Personalising Realistic Medicine: Chief Medical Officer for Scotland's Annual Report 2017-2018
The Chief Medical Officer's fourth annual report on Realistic Medicine, with a focus here on the principle of Building a Personalised Approach to Care.
Chapter 3 Supporting Our Workforce To Deliver Personalised Care
So far, my report has focused on our patients – their needs, preferences, expectations and values. However, to successfully build a personalised approach to care, we must not lose sight of the fact that our workforce, our most valuable asset, are also people and we need to look after them too.
‘You cannot give what you do not have’. Maureen Bisognano
It is rightly a matter of concern that staff working in the NHS are subject to high levels of stress and strain resulting in ill-health and absenteeism. This also impacts on financial costs and, importantly, on patient care. Many of the findings presented in the General Medical Council’s (GMC) 2018 report ‘The state of medical education and practice in the UK’ make for uncomfortable reading. 60% of doctors surveyed across the whole of the UK reported that their satisfaction with their work-life balance had deteriorated (either somewhat or significantly) in the past 2 years, with only a fifth reporting an improvement. 3/10 doctors felt unsupported by management or senior colleagues at least once a week. 1 out of 4 doctors said they had considered leaving the medical profession at least every month. The report concluded that the medical profession is ‘at a critical juncture’. Similar challenges face non-medical healthcare professions.
‘Healthcare is a caring and learning system. It is not driven by data, industrial processes or technology. It is driven by people. It is not systems responding to people but people responding to people. The systems, technology and information are back-up to support people. But the people are first. And if people are dissatisfied, burnt out, confused about what their role should be, unable to work together in teams and unable to communicate, and if people are not surrounded by a culture of safety and gratitude, a culture that recognises their work, a culture that allows them to feel proud of what they can achieve, they will be spent. And if you put those people on the front-line, they will be your final common pathway, your bottleneck in your ability to care in a careful and kind way’.
An effective and sustainable health and care system focuses on meeting the health and wellbeing needs of everyone in that system – patients, carers and staff alike. This is the so-called ethic of reciprocity – making the care you give the care that you yourself would want to receive. It is recognition that the health service must care for its staff in order for them to provide the best care to those they serve.
‘Staff often achieve extraordinary results in spite of organisational systems rather than because of them’.
Peter Homa is a former Chief Executive of Nottingham University Hospitals NHS Trust and is the foundation chair of the NHS Leadership Academy. Throughout his career, he has championed the wellbeing of the health workforce. Peter contends that, while there is first and foremost a moral duty for us to look after staff in the best way possible, it is also the case that staff do great work when they feel supported, confident, appropriately challenged and part of an organisation with core values with which they identify. Furthermore, organisations must ensure that staff from all backgrounds have a strong sense of inclusivity so that, over time, those that serve the population increasingly reflect its diversity.
When considering how best to support the workforce, we should perhaps reflect on two-factor theory, postulated in the 1950s by the American psychologist Frederick Herzberg. The work emerged from Herzberg’s interviews with employees in engineering and accountancy about what pleased and displeased them about their work. Sources of pleasure (termed motivators) included the work itself, professional responsibility, achievement, recognition and opportunities for advancement. Dissatisfaction was determined by so-called hygiene or maintenance factors, such as the work conditions, a person’s relationship with their peers and seniors, and the presence or absence of a culture of dignity and respect. Interestingly, Herzberg found that the factors leading to job satisfaction were separate and distinct from those that led to job dissatisfaction. In practice, this means that job satisfaction cannot be achieved simply by remedying the causes of job dissatisfaction and, similarly, job dissatisfaction cannot be eliminated simply by adding those factors known to create job satisfaction. Instead, there needs to be a dual approach, an understanding that the greatest improvements for staff are achieved when both sides of the coin are examined.
Almost certainly, there are fundamental motivational differences between the employees interviewed by Herzberg and the staff who work in the vocational professions of health and care. However, as a conceptual framework for improving the wellbeing of our workforce, Herzberg’s theory holds value to this day.
In Practising Realistic Medicine, I considered some of the ways in which Scotland is addressing those hygiene factors that lead to job dissatisfaction: the Professional Compliance Analysis Tool (PCAT) to improve working patterns and achieve intelligent rota design; the decision agreed between Scottish Government, NHS Boards and British Medical Association (BMA) Scotland’s Scottish Junior Doctors Committee that, from August 2019, the rotas of all junior doctors will include mandatory 46 hour recovery periods after runs of night shifts; and the Let’s Remove It campaign launched by the Royal College of Surgeons of Edinburgh to tackle cultures of bullying, undermining and harassment in healthcare.
Further progress has been made since my last report. The Health and Care (Staffing) (Scotland) Bill was introduced to Parliament in May 2018. Its general principles were unanimously agreed in December 2018 and stage 2 of the process was completed in February 2019. The legislation seeks to ensure safe, high quality services, creating better outcomes for patients and improving the wellbeing of staff. The Bill will support the professional-led development of evidence-based approaches to workload planning and will encourage an open and honest culture where staff are engaged in discussions around staffing requirements and feel safe to raise concerns.
