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Put staff at the heart of the new NHS

by Virginia Patania
26 September 2017

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Virginia Patania of Jubilee Street Practice, east London, explains how patient satisfaction levels transformed when she gave more responsibility to practice staff.

I joined healthcare because I wanted to help design and deliver high-quality services for patients. I work in one of the most deprived areas in England (our index of multiple deprivation is shockingly above 40), and my aim has always been to offer a five-star experience. Humble expectations indeed. Patient experience matters to me. A lot. Yet I don’t think it is quite as important as my staff’s experience.

With the NHS being such a political football, it is no surprise that patient-focused care is a prominent mantra. When it comes to elections, patients outweigh staff in numbers. Plus, we are all patients, right? What’s the big deal?

The big deal is, it’s staff who deliver this patient-centred care. The higher the patient expectations, the higher the demands on a workforce that hasn’t seen a real increase in wages since before London hosted the Olympics in 2012.

The case for focusing on staff is neither new, nor hard to make. There is vast evidence of the links between higher staff satisfaction and higher patient satisfaction, alongside other links to lower hospital mortality levels, infection levels, and better quality of care. Happier staff mean money is saved, as turnover is lower, sick days are fewer, and less has to be spent on replacement agency staff. There is all the anecdotal narrative in sensationalist journalism: is it true that all our doctors are flocking to Australia? Three friends and ex-colleagues come to mind just as I type.

For these reasons, while I fully agree that patients must be at the heart of our design, I feel this particular club already has plenty of members. The one I want to subscribe to focuses instead on staff.

The main way to improve staff morale, for me, is to enable true leadership. Not among the official ‘leaders’, but among everyone. Control, value and autonomy are some of the most powerful and determining pulls of human behaviour.

So I can’t always offer my receptionists a pay rise, and I can’t give my salaried GPs all the admin sessions they’d like. But I can empower them in ways that make their work more joyful, meaningful and engaging. And I’m measuring that difference monthly, by asking them. Not because it’s part of our contract (it isn’t), not for brownie points with the Care Quality Commission (CQC), but because it matters. A lot.

About a year ago, we got rid of traditional pyramid leadership structures. I relinquished the title of practice manager and called myself something more flexible: transformation partner.

Along with my clinical partners, we then tipped the practice upside down, got rid of all job descriptions and started wrapping people around services, and giving them unobstructed authority to run them. These groups of services and people are called circles, and there are as many circles as the functions and services we provide. Each circle has a charter that outlines their budget (if any), its contractual constraints, aims and risk tolerance. And it is self-running. I no longer have active involvement in accounts, HR, rotas or the Quality and Outcomes Framework (QOF). Yet they run beautifully. And our staff morale is at an all-time high, with people coming to work feeling it is within their power to make responsible decisions. This trust has never been (touch wood) disappointed. People behave like children when treated like children. Grown-up systems nurture adult behaviours.

The same goes with staff members’ ability to contribute to change and quality improvement. Everyone in the practice has two jobs: to do their job, and to do it better. The ‘how’ is up to them. Working this way, we have been able to tap into unthinkable intellectual capital. Junior receptionists act as refined data analysts; nurses coach improvement teams; GPs find themselves experts in workflow redesign. Every idea gets tested, and if it doesn’t work, it’s no problem – we’ll stop, learn and move on. But the point is this – there is no ‘manager’ to ask. No senior partner to look to for approval. Seniority has been made redundant by the super-powers we were already employing.

So what’s in it for the patients? Our satisfaction ratings have been on the increase since 2013 – the moment we started focusing on our staff.

Patients are often on the journey with us – when we decide how to answer our phones, patients help us roleplay and write the new script. And the staff are confident in the knowledge that their care will be better. We don’t call it patient-centred care, because we don’t need to. That’s exactly what it is, but staff are leading the way.