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CNO assesses five challenges now facing nursing as well as looking back at past five years

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The chief nursing officer for England has set out five challenges for nursing, as well as five lessons she had learnt and five achievements during her tenure as the country’s most senior nurse.

Speaking at her annual summit in Birmingham, Professor Jane Cummings said: “We have great challenges ahead, as a system, as a profession, as a nation.”

She cited five challenges in particular for nursing and its leaders over the next years.

These were the need to develop nursing in community and primary care settings in order to cope with the demands of an ageing population, boosting the image of nursing as a profession, making sure technology aided clinical practice and tackling the shortages in both staffing and resources more generally.

Challenge 1 – ageing population

The population is getting older and growing. The need for ever-greater efficiency and effectiveness, as the British population makes more demands on the NHS and social care.

By 2020, a million more people over 65. 7,000 people over 100 years old. 10 years ago one person took responsibility for the organisation of the Queen’s Centenary Birthday cards. Today there are seven. Two out of three babies born today will live until they are 100.

So of course we need a sustainable health and social care system, fully integrated, using every penny wisely and well, and we need to constantly drive towards greater efficiency, better outcomes and experiences.

More care delivered in settings other than hospitals. More focus on community and primary care services.

I am pleased to be leading the investment of £15 million in the General Practice Nursing Workforce, recognising the evidence that shows us the pressure this vital group of our profession continue to be under in relation to recruitment, training and the image of primary care nursing. The plan will cover the following areas:

Entry and recruitment; raising the profile of GPNs, increasing clinical placements in GP settings and ensuring standardised induction is in place, along with return-to-practice programmes focused on general practice

Establishing strong GPN teams: increasing access to leadership programmes for GPNs, and working with GPs/CCGs/STPs to make sure these skills are utilised locally, defining what safe GPN teams look like and giving GPNs the tools to assess cultural factors in the workplace that influence how care is delivered.

Enhancing the role of the GPN and retention of the GPN workforce: more opportunities for professional development, accessible, fit-for-purpose training and clearly defined career progression

Expanding the workforce using widening participation schemes and apprenticeship routes: increasing HCSWs in general practice and supporting the emerging role of the nursing associate.

Embedding ongoing support for GPNs workforce into the future: supporting skills development in a range of clinical priority areas such as frailty and multimorbidity and sharing examples of new ways of working

We will be responding to the work that HEE has already done and the QNI and I will work with the Royal Colleges and ALBs to invest in the areas I have described. We will publish a ten point plan in the next couple of months.

In addition to this I will be working with my national colleagues and professional organisations to ensure we go further and develop a framework for community services, learning from our new models of care and vanguards so we have a common national plan for shifting more services into community settings. I will provide the clinical leadership for this programme and we will be shaping this in the coming months.

Integration as we know is an essential ingredient to delivering services and the realities of making this happen calls for strong leadership. That’s why I have featured this in the next session with Duncan Selbie, Jon Rouse, Sharon Blackburn, David Behan and Karen James who will be honest about some of the challenges but also the successes.

If we value our remarkable NHS, then we need to reshape it for a population size and age profile it wasn’t designed to deal with almost 70 years ago.

Challenge 2 – technological revolution

There is a huge imperative to allow new technology to drive clinical practice, as we live through a technological revolution which is sweeping through every area of our lives.

We often think the technology revolution is yet to come but actually drones and driverless cars are already in the skies and on our streets.

This revolution is speeding up: automation, digitisation, and are transforming clinical care as we speak. In many cases the future is with us and we need to recognise it and ensure we play a full part in leading the transformation of clinical care just as car manufacture or high street shopping has done over the last 5 years or so.

Challenge 3 – workforce

As CNO, I am working with the DH to ensure work undertaken by ALBs and partner organisations is coordinated and communicated so we are clear about the impact of workforce developments, the risks we are facing now and what we will need to manage in the coming years.

We need to ensure we do all we can to maximise supply both through our training routes that are now expanding and through retaining the talent we have.

We all have a role to support this work. HEE have led the work to develop new roles and routes into the professions from apprenticeships to nursing associates. In addition, we have work underway led by the NMC on reviewing preregistration standards of education and also work supported by NHSI, HEE and others on defining the standards and competencies of advanced practitioners. A huge amount of work happening to help us manage the issue of supply, demand and retention but the actions we take must add value, support our patients and clinical priorities and ensure we have a workforce to manage the changing needs of our population.

