THE CHANGING PERCEPTION OF SERVICE DELIVERY
Previously the NHS has been service-led, with an authoritarian, ‘top–down’ approach. The medical model of health care has predominated (Burke 2001). In recent years there has been a paradigm shift in the underpinning philosophy of care delivery, and the focus is now on providing a patient-centred service based on local need (DOH 2000a), which is identified through exercises such as community profiling. There has been a conceptual shift away from illness orientation to health promotion (Naidoo and Wills 2000). There is a greater focus on the social aspects of people’s lives that may affect their health. The individual, whilst being consulted over services, is also being expected to take some responsibility for his/her own health. However, it is recognised that health promotion strategies need to be targeted beyond the individual’s behaviour, as the health of the general public is affected by many factors over which they have no personal control: for example, global warming and air pollution.
The government’s commitment to supporting healthy living initiatives is demonstrated through the introduction of services such as smoking cessation clinics (DOH 1999b). This particular initiative has been placed within the remit of health visitors, district nurses and practice nurses. Their autonomy in this area has been further recognised by their being permitted to prescribe the relevant nicotine replacement therapy for the patients involved. Evidence suggests that this activity is one of the most influential health-promoting activities, and provides a measurable impact on health.The National Institute for Clinical Excellence has published guidelines to endorse this (2002). One example of a simple but effectiveinnovationisdescribedbyRoberts(2002), who, in consultations, used three key questions to determinepatients’readinesstogiveupsmoking.The answers given by the patient indicate whether they are definitely resolved, or are considering ‘quitting’ but require more support to do so. This then enables the practitioner to arrange a suitable follow-up appointment to provide that support. The new agenda is being directed by publications such as The NHS Plan (DOH 2000a) and Shifting the Balance of Power (DOH 2001a), which have evolved from The NHS: Modern, Dependable (1997). It will be influenced further by the forecasted demographic trends over the next 20 years – trends that have been substantiated in the 2001 census. This identified a greater proportion of the population being over the age of 60 than under 16 for the first time. The implications of this fact are enormous, together with the evidence that suggests that a quarter of the health care accessed during a person’s life is accessed during the final years (Wanless 2001). The infrastructure of the NHS has been radically altered. Primary care trusts (PCTs) have now emerged as the main provider of services. Revenue released from the Department of Health gives PCTs control of 75 per cent of the total health budget (DOH 2002b). Services are being delivered in innovative ways: for example, walk-in centres, NHS Direct. PCTs are now commissioning services at a local level, sensitive to the specific needs of their communities (DOH 2002b). Personal medical services (PMS) demonstrate this concept, and walk- in centres provide quick and effective access for clients, especially those who, because they are working full-time, may have found surgery hours prohibitive.
These initiatives have also led to an expansion of nurse-led services, and the timely extension of nurse prescribing has enhanced nurses’ contributions to this target. Other examples of innovations have been in operation over a longer period of time. ‘Intermediate care’ (DOH 2001b) is well established in many communities and offers a service that reduces pressure on acute beds, whilst meeting the needs of clients more effectively than previous arrangements, which were less flexible. This has provided the opportunity for targeting local problems with the appropriate services, building on previous initiatives evidenced by health action zones (HAZ) and health improvement programmes (HIPs) (DOH 1997). More recent publications (e.g. DOH 2002c) provide guidance on the priorities that local organisations are required to consider when planning future developments in community services. The main theme of this document echoes the underlying philosophy of service delivery in acknowledging the perspectives of all parties involved, including the patient. The public health agenda has also been emphasised, as each PCT is required to have a public health professional on the board. This emphasis is further demonstrated by the development of roles for health care professionals that are concerned with promoting public health. Within some community specialist nursing disciplines this has engendered a new conceptual base to the provision of services, particularly significant within the realms of school nursing and health visiting. Historically the school nursing service has been responsible for duties that have mimicked a medical model of care concerned with the completion of school medicals and health screening and surveillance. This image is swiftly changing, following the publication of School Nursing: A National Framework for Practice (CPHVA 2000), which identifies the school nurse as a dynamic member of the multi-disciplinary team, more involved than previously in issues of health promotion and education. A clear example of such innovation has been provided in Liberating the Talents (DOH 2002a), in which a school nurse describes her development of a profiling tool that identifies health and social issues within the school population so that these can be targeted to improve health. It is increasingly obvious that the way that health care is delivered has been influenced by a shift in focus and this is common to all community disciplines. The practitioner’s role is increasingly evolving as one with political and ethical dimensions. One clear example of the public’s behaviour being affected by the media and their own interpretation of risk has been demonstrated through the MMR (measles, mumps and rubella) vaccination debate. Clinical staff were in a prime position to offer advice and influence behaviours. The health consequences resulting from the non-uptake of this vaccine were not clearly defined and therefore the public may not have been fully informed as to the implications of their decisions.The outcome has been that now there are unvaccinated infants susceptible to contracting these communicable diseases and the ‘herd’ immunity relied upon to control them is lost (Lewendon and Maconachie 2002).
