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Practice comment

Join us to show your commitment to the eight high impact actions


Variations in practice must be eliminated to drive up quality care and cut costs. Nurses are ideally placed to lead this challenge, argue Katherine Fenton and Julie Halliday

The dual challenge for nurses and midwives of improving quality and productivity in the NHS is arguably more important now than ever before. The last decade has seen unprecedented investment in the NHS, rising to £118bn in 2010-11. This investment was to improve outcomes while also improving productivity.


The coalition government is committed to reducing the national deficit; all public services, including the NHS, are to play their part in this.

Nursing and midwifery workforces are seen by some as a relatively easy target, as they represent the largest single section of the NHS workforce.

Our plea is that rather than respond to others leading the quality and productivity challenge, nurses and midwives should take the lead. Those who have experienced the slash and burn method will welcome alternatives that keep patients at the heart of services and improve quality while also delivering cost reductions.

Poor quality is common and costly and the need to respond quickly is imperative. Given the size of the challenge, nurses at or close to the front line are extremely well placed to respond. There is evidence supporting the view that savings can accrue from quality improvements, which is where the eight high impact actions for nursing and midwifery come to the fore.

We know that nurses and midwives can lead change and innovate to improve services for patients - but we also know there are undesirable variations in practice and standards, sometimes between wards in the same hospital or between different community nursing teams. We also know that one in 10 patients admitted to NHS care are harmed.

There is strong clinical evidence on what works best, so why is this not universally applied? Just think what nurses and midwives could achieve for patients if this variation and harm could be eliminated. And then consider the options if we do not do so.

The high impact actions, launched last November, are being led jointly by the Department of Health, strategic health authority chief nurses and the NHS Institute for Innovation and Improvement. The NHS Institute published The Essential Collection on 28 June to inspire nurses and midwives and provide a range of live examples where quality has been improved and costs cut. The eight actions are not new, but their universal implementation could reduce variations and reduce the costs associated with poor quality.

We should not assume all nurses and midwives are equipped for the challenges; improvement skills, including learning how to measure what we do, play a part. A refresher on the current key aspects of best practice in the eight actions is planned.

We ask you to join the “I am committed to HIAs” campaign. You can do this via the NHS Institute website or by emailing

We want to make variations in practice and unnecessary harm things of the past. We all have a common aim: that whether patients are admitted to hospital or cared for at home, they all experience the highest quality of care.

Everything has its time - the time has come for nurses and midwives to take a lead in improving quality and reducing cost simultaneously.

Whether you take up the high impact actions or other alternatives, we look forward to seeing the benefits gained as a result of nurses and midwives showing what they are capable of.

KATHERINE FENTON is chief nurse and director of clinical standards and workforce; JULIE HALLIDAY is director of implementation, high impact actions for nursing and midwifery; both at NHS South Central.

  • Click here for the Practice Review article on one of the eight actions, nurse led discharge

Readers' comments (10)


    I am astounded today to read the headlines.On one hand Nurses have been informed that they have a moral duty to save NHS money.and on the other hand they have the role of improving quality and productivity. are we dealing with people here or are nurses working in factories. Next we will have men in white coats walking around the wards doing time and motion on procedures. what is this world coming to.

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  • Sandra I agree with you. The people who come up with these policies and ideas, should spend a month working on the wards and then they will get in touch with the real world. These people are policy makers and live in Lala Land. and paid a fotrune. Far more than the front line staff.

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  • I already do study days in my own time so I can improve the quality of care I give to my patients, but don't get paid for going, if a nurse on the next shift phones in sick I stay on to help my colleagues out, I do extra hours but never get paid or time owing back. If essential items are missing from the ward I buy them from my own pocket. Like so many other nurses I think we've already done our bit of cost saving. Maybe we should vote out some of the chief nurses and nursing directors who have nothing better to say and aren't up to the challenge, just good at passing the book onto frontline staff as usual.

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  • It always seems to be the same message. Its always ward based nurses that are paid the least and are forever being asked to give just abit more. If the quality of care is poor that is more often than not related to ward closures, cutting staff and high stress levels. The realistic expectations of what we can actually achieve is ludicrous within the constraints set. I also end up staying after work, doing study in my own time in order to try improve my practice. They are always bringing out some new policy, equipment, care standard, target that we have to reach, but noone will pay for us to keep up!

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  • I agree with the above comments, how much more can we take on. La la land! you areso right, I really do think that whoever it is wanting all this extra work from ward nurses should come and work for a couple of months, to have an infusion of common sense, and then modify their demands of us. I dont feel like a nurse anymore, I spend more time auditing, and like others, never getting a break, and coming home and trying to keep up to date. I dont feel happy anymore, I feel despondent, and I am planning to retire earlier than I wanted to. I only hope that when it is my turn to be a patient, which I am sure I will be one day, then I am nursed by someone who is looking at me, and not at targets and audits.

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  • If "the time has come for take the lead" for quality and reducing costs then I would suggest it is also the time for them to be empowered to be able to do so. Being told that you have a moral duty to address this, as the NHS Institute has done (current DH funding around £71 million per annum for this advice) does not inspire hope and determination but is simply finger-wagging.
    All wards have managers. These managers have their own managers and all the way up to the top. Where is their lead, their innovation, their ability to transfer policy into realistic, achievable interventions on the wards? It is hard to escape the conclusion that if we need to fund people to tell us that falls and poor nutrition and pressure sores are bad things then we are doomed!
    I love nursing, value the NHS but remain in despair for its future.

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  • Here's a new headline.

    'Join ME in working to rule with the threat of striking, to get better pay, better working conditions, a Nurse/patient ratio and to tell these managers/ government/ leaders/ directors/ quango's, etc they can shove their impact actions and their quotas and their nonsensical money saving ideas up their arses.

    A bit of a long title, but let's see how well that headline goes down!

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  • They really don't get it do they? There's only so many times we can repeat the same message. I actually had a scoot through the document and surprisingly little is relevant to my department with the management we have right now who wouldn't know staff care and support if it had blue lights and bells on.

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  • How much further can we be stretched - doing more with less in a smarter faster way is laudable but not at the expense of the mental and physical health of those trying to deliver these unrealistic expectations.

    I agreee totally with colleagues who suggest those who impose these ridiculous targets /audits need to come and experience their impact first hand. On a 12 hour shift, in the same working conditions as the ward staff, they just might have wit and will enought to think again.

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  • Probably because nurses are taught the square root of sweet F.A. at schools of nursing and have to rely on the sketchy knowledge of most ward staff to develop into paragons of nursing practice? Just a wee thought?.Why very few hospitals have rotation programmes for newly qualified nurses or even those moving to a new area of practice (go on get out of your comfort zone, it's good for you). I made up my own career path through a maze of boredom/interest dialectic and the realisation that I was loosing years of longevity and deep life joy through working nights, weekends, hatchet faced harpies with the I.Q. of a fish telling me to get the patient out of the dept up to the ward NOW!

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