We can be creative through STPs, and the FYFV Delivery Plan, using our leadership and influence to create opportunities for flexible working, encouraging STPs to create training hubs and rotational posts that attract practitioners because it provides not just variety and a chance to develop more skills but it aligns them to the whole environment that the people they care for experience

Retention, is key; flexible working, training and development and encouraging colleagues to look after their health and wellbeing. Understanding what matters to them and building team development plans and individual development plans that create spaces for them to be confident and creative. I am delighted we have a whole session dedicated to what matters to staff in the summit.

For as long as there has been a National Health Service, there have been nurses from other countries. For example, we have rightly celebrated the contribution of the 40,000 nurses who came from the Commonwealth to answer Aneurin Bevan’s call.

Today, around 4% of nurses and midwives in the NHS are from European Union (EU) countries and 10% are from non EU countries.

Following the referendum vote, I issued a tweet which said: “I wanted to take this opportunity to confirm to all EU nurses, midwives and care assistants working in England’s health and care system that you are valued and hugely appreciated. You are an integral and vital part of the health and care family, and your skills and compassionate care directly benefits patients, families and communities.”

Colleagues from the EU face an uncertain future in coming months. They will need our support. They help represent the communities we care for and we will continue to make them feel welcome.

Challenge 4 – resources

We can be proud of how the NHS has coped over the winter and in recent times. Working with tight resources has required tenacity and flexibility which I have seen as I spend a lot of time on the front line.

I do continue to be inspired by the leadership and innovation that continues despite the pressures because our profession focuses on the safety and experience of people like no other.

We have to face the facts though that demand is rising and budgets continue to be tight.

Every penny and resource has to count, every intervention has to have an impact that adds value.

When it comes to commissioning and providing services, Sustainability and Transformation Plans (STPs) are the best opportunity for us to demonstrate real leadership and focus on doing the right things that deliver safety and the Triple Aim of good care, improved health, and best use of resources.

We often talk about efficiency in relation to money but there is another language or currency that demonstrates efficiency and this is where we need to use our leadership.

Take Mandie Sunderland’s work at Nottingham University Hospitals NHS Trust. Mandie as the chief nurse has provided space for her ward nurses to lead the procurement of the best products and supplies that are used by staff on their wards. This has led to increased savings and improvements in patient experience and outcomes.

As a result of Mandie’s work, she demonstrates that we can apply our leadership to make significant savings nationally. Saving 1.3 million on disposable continence equipment equates to 43 band 5 nurses and for wound care, saving £18m equates to 600 band 5 nurses.

In Dartford, 15,600 hours of staff time were released following a lean and leadership course. This equates to 8 WTEs. The release of time is critical and reducing time wasted must be a priority.

Challenge 5 – image of nursing and midwifery

The way nursing and midwifery is seen, portrayed in the media and popular culture affects how we feel as individuals and as a collective. It affects how the public and other professions also see us.

It has an influence on how successful we are at attracting the best, retaining the best and being the best we can be, at the top of our game.

I will be championing a piece of work that will focus on promoting the image and pride of our profession, tackling misconceptions and stereotypes.

I want to build on the fact that 93% of the population trust nurses, higher scores than any other profession. This is a testament to your dedication, your hard work.

Our standing as a profession should reflect this stratospheric level of public support, and so should our status.

I want to make sure this is translated into true pride and respect for what we do and the recognition of the impact of our work.

I’d like to think about the concept of social millionaires - positively impacting on lives of a million people. The NHS, nurses and midwives impact on the lives of over a million people every 36 hours. This has such potential. Each nurse and midwife matters and we should all be proud of that.

Some organisations and teams such as HEE and the RCN have started work on the image and profile of the profession with the focus being on attracting new nurses and retaining what we have. All elements are important and I want to work with you all to ensure we combine our activities so we have a coordinated and cohesive set of messages that realistically build our profile and standing.

We need to work with the profession and the public to do this and today, I have created a space in the exhibition area for you to give me your ideas and thoughts about how we both inspire and retain those we have, and then, use this to inevitably inspire future generations, supporting HEE’s leadership in this area.

Professor Cummings also noted that it was now five years since she had become CNO for England, encompassing a period of “challenge and change”.

The CNO highlighted five areas in particular, in which she thought she had achieved success and was especially proud of.

