not a 4-hour target or an 18 week problem; not a cost pressure.
I was interested to hear about the experiences of Dr Kate Granger, who has highlighted the importance of treating patients as people. Kate is a doctor who specialises in the care of older people and who is also terminally ill. She has started the campaign #hellomynameis, which has become increasingly well-known and is based on the simple but vital courtesy of introducing yourself when meeting a patient for the first time.
We can all learn from this.
And perhaps, also, all doctors need to be generalists to a certain degree in order to make sure a person’s whole needs are taken account of - what the Royal College of GPs calls “whole person medicine”.
Whole stay doctors
Now Ministers can change a policy or a financial priority in an instant.
But changing a culture is different. That only happens with consent and is only sustainable if it comes from inside each and every person on the frontline.
The care for people with dementia here at Guy’s and St Thomas’s; the safety culture at Salford Royal; the evidence-based improvement culture at QE Birmingham – these cultures take root because over many years inspired leaders have patiently rewarded, encouraged and ingrained positive behaviour.
Sometimes, too, a new culture can be fostered by small but symbolic changes. I want to talk about one of those today.
Last year UCLH and King’s adopted the practice of putting the name of the lead nurse and lead consultant above the bed of every patient. Nurses introduced themselves to patients as they came on shift and updated the board. It is popular with patients, families and staff alike and can drive real culture change. Patients feel they are the most important person to that nurse, the person they feel safe with and the person who whilst they are on duty will be their advocate. They know which doctor is overseeing their care and who they can discuss their care and treatment with during their stay. A simple change making a big difference to patients and their families.
This used to be the norm in every hospital, but about 10 years ago “names above beds” started to be phased out, in many cases after concerns about data protection compliance were raised, or with the arrival of multi-disciplinary teams. The thinking was that patients, especially those with complex needs, needed the skills of a range of professionals - and so it would be wrong to say one consultant was in charge.
How flawed that thinking was. Because it is precisely those patients with a complex set of long-term conditions who most need a consultant in overall charge.
In the United States, this role is fulfilled by what are called “hospitalists”, but here I want to call them “whole stay doctors”. A doctor not just responsible for dealing with the main cause of a patient’s admission, but someone with an overview of the whole case, someone accountable for an entire in-patient care plan, and someone who makes sure there is a proper handover to a named, accountable GP on discharge.
This system has proven highly successful in countries where it is adopted. Lengthy stays and costs can be reduced - for instance, a recent study looking nationally across the USA showed the presence of hospitalists was associated with lower probability of readmission for heart failure, acute myocardial infarction and pneumonia.
Of course where a patient’s primary diagnosis changes mid-stay, a hospital might want to change who the whole stay doctor is. And there may be times when the implementation of a joined-up care plan is delegated to other key clinical staff such as nurses. So I have asked the Academy of Royal Medical Colleges to develop guidance to support hospitals to take forward best practice, and this will be published in March.
With sensible flexibilities, the concept must surely be to ingrain continuity of care as one of our key priorities for each and every NHS patient, exactly as the Royal College of Physicians recommended in their excellent Future Hospital Commission.
And with improved continuity of care will come renewal and empowerment for staff. Because the system changes and barriers which impaired personalised care also deprofessionalised and in places demoralised doctors and nurses.
So I want every hospital in the country to adopt whole stay doctors. But true continuity of care needs to go further and extend beyond the boundaries of the hospital. So as we progressively introduce named GPs – starting with the over 75s from this April – I want to see proper, seamless discharge handovers from named consultants to named GPs with direct communication between both parties to ensure that care is never interrupted.
As we know from a study by the King’s Fund in 2012, continuity is fundamental to high-quality care. But they also pointed out that breakdowns in continuity of care not only put patients at risk and cause duplication – they also add avoidable costs to both health and social care. I would echo that point – continuity cuts costs for the NHS as readmission rates fall and clinical outcomes get better. Which in turn leads to a more sustainable service with a more secure future.
