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Creating a climate of trust

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VOL: 97, ISSUE: 45, PAGE NO: 33

Mona Walker, MBA, RGN, RHV, is director of nursing, Princess Alexandra Hospital NHS Trust, Harlow

David Gilbert, MSc, is head of patient and public involvement, Commission for Health Improvement, 'London

Involving patients, carers and the public in decisions on care, treatment and service planning and delivery is an NHS priority (Department of Health, 2000). However, organisations are not sure how to implement this.

Involving patients, carers and the public in decisions on care, treatment and service planning and delivery is an NHS priority (Department of Health, 2000). However, organisations are not sure how to implement this.

Patient involvement requires the development of a more inclusive style of leadership and new approaches to health care delivery (Belasco and Sayer, 1993). The Princess Alexandra Hospital in Harlow decided to find a meaningful way of involving patients in improving quality and planning services.

Before the project began, the key principles for patient and professional engagement needed to be defined. Clarity of purpose and careful planning were essential. The Office for Public Management was asked to assist in developing a model that would link patient engagement with clinical governance and the wider professional and organisational development agenda.

Discussions were held with all relevant internal and external stakeholders, including the trust board, lead doctors, senior nurses and allied health professionals, local GPs, community health councils (CHCs), social services and patient representative groups. It was agreed that the project should initially focus on one area of service provision, then be extended throughout the trust.

For a number of reasons, the cardiac service was selected as the area on which to focus. Cardiac services are both a local and national priority, particularly since the publication of the national service framework (NHS Executive, 2000). Also, there was evidence that good cross-boundary working already existed in this service.

The overall purpose of the project was to extend patient involvement at the trust. This would be done by linking developments in cardiac services to the trust's clinical governance framework through:

- Developing work on quality improvement linked to patients' and professionals'/managers' perceptions;

- Developing patient outcomes for future care (based on the national service framework standards/benchmarks);

- Improving and developing work on patient involvement.

There were several key challenges to overcome. The most important were supporting patients and professionals during the process and creating an environment of mutual respect and trust. If the project was to succeed in linking in with existing trust quality and clinical performance indicators, known as Achieving Improved Measurement (AIM), it was essential to change both groups' perceptions from a complaints culture to one of cooperation and shared learning.

Patients as teachers
We decided to use the 'patients as teachers' model (Fisher and Gilbert, 2001), in which delegates from patient focus groups join professionals in workshops to discuss quality in service delivery - what works from a patient's perspective.

We needed to engage key contributors to secure ongoing organisational and professional commitment. The professional and managerial workshops therefore included consultants, GPs, acute and primary care nurses, general managers, senior nurses and primary care managers, as well as the trust's chief executive, non-executive director, chair of the clinical governance committee, medical and nursing director. The workshops then split into groups to develop priorities and action plans to address areas of concern and highlight examples of good practice.

Another consideration was how to involve patient and community representatives, such as local CHCs, which have expertise in patient-centred strategic decision-making and quality monitoring. West Essex and Hertfordshire CHCs were informed about the project and willingly participated in the interactive workshops.

The project
To identify the concerns of people with recent relevant experience, recent cardiac service users were recruited to participate in the focus groups. We invited 250 patients and received about 100 positive responses. Of these, 50 wanted to participate in the focus groups.

Three focus groups were formed and included 33 patients - 20 men and 13 women aged from 49 to 82. All lived within 25 miles of Harlow. There was a good cross-section of life, treatment experiences and socioeconomic circumstances. Patients were paid £15 plus travel expenses.

A topic guide was produced to aid discussion. It covered a wide range of quality issues from a patient perspective. Ground rules, including confidentiality and anonymity, were agreed at the outset.

The groups were independently facilitated and recorded. With participants' agreement, recordings were transcribed and analysed to identify the main themes. Fifteen were identified (Box 1) and both patients and professionals were asked to rank them in order of priority, giving a set of comparative rankings (Box 2).

Supporting professionals
Two facilitated workshops for key personnel were run concurrently with patient focus groups. One aim was to identify participants' anxieties about the process. These included:

- The process itself - confidentiality;

- Previous experience of meeting former patients as complainants initially clouded the process;

- Divergence of priorities - professionals and managers were reassured that the purpose was to agree priorities for action plans and ways forward;

- Where the process linked practically to clinical work;

- Action oriented - would it make a difference?

- Although patients and professionals differed on ranking priorities (Box 2), there was consensus on which required immediate and long-term action.

In a final patient-professional workshop, 10 patients met with about 30 professionals. The project was taken forward in four clusters:

- The way we talk to each other;

- How we work together - the chain of care;

- Support at home;

- Caring for people in hospital.

This project was a powerful way to engage patients, professionals, managers and stakeholders in the wider health economy. By the end of the process there was a collective sense of purpose and a positive and constructive patient-professional relationship. Several priorities were agreed, including the development of patient information, hospital pharmacy and discharge arrangements.

There have been a number of tangible outcomes for the local health service, including:

- Another cardiac rehabilitation nurse specialist has been appointed;

- All information processes have been reviewed;

- Better discharge arrangements and after-care have improved patient throughput;

- The A&E department is working to streamline patient throughput;

- There is a real commitment to ensuring patients have a voice in deciding how services are provided;

- A trust bid to pilot a patient advocacy and liaison service, building on this work, succeeded.

Constructive and positive feedback from both patients and professionals suggests that the project was effective in linking the two groups' views. Both have greater understanding of the complexities of contemporary health care and have benefited from meeting in an environment in which they had equal control over the agenda.

The results have been incorporated into the trust's AIM quality improvement programme. Clinical indicators are devised with patient involvement central to the process, for example, care pathway development and monitoring.

This consultation process can enhance clinical governance and continuing professional development agendas by explicitly linking patients' experiences and views of service quality and delivery with those of professionals. Investment in such work can help to create a climate of trust, resulting in better outcomes for patients, professionals and managers.

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