Achievement 1 – Compassion in Practice strategy

NHS England

CNO sets out five main challenges, lessons and achievements

The first piece of work we did together as a leadership community, and it put us on the front foot before the Francis report landed. It saw us through a critical phase in our history where confidence and uncertainty in the profession was affected. Throughout, I ensured we built national programmes that focused on areas of safety, leadership, culture, measurement.

Through Compassion in Practice, I ensured we had the first national programme on staffing, working with Ruth May and the National Quality Board to develop early guidance that brought focus and attention, discussion and accountability at the very top and ward level about workforce numbers. That was the platform from which we built the safe staffing programme that we have today.

We focused on culture through the work on the cultural barometer and the Compassionate Leadership publication. We developed national leadership programmes including more than 10,000 nurses and midwives attending programmes at the Leadership Academy, with over 50% having since been promoted. We also built and connected new and aspiring leaders through our CareMakers, 900 of which are active and remain our ambassadors today. In the eye of the storm, when nursing was being criticised like never before, we came through better and stronger.

And I am proud to have been the CNO as we all achieved great things and we reached beyond our professions to patients and communities who have championed and influenced work with us. All of this was driven by our values that I clearly articulated through the 6Cs They anchor all that we do. They sustain us. Guide us. Make us who we are.

And building on the success of Compassion in Practice, I launched Leading Change, Adding Value in May last year, reaching an audience of more than 3.5 million people in the first week, both in England and other countries. Leading Change, Adding Value builds on Compassion in Practice but takes us further and turns our collective attention to demonstrating how we as a profession lead in reducing the 3 gaps of health and wellbeing, in care and quality, and in funding and efficiency.

Using measurement as a powerful tool for improvement. It is the framework that is turning our attention to demonstrating our impact through the measurement of the triple aim outcomes, ensuring efficiencies and improvements are not just driven by finances.

Leading Change, Adding Value has had an impact beyond these shores, with our nursing colleagues in other countries engaging with what we are doing.

Achievement 2 – promoting the value of diversity

Our profession must reflect the rich diversity of our society. We owe it to the people we care for so everyone has the chance of receiving personalised care and better outcomes.

I am the national lead for the NHS Workforce Race Equality Standard and I am determined to ensure employees from BME backgrounds have equal access to career opportunities and receive fair treatment at work through clear, measurable and transparent reporting of standards, accompanied by support and best practice improvement programmes that help achieve these standards.

We are all driven in some shape or form to recruit staff to represent the populations we serve. WRES applies to all NHS settings.

We have some confidence that when the WRES data analysis for 2016 is published next month it is likely to show some early signs of an increase in the number of BME nurses and midwives at bands 6 to 9. We will have to wait for the final figures but we are encouraged by the way in which NHS organisations are putting their minds to tackling the waste of talent that previous data has shown.

I am supported by my CNO BME Strategic Advisory Group, whose work and advice I value highly. I want to take this opportunity to thank Joan Myers, the outgoing chair, and today I can confirm and welcome Professor Laura Serrant who has just been appointed as the new Chair. Four new regional co-ordinators will also be appointed very soon.

Achievement 3 – supporting and leading the workforce

Within Leading Change, Adding Value I have ensured we collectively continue our work on staffing. As CNO I have commissioned further work on staffing improvement resources across a range of environments and Ruth May and Mark Radford from NHS Improvement lead this work.

Leading Change, Adding Value, with its focus on the Triple Aim is the perfect platform for the whole series of improvement guides being developed by NHS Improvement which will be launched by the NQB.

The focus of commitment 9 goes beyond the staffing guides and I am determined through this commitment that we work with the system to bring coherence, surveillance and have an agreed narrative about new roles, training routes, and the challenges of workforce supply and demand.

To this end I am supporting the Department of Health to ensure all ALBs come together as system leaders so that we join our collective efforts to do the best we can in the current climate, ensuring we understand the gap between supply and demand and the efforts we need to put in place to have a workforce competent and able to deal with the challenges ahead. I am determined to see the best people coming into and remaining within our professions.

Achievement 4 – developing leadership

We are all leaders. I have worked hard to encourage leadership potential across the system, through the BME leadership programme, the NHS Leadership Academy, and the Nursing Talent Pipeline Leadership development programme.

Leading Change, Adding Value reminds us that everyone needs to recognise their leadership potential. This doesn’t just apply to senior leaders, but all nursing midwifery and care staff.