Currently practitioners are trying to understand and manage transition. New roles have been created, job descriptions reconfigured and employees are reorientating to their new responsibilities within the emerging structures. These events have taken place against a backdrop of quality enhancement and clinical governance (DOH 1999d). There is a focus on measuring and justifying the delivery of services whilst ensuring that the patient’s perspective is sought and documented (DOH 2002c). For those engaged in delivering services and providing continuity of care whilst all the reorganisation is occurring there is a sense of unease and instability. These behaviours can be clearly related to Tuckman’s (1965) model of group life in which the group of individuals pass through several stages of ‘forming’ and ‘storming’ prior to settling into any type of team formation that is able to perform effectively. However, it is an environment that can provide opportunities for those who feel enabled. Other practitioners may resist change by raising barriers to prevent any development being successful. These issues will be considered later, and coping strategies discussed. Other major influences on the delivery of care are the monitoring procedures established to measure performance and the penalties incurred for failing to achieve targets. The National Institute for Clinical Excellence and the Commission for Health Improvement are both involved with ensuring quality in health care delivery underpinned by the implementation of research and evidence-based practice. One key element of the new approach to the delivery of health care has been the emphasis on widening access. The changing perception therefore relates to both patients and staff as new initiatives are operationalised. The intention is that patients see a health service that is responding more appropriately to individual need and staff are increasingly aware that the provision of care is becoming more patient focused. The new public health agenda has a strong emphasis on involving, inspiring and supporting local communities to undertake projects in which they, the public, propose and lead the changes (James and Barker 2001). It may be useful to view this concept in relation to the principles of ‘social marketing theory’, first described by Kotler and Zaltman (1971, cited in Lefebvre 1992 ). Lefebvre’s (1992) definition states that social marketing is ‘a method of empowering people to be totally involved and responsible for their wellbeing: a problem-solving process that may suggest new and innovative ways to attack health and social problems. It is not social control.’ The principles are adapted from a business base but have relevance to the introduction of health promoting behaviours from a micro and a macro perspective.
THE ORGANISATIONAL CULTURE
Central to the notion of patient-centred care is the fact that a new approach is necessary. The structure of the whole organisation has been radically altered to facilitate this. Care cannot be delivered in a vacuum so the devolving of decision making and commissioning to localities should assist in the provision of services sensitive to local need (DOH 2002b).
However, these policy initiatives cannot be introduced without a consideration of the staff who will be implementing them. Many of the changes have already caused confusion as new roles have been established and new services developed. Sometimes this has been done without considering the services already in place. Poole (2002) advocates that real working in primary care necessitates an understanding of the complex issues involved. The nature of the work concerns investing in relationships and dealing with people who do not function in a predictable way like machines. Consequently staff must also adapt to the situations in which they find themselves and be aware of the loss of control that might be experienced. The authoritative or ‘top–down’ model of health care delivery has been succeeded by a more democratic, negotiated model. Poole offers some practical strategies for coping. She suggests that those delivering the services should invest time in developing relationships rather than focusing on roles and functions. Other essential considerations are flexibility in structuring working practice and, underpinning this, a sound communication system.
Community nurses are central to the delivery of the change process. The clinical governance agenda strongly influences working practice, with audit being an important component of practice. The nurses’ contribution to the development of a ‘new NHS’ was documented in Making a Difference (DOH 1999a). This publication outlined the leadership qualities necessary to manage a swiftly changing service and initiated programmes such as the LEO (leading empowered organisations) programme to prepare nurses for their pivotal role (Garland, Smith and Faugier 2002). A culture shift has also been experienced as budgets were amalgamated between health and social services. This was to promote the provision of a seamless service and to encourage integrated working, necessitating the removal of professional boundaries. One practical example of the Department of Health’s commitment to such initiatives is the ‘Single Assessment Process’ outlined in National Service Framework for the Older Person (DOH 2001b). This has required professionals to co-operate in new ways to deliver appropriate care. Wild (2002) comments that a truly person-centred approach will only be achieved when professional boundaries have been dissolved.
Public service management styles require to be analysed in order to understand the philosophy underpinning the change of emphasis. The evolution of PCTs has ensured that the hierarchical and bureaucratic structures formally associated with health service management are becoming flatter and more democratic, with decisions being taken by those who are closer to the point of delivery and more aware of the outcomes. The NHS bears little resemblance to the organisation it was even a decade ago. Confusion persists over the new structural components and role definitions. Job titles appear creative and expansive as boundaries and expectations have not been clearly identified. ‘Skill mix’ has become a term encompassing innovative strategies to develop members of the workforce to enable them to offer support in a variety of ways; for example receptionists who are also trained as phlebotomists and ECG (electrocardiogram) technicians.
