How to provide better quality care with fewer resources

27 October, 2009 | By Alastair Henderson

Alastair Henderson on improving quality and releasing savings

Maintaining morale and sustaining high quality services against the backdrop of the current economic climate is a leadership challenge that all boards face. We know NHS organisations are going to have to realise billions of pounds of real terms savings and we want to ensure that the quality of services is as good or better than now at the end of the process.

That’s a challenge for boards, managers and staff. So, what are the implications for the largest part of the workforce - nursing staff?

I am clear that employers, as well as the Department of Health and the government, are absolutely genuine when they say they do not want to see an indiscriminate slash and burn approach to cost reductions which will cause long term damage to the service. But there is no single silver bullet to find solutions that cut waste, improve processes and quality, and release savings.

‘We need to enable nurses to spend more time on direct care, a key to delivering the efficiencies required, and ensure support staff are utilised in the most effective way’

The answer will not come from management consultants, academics or even those responsible for policy development at the Department of Health or NHS Employers, although trusts must be open to ideas and support from all quarters. Equally, it is not going to be just the board and senior managers of trusts who are going to find the solutions to help their organisations through these difficult times.

It will come from those staff who, on a daily basis, are working in the system, who understand existing processes - and the frustrations they can bring - and who have the knowledge to suggest the improvements and innovations that will both improve quality and release savings.

So workforce engagement has a central role to play as the recession places demand on the public sector to demonstrate savings and efficiencies while increasing quality and maintaining public confidence. Employers must find ways for staff to contribute their knowledge and share good practice so real savings can be made.
The good news is that there is external support and assistance to help employers.

My own organisation, NHS Employers, has produced a discussion paper to stimulate debate which looks at “the role of the nurse”. Recently, the NHS Institute for Innovation and Improvement launched a website where nurses and midwives can share examples of service changes they have made that have improved the quality of patient care.

We hope that outcomes from the Prime Minister’s Commission on the Future of Nursing and Midwifery will set the context to take forward change.

One of the areas that we will need to revisit is that old question of achieving the right skill and role mix in nursing so that we might improve capacity in the workforce. This is going to be particularly important as we move to degree level registration for nurses.

Nurses should not be wary of this as simply a management plot to dumb down quality and save money.
Employers do not like rigid formulas to set staffing level and mix - although all organisations should have a rationale for setting staffing ratios - but there is plenty of evidence, including that from Mid Staffordshire Foundation Trust, of the importance of having sufficient levels of qualified staff to maintain quality.

It really is about the right mix to deliver the quality of care required using the level of skills for the tasks required.
We need to enable qualified nurses to spend more time on direct clinical care, a key to delivering the efficiencies required, and ensure that clinical support staff are utilised in the most effective way to support this. Employers therefore must engage with their own nursing workforce as they are best placed to advise on the barriers and solutions that exist.

This is happening in many trusts. South Tees Hospitals Foundation Trust is a good exemplar of a trust that has already begun to take steps to free up nurses’ time. Recognising the contribution that support workers give to registered nursing staff, they have sought to further build up the skills of those workers.

At South Tees, a specific role was created for the assistant practitioner which included technical elements of care provision and other responsibilities that normally fall outside the role of the healthcare assistant and, historically, may have been carried out by a qualified nurse.

An initial cohort of HCAs were invited to train in skills that will enable them to fulfil the job description. In this way the trust has not only gained motivated and skilled practitioners who are confident enough to handle the type of work expected of them, but, by ensuring they are appropriately trained, they instil confidence in the registered nursing workforce who feel able to trust these workers to undertake the tasks asked of them and thus have time to concentrate on more appropriate clinical tasks.

As the nursing workforce undertakes what is a historic period of review and change, it is vital that we capture and share these examples of best practice so that they might be replicated elsewhere.

If we do this, and harness this innovation, we do have the opportunity to achieve this grail of better quality and lower cost.

Alastair Henderson is deputy director at NHS Employer

Readers' comments (8)

Philip Darbyshire | 31-Oct-2009 0:05 am
Of course this is not about dumbing down and of course this is a quality initiative as opposed to mere cost saving.

As the great Theodore Dalrymple once observed in another context....... in exactly the same way that Magritte's great painting is: 'This is not a pipe'.
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adam WILLIAMS | 1-Nov-2009 12:24 pm
I think, unfortunately, you are missing the point. None of those 'skills' you mentioned necessarily have to be undertaken by a qualified nurse. Just because a qualified nurse has a diploma or degree does not mean they automatically gain these advanced communication skills you mention.