In the last month we held a Health Care Assistant conference, training over 250 front line members of staff what unwarranted variation is and measuring the impact of what HCAs and care staff do. This will build on the care certificate successes of creating minimal education standards for this important workforce. It was a huge success and we will be exploring how to roll out this out in the coming year.

Achievement 5 – national programmes

As CNO, I lead two national programmes within NHS England: the maternity transformation programme, and the learning disability programme. Challenging, but rewarding work.

We are seeking to transform the delivery of maternity services. New ways of working, new models of care. We’ve been running a number of pilots and change is coming. We want maternity services to be safer, reducing stillbirth, neonatal and maternal death by 50% by 2030. Women want services to be more personalised and family friendly, where they are given informed choice to influence and inform the care they wish to receive. We have developed a new employer led model of midwifery supervision which is currently being evaluated and is due to be rolled out imminently.

I am also the national lead for the transforming care, transforming lives learning disability programme. Through this programme we are reducing the number of people cared for in hospitals and improving community based services, making sure people don’t stay in hospital for longer than they need to and ensuring that the care they receive in both hospital and community settings is of high quality and individuals are supported effectively. Overall, we’re making good progress – the number of inpatients has reduced by 12% from March 2015 to November 2015.

Professor Cummings also set out the main five lessons she had learnt over the past five years. She told delegates she had learnt the “value of resilience” in the “face of pressure, challenges and personal criticism”.

“As nurses and midwives, we all learn early on to bolt on the armour before we face the day, but also the importance of not losing our compassion,” she said.

“We all need to build our networks of trust. Believe in ourselves. Allow others to offer their support,” she said. “And look after our own well-being.”

She also said she had learnt the values of integrity, teamwork, and honesty and also how to navigate complex and changing systems.

Lesson 1 – value of resilience

NHS England

CNO sets out five main challenges, lessons and achievements

Resilience in the face of pressure, challenges and personal criticism. As nurses and midwives, we all learn early on to bolt on the armour before we face the day, but also the importance of not losing our compassion. So we all need to build our networks of trust. Believe in ourselves. Allow others to offer their support. And look after our own well-being.

Lesson 2 – value of integrity

In this job, you see many people come and go. You see them at their best and at their worst. You realise that integrity is an enduring characteristic: unbending honesty, unyielding values, personal honour. You realise something else too: it’s not about others seeing you behave decently and well, it’s about doing it even if no-one is watching.

Lesson 3 – value of teamwork

An individual, cannot hope to make the impact they want inside such a complex system. What you learn is the value of working with others towards shared goals, so we become more than the sum of our parts.

Yes, it can be challenging. People may tell you things you don’t want to hear. People behave in ways you didn’t predict. But true teamwork can be life enhancing, and deliver brilliant results for patients.

I’ve had the privilege of working with patients, families and carers who have told their stories, challenged practice and helped to improve care. People like Melissa Mead, Tommy Whitelaw, James Titcombe, our colleagues with a learning disability who work in our team, Lesley Goodburn (Homeward bound) and Carrie, our Chair who has been deliberately invited to my Summit as a patient and carer.

And I’d like to thank all of you here for working with me for the last five years to tackle the most challenging issues and create the most amazing things. With thanks also to my senior colleagues in all ALBs and professional organisations who work with me to ensure we do the best we can for our profession.

Lesson 4 – to navigate complex and changing systems

The NHS and social care is a labyrinth. It is easy to get lost in it. We can be bombarded, bamboozled and baffled by processes and systems, acronyms and jargon.

Yet often, underneath all that, is a simple truth. A single-minded desire to do the best for people and our patients. So I’ve learned to cut through, face down the frustrations, and make the systems work.

Lesson 5 – honesty

I value honesty. Honesty is at the core of my practice that is realistic and unafraid to call it how I see it. And most of all having the confidence to speak truth to power and doing things respectfully and for the right reasons. To speak up when I need to. And to be unafraid of the consequences for myself.

Most of this happens behind closed doors, along the corridors of power. It goes unreported and unseen. But I want you to know that I never miss an opportunity to speak up for our profession, on the public stage, or behind the scenes.


  • 1 Comment

Readers' comments (1)

  • Regarding challenge 5

    Appearing in and promoting this as the face of Nursing can only make us a laughing stock within and outside the profession.

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