But to make a reality of continuity of care, we need to do some other things as well:
We urgently need proper information sharing. Too many hospitals still don’t have a proper PAS system allowing key patient data to be accessed electronically anywhere in the hospital. Our Tech Fund is giving hospitals access to £500m of my Department’s capital funding to progress this, and we need to put the IT problems of the past behind us and get on with this as quickly as possible;
As the RCP says, we must look at whether medical specialties have become over-specialised, not giving as much emphasis as necessary to a broader range of skills. Specialisation has enormous benefits, but it should never be at the expense of personalised care;
As the RCS says, we must look at rigid shift patterns imposed in part as a response to the European Working Time Directive. Good teamwork involves getting to know colleagues who then work more productively in an environment where everyone feels more valued. Of course no one wants to go back to the bad old days of exhausted junior doctors working round the clock. But we should look at whether more flexibility over shifts could improve both training and continuity of care for patients. I look forward to the results from the EWTD Taskforce chaired by the President of the RCS when it concludes in the spring and the Health Education England “Better Training, Better Care” work programme;
We urgently need to progress greater provision of 7-day services in the NHS. Some of the biggest problems occur when the integrated teams available Monday to Friday disappear over the weekends and continuity of care is lost. I strongly welcome Professor Sir Bruce Keogh’s inspired leadership on this agenda and the work of the Academy of Medical Royal Colleges;
We also need proper plans to reduce the number of ward transfers during a single hospital stay. According to the RCP, every change of ward lengthens the average stay in hospital by a day for elderly patients. Of course, for some diagnostic procedures or operations, the patient will need to come to where the kit is – but the basic principle should be care being organised around where the patient is, not patients organised around where the care is. As part of this we need to be better at sending patients to the right ward first time;
We also need to make within-hospital referrals easier and end the referral ping-pong that is such a nightmare for patients with complex needs – as well as being expensive for the NHS. Commissioners should think about creative approaches to making in-hospital referrals easier - such as CCGs and providers agreeing categories of referrals that are automatically approved, or having a clinician on-call to make more complex decisions within 24 hours. Other countries have clinical staff on hand either in the hospital or remotely who are able to authorise further referrals and treatment on behalf of the purchaser;
Services must also adapt to ensure patients can always be discharged safely, like here at Guy’s and St Thomas’s where the pharmacy operates 7 days a week so the right medicines are almost always available when the patient is ready to go; and
We also need to make sure that the right financial incentives are in place for organisations to join up care inside the hospital. I will be asking NHS England and Monitor to consider this as they further develop their new approach to pricing and tariffs.
So - Whole stay doctors. Whole person care. Named consultants liaising with named GPs in a way that transcends the walls of a hospital. With names above beds inside hospitals as the starting point.
Our most recent information suggests that around 39% of Trusts in England have names above the bed. Or beside the bed, like here at Guy’s and St Thomas’s where you are doing excellent work on implementing this concept.
I am also delighted that the Care Quality Commission has decided to make this one of the indicators that informs the Chief Inspector’s assessment of how well a trust cares for its patients.
So I hope names above beds and whole stay doctors become not just best practice, but universal practice. Universal practice not because of Ministerial fiat, but as part of a genuine culture change in which the holistic needs of patients are put at the centre of all the care they receive.
When I was appointed to this job, I said it was the greatest privilege of my life. To have responsibility for one of our nation’s greatest treasures, an institution that tells the whole world not just about our healthcare but about our values as well.
Listening to patients and treating them as people is an essential part of those values.
And we can do that by listening to the doctors and nurses who deliver that care and who are the biggest champions of a more joined-up approach, both inside and outside hospital.
The vision that I have set out today on whole stay doctors is supported by the CQC, NHS England, the Royal College of Physicians, the Royal College of Surgeons and many other professional bodies.
But professional support is not enough, welcome though it is. Because this is a change in culture that has to be adopted enthusiastically - not imposed unwillingly.
By giving doctors and nurses the freedom, power and ability to treat patients as people.
By giving patients the confidence that their voice will be heard, and they will always know where the buck stops.
And by giving everyone who cares about the NHS the confidence that we are not discovering the values that make continuity of care possible for the first time, but rediscovering how to express those values as we face up to the challenge of an ageing population.