Localities operate in very different ways, and moving from one area to another can provide a culture shock in itself. The sense of change in the organisational culture is devolved to a very personal level. However, the reorganisation of community care is a constant feature throughout. The drivers for change are also similar, but the interpretation of how the agenda will be met may vary enormously according to the location in which the care is delivered.
NEW WAYS OF WORKING
The NHS Plan (DOH 2000a) has outlined a 10-year plan of investment and reform in order to modernise the NHS. The workforce is central to that plan. As previously noted, the NHS must acknowledge that a culture shift is required. Bureaucratic management concentrating on service provision dictated by resource allocation is no longer acceptable. A dynamic and flexible approach is advocated, which places the emphasis on patient participation in decision making. This approach must be transparent, and a variety of options have been developed to facilitate this.
The introduction of local patient forums and the formation of patient advisory liaison services (PALS) indicate that the public are being consulted (Chapman 2002). Collaborative working must be embraced in its widest sense – to include the recipient of care. Further evidence of the government’s commitment is clearly demonstrated by the introduction of the white paper The Expert Patient (DOH 2001c). Whilst acknowledging that many patients with chronic diseases have a more in- depth knowledge of the personal management of their particular condition than the professional, it also conveys the message that patients are able to be more independent if encouraged to take control of the management. This relates to the theory described by Rotter (1954) concerning ‘locus of control’. It is also aligned to the concept prevalent in the government documents that the patient should remain in control of the decisions about their health and treatment.
Health promotion strategies to prevent the onset of chronic diseases such as coronary heart disease and diabetes are also advocated. Again the government’s commitment to this has been demonstrated by the publication of national service frameworks, for example DOH 2000c and 2001b, which prescribe standards, respectively, for the care of individuals suffering from coronary heart disease, and for the care of older patients, in order to provide equity of care throughout the country. Integral to these frameworks are initiatives concerned with providing both primary and secondary prevention. An example of responding with a team approach is quoted by Fairhead (2003), who describes how a community mental health nurse worked alongside a practice nurse to develop her expertise in managing patients with depression. The general practitioners and patients gave a very positive response, when surveyed, to the resulting improvement in services.
New ways of working are emerging in response to the demographic influences within the workforce. The shortage of nurses is already apparent, and is set togetworse,particularlyastheprofileofcommunity nurses indicates an ageing population. The problem was identified in 1999 (DOH 1999a) and a response by the government was to provide more training places. However this was not sufficient to resolve the problem. Other solutions have been considered, various of them initiated by the document A Health ServiceforAllTalents(DOH2000b).Cadetschemes have been reinstated. Further incentives have been provided for those workers (health care assistants) withNVQqualificationstoundertakemorein-depth training. These schemes are supported by their employers and delivered in the workplace environment whilst they continue with their employment. This has several advantages in that the workforce is not depleted whilst the care assistants are training and they continue to receive a salary whilst extending their knowledge and skills. Once trained, their employment status will be enhanced to that of ‘assistant practitioners’. They will also qualify academically with a foundation degree (Greater Manchester Workforce Development Confederation 2002). The intention is to initiate a ‘skills escalator’, whichpractitionerswillbeableto‘stepon’and‘step off’, to provide flexible learning and training, accessible to all individuals at all grades (DOH 2003). The government has pledged its commitment to initiatives to educate the workforce and support life- long learning for all sectors of the workforce, and such initiatives as this demonstrate the commitment.
Flexible working is further enhanced by ‘family- friendly policies’ advocated in such documents as Improving Working Lives (DOH 2002d) The emphasis is on recruiting and retaining staff by offering working hours that complement domestic responsibilities. As previously discussed, the different community disciplines are challenged by a variety of demands according to their roles, although some issues are common to all. This is considered within specialist practitioner degree courses. All community nursing professionals are educated within a core course which includes a specialist element to reflect their specific discipline. This demonstrates the value placed on all these professionals’ contributions to the primary health care team in fulfilling the health improvement agenda.
The NHS Plan (DOH 2000a) placed great emphasis on the development of integrated teams and this was to include practice nurses, who historically have been set apart from their community nursing colleagues due to their employment contracts with GPs. In many instances these arrangements are changing following the formation of PCTs. New ways of working and managing care are continually being influenced by advances in technology and the health service’s attempt to embrace them. Examples of such influences are the increasing use of telemedicine and the computerisation of patient records. The improvement in communication provided by these systems with their ability to transfer information, particularly between hospitals, laboratories and surgeries has an impact on patient care.