I believe HCA's can learn and develop these skills and play a valuable role in the team. However, my concern lies with advancing their skills into realms of administering medications. It is my understanding that the qualified nurse 'in charge' of the HCA or team of HCA's would be responsible for their practice. Therefore if an error occurred it would be the registered, qualified Nurse having to answer for it. This i feel is totally unacceptable. HCA's should have specific, standardised additional training to take on these skills if they wish to, and above all, should be answerable to their own practice.

Those with the passion and drive to develop would surely be more than willing to undertake such training? it is inevitable that these roles will develop, as with nursing, because I am undertaking my advanced practitioner training , taking on roles traditionally undertaken by doctors, but this is change and it has to happen. I HAS to happen safely, appropriately and with adequate training, support and regulation.
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Anonymous | 1-Nov-2009 2:12 pm
I think HCA's should be able to train to undertake more clinical tasks. I don't think this has a negative effect on care as long as qualified nurses retain the decision making and delegate these tasks. I completely agree that HCAs should be regulated and completely responsible for their own practice.

At my trust many HCAs have taken additional training and been recognised with band 3 salaries but these tasks (and salaries) are being taken away from them by policy makers, leaving them feeling undervalued. I find it a massive help when I work with a HCA who is observation trained, as it can take a lot of pressure off me.

Unfortunately most of the time even these HCAs are hard pushed with basic care and unable to help. We do not have enough trained or untrained staff and I fear these discussions at board level will just lead to replacing nurses with HCAs.
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Anonymous | 1-Nov-2009 7:30 pm
When push comes to shove and at the end of the day it is all about getting anyone available who will do the job but cost less!!!
In any other successful enterprises ie. business, people who do additional training and take on added responsibilities are financially remunerated. In the NHS it's more a case of "you will do it; but don't expect any monetary recognition".
I am an independent non-medical prescriber who studied damned hard to gain that qualification and prescribe frequently in my autonomous capacity - yet I am on the same salary as other colleagues who don't carry the same responsibility!!!
I do it because I'm patient focused. The Trust does it because I'm cheaper than employing a doctor; and that has nothing to do with being patient focused. No doubt if the NHS carries on along this route in years to come it will be a HCA writing the prescriptions while I perform open-heart surgery on babies and hospital consultants will be found in museums arcane artefacts from the mists of time!!!!
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Pat Huxtable | 4-Nov-2009 4:37 pm
The first reply to this article was anonymous, wish it wasn't! What the writer said is how so many of us older nurses feel. I've recently had to retire through ill health from a profession that I regarded like a vocation, I am saddened by what I see passing for nursing in many respects nowadays and know full well that I'm not alone. There are many within the profession who do not like the way it's going and there are many many patients who bemoan the passing of real nurses, those who care and actually want to look after people in the widest sense of the word.
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elizabeth holmes | 17-Nov-2009 8:51 pm
I can understand many of the comments already made. However, I currently work with a number of HCA's competent in different "nursing" tasks, such as completing baseline physical monitoring, which has given me time to have valuable client interactions.

I am not naive, and whilst my concern is patient care, concerns higher up may sway more towards implications for organisations when things go wrong. That said, if I get a bit more time with my patients because my colleagues are able to competently lighten my workload, I do not see the harm. However, organisations need to ensure basic standards. A central register for HCA's that have achieved minimum standards of relevant courses, such as NVQ level three would be a start.
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Anonymous | 21-Nov-2009 2:49 pm
"The answer will not come from management consultants, academics or even those responsible for policy development at the Department of Health or NHS Employers, although trusts must be open to ideas and support from all quarters. Equally, it is not going to be just the board and senior managers of trusts who are going to find the solutions to help their organisations through these difficult times."

does anybody know what financial impact the employment of this very essential work force's existance has?
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Anonymous | 14-Jun-2010 10:44 pm
In answer to many of the comments and worries listed above, I have worked as a health care assistant on an acute admissions unit for the past several years,and had many training days and weeks in a variety of skills and competacys within the trust I work. This has allowed me to work as a qualified practitioner in venapuncture and cannulation,(once deemed a doctors role) and is now part of my duties I preform on a daily basis. I do not see myself as a threat to the multidisciplinary team that I work with but a vital part of the team, that enhances the way the unit works, patients would have had to wait many hours for the attending doctor to arrive to cannulate the patient so IV medication could be administered or pain relief given, this only has to be an improvement and should not seen as a hindrance or a
threat to the role of the qualified nurse it is after all the patients journey that is important.

Training is ongoing, all aspects of care for the HCA included in this is, the importance of recording and reporting correctly patients vital observations, risk assessments charts such as the early warning score charts fluid balance charts, aseptic technique, safe disposal of sharps.

I have now completed two years at university gaining a foundation degree in health care practices, and did this whilst working full time. This has allowed me to link all of the skills I have learnt and to underpin this with the knowledge the university course has taught me, hoping this has clarified some of the issues addressed in these letters with thanks mary123.

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