Following the GMC 2018 report, there is now a UK-wide review of medical students’ and doctors’ wellbeing, led by Professor Michael West and Dame Denise Coia. Dame Denise is also co-chairing the Scottish Advisory Group on the Wellbeing of the Medical Profession, established in August 2018 by the GMC and NHS Education for Scotland, and attended by stakeholders from the NHS, BMA, GMC, Royal Colleges and Scottish Government.
We should also be proud to acknowledge our successes. In their most recent national review of Scotland Deanery, the GMC identified many areas that are ‘working well’, defined as not only meeting GMC standards but well embedded across our organisations. These included supportive departmental cultures and the ready availability of pastoral support. There were no concerns identified over bullying or undermining. We are also gauging staff wellbeing through staff governance monitoring processes in every health board and the iMatter Staff Experience Continuous Improvement Model. Evidence from the first national report suggest that the model is having a positive impact.
We should also direct our focus towards motivators, those factors that lead to job satisfaction. We must allow our staff to find what the Institute for Healthcare Improvement (IHI) describes as ‘joy in work’, the feeling of success and fulfilment that results from meaningful work. Just as health is more than the absence of disease, so too joy is more than the absence of burnout.
In Peter Homa’s experience, some of this can be achieved by leaders connecting with staff, providing them with formal and informal opportunities to share their sources of fulfilment and frustration in their role and designing services based around them:
‘Many of our hospital systems are designed around the convenience of the organisation. Listening to patients and to staff provides a hugely important and valuable opportunity for redesigning services in a way that makes much better use of patient time and staff time while improving the experience for both’.
In Chapter 1, we considered the importance of asking patients ‘what matters to you?’, but we must also ask the same question of our staff. Just under half of doctors (49%) surveyed by the GMC believe the time available to reflect on their practice has decreased, with only 16% saying it has increased.
Finally, we must find space in our system for approaches that address both sides of Herzberg’s model. A good approach is to introduce Schwartz Rounds. The connection between supported staff and positive patient experience has been at the heart of the Schwartz model from its inception. Kenneth Schwartz, after whom the Rounds are named, died in 1995 from lung cancer. During the course of his treatment, he wrote about the way that healthcare professionals, while unable to cure his disease, made his plight more bearable by attending to the so-called ‘small’ things that matter to people. After his death, the Schwartz Center for Compassionate Healthcare in Boston, USA, developed and evolved the Rounds model. The Point of Care Foundation introduced Schwartz Rounds to the UK, and continues to train facilitators and support organisations to establish Schwartz Rounds programmes. Box 6 explores this in more detail.
Box 6 – Schwartz Rounds
Jocelyn Cornwell is Chief Executive of The Point of Care Foundation and is credited with bringing Schwartz Rounds to the UK
A Schwartz Round is a multi-disciplinary forum for clinicians and support staff at all levels to reflect on their work in healthcare and its psycho-social and emotional impacts. The aim of Rounds is to strengthen relationships with patients, build empathy and compassion across organisations and provide staff with a safe psychological space in which they can talk to each other about all aspects of their work.
It is hard to communicate exactly what makes a Schwartz Round different from other meetings, but how they work is simple. They take place each month, usually at lunchtime with a snack provided, and last one hour. They require expert facilitation by a facilitator and clinical lead appointed from within the organisation and trained by The Point of Care Foundation.
The numbers who attend Rounds vary between organisations: in large hospitals, audiences can be as big as 150-200; in small and more dispersed organisations, they average 30-40.
At the beginning of a Round, the facilitators remind people about the ground rules. Rounds are only for staff and allow a confidential space for reflection. During the Round, everyone in the room is equal. A ‘panel’ of three people briefly introduce a story about a patient or an experience at work that is connected to a pre-agreed theme. The facilitators then invite the audience to ask questions, comment and reflect. A Schwartz Round is not a debrief or a place for decision-making or teaching. Often, there are short periods of silence. Invariably, there is a remarkable level of active listening and attention.
The simplicity of the model belies its impact and effectiveness. Evidence shows that people who attend Rounds regularly are half as likely to suffer psychological distress as their non-attending colleagues, and that participating in Rounds, even for people who never speak, reduces isolation, makes them feel more connected to colleagues and puts them back in touch with the motives that brought them to healthcare in the first place.
Paul Graham is Head of Spiritual Care and Wellbeing in NHS Lanarkshire and was one of the first trained facilitators of Schwartz Rounds in NHS Scotland
The first ever Schwartz Round I attended was in spring of 2013 at the Golden Jubilee National Hospital, where it became a regular feature in the Hospital’s calendar for staff. In University Hospital Hairmyres, we identified a core group of colleagues from across disciplines who would become trained facilitators and would plan and organise a programme of Schwartz Rounds each year.
We have heard a variety of themes discussed at the rounds: “A patient I’ll never forget”, “When things go wrong”, “What happens when you can do no more?”, “When the unthinkable happens!”, “Can we be friends with our patients?”