KEY SKILLS FOR LEADERSHIP AND MANAGEMENT OF CHANGE
The community environment is changing beyond recognition and there is a requirement for practitioners to change their ways of working to manage it. Practice development can be achieved in many different ways and the success of it depends on the management of change. As previously stated, examples of innovative schemes have been published in the document Liberating the Talents (DOH 2002a). This publication describes creative ways in which health care can be delivered, acknowledging the fact that 90 per cent of patient journeys involve a contact in primary care (O’Dowd 2002). Unsworth (2001) contends that within the NHS professionals are expected to plan and implement change in practice, often with very little support. Business organisations meanwhile will import experts to manage the change process. These approaches to managing change refer to ‘external’ or ‘internal’ change agents (Broome 1998). However, change management is a complex process for which practitioners need adequate preparation. The requirement for preparation was clearly identified in Making a Difference (DOH 1999a) and reinforced in the recommendations of The NHS Plan (DOH 2000a), in which nurses were proposed as the main implementers of the new agenda in practice. A national nursing leadership project, initiated by the Department of Health, is providing training for those considered best placed to move practice forward, advocating an empowering approach. Well established in this area is the LEO (Leading an Empowered Organisation) programme (Garland, Smith and Faugier 2002). The Department of Health has invested in a variety of measures to ensure that leadership training is devolved to all levels of staff, since leadership qualities do not necessarily only exist within those staff in positions of seniority. Clinical ‘change agents’ do not need to be team leaders but any practitioner who is supported to change practice.
Certain approaches need to be considered if change is going to be effective and smoothly implemented. A primary consideration is that of planning the change and providing a sound rationale for the need to change. If this is clearly articulated and agreed by the team members the chances of success are more likely. The nature of current change is that it is government-led and -driven, which means that it is difficult for the practitioner to see the need for change or take responsibility for it. This often leads to resistance and hostility. It is vital to consider the perceived benefits of change. SWOT analysis is a useful exercise that will help practitioners do this (Adams 2000). It involves compiling a list of statements that identify the effects of the change under four headings: strengths, weaknesses, opportunities and threats. It must be remembered that the type of change mainly associated with the new arrangements is ‘imposed change’, often unplanned and swiftly introduced, and with those people who will be most affected are not being consulted over the best means of implementation. Unless SWOT analysis shows obvious benefits to all concerned, practitioners will continue to lack enthusiasm and motivation. It is clear that change cannot be effectively managed unless certain procedures are followed to identify the need for it: for example, audit, research, reflection, SWOT analysis (Adams 2000). These provide the evidence for change, after which planning the change process must be undertaken. If the ideas of those who will be involved are incorporated, or their comments sought, they are more likely to support rather than resist the change. ‘Planned change’ is generally better received and more likely to succeed than ‘unplanned change’ (Broome 1998). It is worthwhile pausing here to consider the components of change management theory discussed by Lewin (1951), as these underpin any strategy that may be devised to manage change in the working environment. Lewin describes a three- stage approach: unfreezing, moving (or changing) and refreezing. The unfreezing stage concerns recognising that a change is necessary. This need may be identified through reflective practice or examining research that promotes different ways of working. The change requires planning in order to achieve the proposed outcomes. Finally, once the change has been implemented refreezing occurs as the new practice is adopted. As with any new initiatives there will be those who are motivated to change and those who are cynical and less keen; enthusiasts ready to accept and implement change; but equally ‘laggards’, who are difficult to convince.
Managing these ‘laggards’ is the real challenge, and the leadership style of the person who is facilitating the change is relevant to success. Styles of leadership vary according to the character of the individual and their position in the organization. The above is an extremely simplified explanation of the change management process. In reality, the successful implementation of a change in practice is a complex task. Mulhall’s text (1999) examines various theoretical perspectives. Ultimately however, the culture of the practice environment has a strong determining influence on whether the change is effectively introduced and adopted. Therefore practice development is the remit of all staff, and to achieve success in this area requires an inclusive approach, in which everyone feels they can contribute.
It is necessary and indeed the responsibility of all NHS employees, in order to meet the demands placed upon them, to become involved in providing a service that sets the patient at the centre. It is also important that health professionals are responsive to the feedback offered by the patient (Hollins 2002). If the targets of the NSFs are to be met, practice innovation and new ways of working are required in which individuals are empowered to be self-supporting in taking responsibility for their personal health and wellbeing and that of their community. Models of community health practice (Chalmers and Kristajanson 1989) and practice development (Page 2002) can provide a framework for this activity. The community nurse’s role is multi-faceted and the approach must be adaptable in order to respond to the variety of caring, supportive, or pro-active roles that she may be required to adopt in this diverse area.
The Chief Nursing Officer summed up the diverse roles of primary health care practitioners when briefing PCT lead nurses:
It isn’t just what you do that matters, it is also how you work that is important – putting the patient and community first, empowering front line staff and working in partnership across health and social care. (Mullally 2002)