UK healthcare debate risks missing real evidence on reforming the NHS

Thomas Cawston
THE government and the main nurses’ union are in violent disagreement about the best way to get nurses to care for patients. David Cameron and health secretary Jeremy Hunt want all nurses to train as “healthcare assistants” for a year. The idea is that every trainee should know how to do the most basic tasks, and appreciate that nothing is beneath them. The Royal College of Nursing calls the idea “stupid”, arguing that trainee nurses already spend up to half of their time on hospital wards. It wants better nursing through a government guarantee for a certain number of nurses on every ward, alongside firm regulation of healthcare assistants.

Both the government and nursing leaders are well-intentioned. But they risk missing how the best hospitals in the NHS are already achieving higher quality care. They have not waited for the centre to set the direction for change or for a new national regulation that mandates a new way of managing staff. They have taken the initiative to deliver reforms that improve care.

A key trait among the premier league of NHS hospitals is creating a culture of excellence where quality is prioritised above all else. Hospitals like University College London and Salford Royal have taken it upon themselves to make clear commitments to patient safety and customer service. Like the world’s leading companies, they have a sense of mission that runs from board to ward. At Salford Royal, for instance, the hospital explicitly set itself the objective of becoming the safest hospital in the NHS and to save an extra 1,000 lives. It has worked to engage its staff in this culture, and to recruit based on values and not simply skills.

The best healthcare providers around the world are now practising what business realised long ago – that what gets measured gets managed. Modern IT has strengthened the ability of hospital leaders to manage clinicians. University Hospitals Birmingham, one of England’s leading centres of excellence, invested in a purpose-built IT system that tracks decision-making on the front line. Hospital leaders can monitor the performance of individual clinicians on the shop floor in real time, identifying poor performers and ensuring high standards. Since introducing the system, the number of medication errors has decreased by 66 per cent.

And rather than focusing on the skills of individual types of clinicians, modern healthcare is a team sport. The world-leading Mayo Clinic in the US is based on the primary value that “the needs of the patients come first”. Doctors, nurses and other clinicians are made to pool their talent around the needs of patients. The hospital has created a culture where the skills of each caregiver is recognised and respected.

The key ingredient to this success is meaningful performance management. Too often in the NHS, pay and reward do not reflect performance, while for many doctors and nurses annual appraisals have become a fireside chat. The process of nearly all staff receiving automatic annual pay increments reinforces mediocrity. In contrast, senior management at Salford Royal hospital has created a “system of consequence” for its staff. Individual staff members are assessed regularly for their achievement and values, ranking them from “role model” to “unsatisfactory”. Pay increases, and other non-financial benefits, are linked to these appraisals. While some argue that this creates a bad deal for staff, employee satisfaction at Salford Royal is now the highest in the NHS and the hospital ranks very highly for quality and safety.

Excellence is about people and many leading providers have adopted practices common throughout the private sector to maximise the performance of staff. Rather than seeking a national answer to the NHS’s woes that further disempowers hospital leaders, including minimum staffing ratios or restrictive accreditation for staff, the government needs to empower leaders to deliver excellent care.

In the wake of the tragic failure of care at Mid-Staffordshire, both the government and the Royal College of Nursing are under some pressure to deliver a “quick fix” solution that purports to guarantee high standards of care in every NHS ward. But the regulatory magic wand hasn’t worked beforeand won’t work this time. It is strong management and leadership from hospital chief executives and their boards that make high quality possible.

Thomas Cawston is research director at the independent think tank Reform