As a trained facilitator, it is essential that we create and hold a safe, confidential space for colleagues to share their experiences. People are often surprised by the emotions they experience when re-telling their story. Although it can be overwhelming to realise that we carry so much ‘emotional residue’ from our previous encounters, it can also be very helpful to hear that we’re not on our own and that it’s OK to feel the way we do. That’s why we allow time at the end of a Round for people to chat before going back to their workplace.
Hospitality and welcome is an important aspect of Rounds so we always start with some food. There is something simple and profound that happens when we eat together: we create a place for building relationships and trust and for establishing community across professional and hierarchical boundaries. The dynamic in an organisation changes significantly when you hear a Chief Executive speaking about a patient he’ll never forget, a Medical Director recounting an experience that has stayed with her for over thirty years, or a Nurse Director describing the impact on her of a poor outcome for a patient and their family. People often comment that, if you’ve heard someone share a story at a Schwartz Round, it becomes easier to contact them in day to day work.
Hearing about the impact of events on our colleagues opens our understanding of the personal toll of working in healthcare. Who would have thought that the death of a patient would impact colleagues working in departments which may not have been considered ‘front-line’? I remember a situation where the kitchen staff realised that the name of a long-term patient was no longer on their list for special meals. On finding out that the patient had died, they held a minute’s silence in respect. Likewise, what is the impact on colleagues working in our laboratories when preparing test results that can only indicate a very poor prognosis? The Schwartz Round is the safe forum for discussing and reflecting on these challenges.
‘Powerful and emotional. You do forget that other colleagues feel the same as you’.
‘It’s important that we get staff off the wards to attend events like this. It’s for their wellbeing as they are faced with these scenarios and stories every day’.
‘Glad to know that I’m not alone in trying to walk in other people’s shoes, and walk their path along with them in support’.
A supported workforce in isolation is not enough. We also need strong clinical leadership to ensure that the norms and values of our NHS reflect its core purpose and its workforce’s values. When the NHS was founded in 1948, its core work value was compassion, to serve a society still deeply traumatised in the aftermath of war. 70 years later, compassion continues to fuel those working for the NHS. We therefore need leaders at every level in every NHS organisation in Scotland to embody compassion.
Professor Michael West is a Professor of Organisational Psychology at Lancaster University Management School and an expert on leadership within the health service. He is also co-chair of a UK-wide review of medical students’ and doctors’ wellbeing. Professor West’s vision of ‘compassionate leadership’ is one that we must adopt in order to support our workforce to deliver Realistic Medicine. He argues that it is not difficult but it relies on four behaviours:
- Attending – paying attention to staff and ‘listening to them with fascination’;
- Understanding – talking with staff to understand better the challenges they face in delivering care;
- Empathising – displaying empathy to staff, particularly as we know that between 30% to 40% are experiencing chronic stress;
- Helping – maintaining a focus on helping staff to do their jobs effectively.
For many years, research has demonstrated that these four behaviours are fundamental to effective leadership, with listening being the most important skill for a leader and helping being the most important task.28,29 Compassionate leadership ensures high levels of staff engagement, a key factor in strong health service performance, care quality and patient satisfaction. In turn, there is more quality improvement and innovation and better relationships between all groups involved in the delivery of health and care.
Peter Homa echoes Michael West’s sentiments by talking of ‘compressing the distance between board and ward’. We need to make sure that board members and other senior leaders are not satisfied simply with attempting to understand their organisations through written reports. Instead, they must triangulate this by investing time in visiting and listening to staff in their workplaces.
Patient safety conversations are a particularly potent mechanism for understanding the challenges that staff face. Simple but open questions can unlock a wealth of vital information – How safe is this ward or department? What was the last harm event? What do you think the next harm event will be? What might we do to avoid it? By listening to staff and valuing what they say, everyone finds greater meaning in their work and, importantly, patient care improves.
Culture of Stewardship
‘A good steward leaves the farm in a better condition than they found it’.
To build a more personalised approach to care today, we need the three components I have discussed already: engaged patients, a supported workforce, and compassionate leaders. However, to deliver Realistic Medicine into the future, a fourth component is also required. It’s what Muir Gray calls the ‘culture of stewardship’.
Stewardship refers to holding something in trust for another generation. We must recognise that we are responsible not only for the health service of today but also for the health service of tomorrow. This means making good decisions that focus on delivering better value care and creating a culture that will deliver a sustainable health and care system for decades to come. For parts of our Realistic Medicine vision, this can be thought of as prioritising those things that add value. For the principle of personalised care, this means placing the patient at the centre of our health and care system whilst also recognising that our workforce is our most valuable asset and needs to be supported now and in the future.
Creating environments where staff feel valued, respected and supported is vital if we are to retain and develop our workforce to respond to the challenges of delivering a world class health and care service for the people of Scotland. To do this, we must properly understand the challenges faced by our staff and we must support them with effective, compassionate leadership at all levels and in all places. Our call to develop a culture of stewardship is not just about how we create clinical value for our patients, but also about how we value and sustain the very people who provide this care every day. Peter Homa is frank in his assessment of the challenge ahead:
‘the question is not if the opportunities for improvement exist but if we choose to take them’.
By practising Realistic Medicine, we can make it the latter.
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