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'Nurses are by far the largest part of the workforce and any successful change must involve them'

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The political parties have published their manifestos and the NHS is firmly in the spotlight. Even nurses have made it onto the wish lists – sorry, manifesto promises.

Chris Hart

Chris Hart

More money for the NHS, more nurses, higher pay for nurses. It’s a shame we can’t vote for every party and really hit the jackpot.

And yet.

For all the talk about extra money and improvements, of change to reverse the change that was changed to reverse the last change, further cuts loom and no politician seems able to solve a problem that has been there since the inception of the NHS – how, and by whom, it should be managed.

If we were referring to a new medical diagnosis, we would be describing it as mural dyslexia – the inability to read the writing on the wall.

“If we were referring to a new medical diagnosis, we would be describing it as mural dyslexia – the inability to read the writing on the wall”

That writing tells us that those charged with the safekeeping, development and good management of the NHS have failed miserably over the past few decades. At the heart of that failure has been the refusal to involve nurses other than at the margins. And nothing will change until that policy is reversed.

Nurses are by far the largest part of the workforce and any successful change must involve them. Moreover, they understand the problems of the service and – given the opportunity - have the solutions.

Indeed, it was almost 20 years ago that Frank Dobson, the then Health Secretary, had to tell an audience of NHS managers that nurses were “part of the solution for the NHS, not the problem.”

He was highlighting an issue that has progressively worsened since the introduction of general management in the 1980s, was exacerbated by the centralisation and targets of New Labour and finally pushed over the edge by the Coalition’s combination of severe cuts and the most chaotic reorganisation of the past 70 years.

So why has this wholly dysfunctional system been allowed to persist?

Largely because of class, gender and power. The vast majority of nurses are female and from far poorer backgrounds than their medical colleagues.

“Why has this wholly dysfunctional system been allowed to persist?”

In 1948, civil servants regarded nurses as little more than “one step up from domestics.” They formed a strong alliance with hospital managers and, of course, the medical establishment who are extremely reluctant to give up the power they’ve wielded to such advantage for so long.

Has much changed since then? Certainly not in terms of involving nurses in policy and decision making.

Successful healthcare systems are built upon the principle that they’re relatively simple in structure and effectively managed. It’s clear the NHS currently lacks both elements and continues to thrive as much as it does due to the efforts of its staff. But rather than focus on further costly reorganisations, all the evidence tells us effective management can be introduced relatively quickly and cheaply.

And, potentially, it can save billions – if nurses are given authority and involvement in decision making at every level. Not in the old way, of being bumped up to ward manager and then ‘senior’ manager, with no preparation, training or support. Nor working within a half baked model of business management that is doomed to fail because it doesn’t recognise the NHS is a public service and works to an entirely different economic model.

“A new managementmodel is required”

A new managementmodel is required, underpinned by different values, operating within a different culture. It needs to be peopled by those who understand and represent the workforce, who can integrate the clinical and administrative agendas of the NHS and deliver effective change alongside those people it manages.

Nurses need to be at the heart of that change because, as well as its sheer numbers, nursing holds the key role in the world of healthcare, providing the continuous human interface between the service and the patient.

It can be an overblown cliché, lost in the mythology of ‘angels’ and notions of vocation, but there is something unique about nursing and the work nurses do, the emotional labour, the time spent caring for the sick and the dying – far more than any other healthcare professional - involved in every aspect of their care.

“There is something unique about nursing and the work nurses do”

This is about relationships and, inevitably, the nurse-patient relationship will be modeled on that between the nurse and manager.

We could have 600 Cs and still find ourselves bedeviled with problems unless this relationship is fixed once and for all; it is crucial to creating a stable framework within which the decisive nurse-patient relationship can flourish.

Of course, proper training and support for managers, as well as systems and organisation are an essential part of the equation. But evidence suggests an effectively managed, equitable service, that values and reasonably rewards its staff, and involves them in key decisions will create a more stable, better motivated workforce.

The potential benefits are immense.

Improving recruitment and, most particularly, retention would cut the billions lost on agency staff. What immediately flows from that? Greater consistency, team working and staff satisfaction would increase clinical effectiveness, which would impact positively on patient care, in turn impacting on discharge rates, both in hospital and the community.

A simple change could be transformative.

“We could have 600 Cs and still find ourselves bedeviled with problems unless this relationship is fixed”

Yet, depressingly, it doesn’t feature on the radar of even our so called ‘radical’ politicians, let alone get into any manifesto.

However, if the next government doesn’t act, the outlook for nursing must be bleak.

Universities responsible for future generations are immersing themselves in the same toxic mix of targets, checklists and an unthinking ‘training by numbers’ response to every ill thought out government initiative.

Meanwhile, the level of disaffection, disillusionment and distrust among the existing nursing workforce seems ever more widespread and though most nurses find the reward and satisfaction of nursing still there, few enjoy the way they are managed or think of their NHS Trust as a good employer, which is a dreadful – and unnecessary - state of affairs.

The writing is, indeed, on the wall. Will any politician, anywhere, take the trouble to read it?

Chris Hart is senior lecturer in mental health at the faculty of health, social care and education at Kingston University and St George’s, University of London

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