Transforming Primary care:
Vision and Reality
A whole systems approach to developing the workforce
Carrie Jackson & Prof Kim Manley CBE
England Centre for Practice Development
Overview
• Assumptions underpinning presentation – whole systems approaches and
the skills required for culture change
• Developing a shared purpose for primary care. Drawing on:
– Whole systems approach to urgent and emergency care
– Implementing shared values
– Developing shared purposes across organisations: EKHUFT/Community
Trust/Mental Health Trust
• Developing the skills sets to be leaders:
• Aspiring Consultant Programme
• CLP programmes across the multi-disciplinary team
• Community of practice –Health Visiting
• Capturing complex interventions to inform workforce development across
community nursing roles
• Integrating indicators of effective CPD into workforce development,
learning & development activity
Assumptions
• Whole systems approach integrating the role
of systems clinical leadership to make this
happen
• Links between whole systems clinical
leadership and how culture change happens
• Massive recruitment and retention agenda for
all staff means that leadership needs to be
exceptional
Assumptions
1. Patients, service users and
staff are at the top of the
pyramid
Patient/service users
direct service
providers
Support services
Board
2. Culture does not change
through ‘training’, targets,
compliance, directives or top
down cascades
Which Culture?
• Organisational culture?
• Workplace culture?
• Team culture?
• Practice culture?
• Systems culture?
• Corporate culture?
‘The most immediate
culture experienced
and/or perceived by
staff, patients, users and
other key stakeholders.
This is the culture that
impacts directly on the
delivery of care.’
Manley, Sanders, Cardiff,
Webster, 2012
Understanding the culture change
journey (Manley 2014)
Talking about
purpose &
values
Relationships
Agreeing
shared
values,
purpose &
ways of
working
together
(values
espoused)
Challenging
and
supporting
each other to
LIVE the
shared values
& purpose
(values lived)
Embedding
shared
purpose &
values in
systems
(‘Form
follows
function’)
The core values underpinning effective
workplace cultures
Essential Attributes of Effective Workplace
Culture (Manley et al 2011)
Specific values promoted
in the workplace, namely:
•person-centredness
•lifelong learning
•support and challenge
•leadership development
•involvement and
participation by
stakeholders
•evidence-use and
development
•positive attitude to
change
•open communication
•teamwork
•safety (holistic)
Effective workplace culture Attributes 2-5:
Embedding values & beliefs in practice
3. Adaptability,
innovation &
creativity maintain
workplace
effectiveness
5. Formal systems
enable continuous
evaluation of
learning, evaluation
of performance &
shared governance
4. Appropriate
change is driven by
needs of
patients/service
users/communities
2. Shared vision,
values direction
realised in practice,
with individual &
collective
responsibility
Manley K; Sanders K; Cardiff S; Webster
)
2011
• Whole Systems Integrated
Leadership
• Workplace learning
• Growing a critical
community of people with
skills to change the culture
• Celebrate success and
making improvements in
real time
• Working with live feedback
• High challenge high support
• R, D & I programme linked
to shared purpose and key
priorities
Developing a Shared Purpose Framework Manley, O’Keefe , Jackson et al 2014
Project Partners:
East Kent Hospitals University NHS Foundation Trust,
SEACamb, NHS Ashford CCG,
NHS Canterbury & Coastal CCG,
NHS South Kent Coast CCG
NHS Thanet CCG
Kim Manley, Carrie Jackson, Ann Martin
Juliet Apps, Ian Setchfield, Gemma Oliver
Health Education Kent Surrey
Sussex funded project
INPUTS
Enablers:
•Commissioning
•Leadership,
expertise,
ways of working
•Staff recruitment,
competence, role
clarity,
empowerment,
support
•Public information and
understanding
SYSTEMS LEADERSHIP
More than a Case Manager/Co-ordinator!
Culture Change expertise
Joint Appointment
Integrated Urgent &
Emergency Care Whole
System*
(Any place, any context)
SINGLE
COMPETENCE
FRAMEWORK:
Interdependent
Partners
* Criteria identified
•ASSESS
•TREAT
•SORT
In any context
INTEGRATED FLEXIBLE
CAREER PATHWAY
(NHS Career
Framework)
Work based
facilitators of
learning and
development
OUTCOMES
•Timely care at time of crisis
in the right place
•Provision of urgent and
high dependency care to
prevent loss of life or ongoing illness
•Consistent approach to
care delivery across regional
communities and population
Curriculum Content
•HEIs
•FECs
Workplace
programme
Accreditation
•Promotion of positive
workplace culture to enable
person-centred care delivery
•Improvements in mortality
and other quality outcomes
•Effective use of financial
resources through reducing
duplication of effort
A whole systems approach to integrated urgent
and emergency care
COMMISSIONING
• Whole pathway commissioningconjoined information, thinking & funding
in the right place with shared risk-taking ,
Integrated electronic and information
systems to enable data sharing, single
patient record
LEADERSHIP, EXPERTISE, WAYS OF
WORKING:
• Systems leadership that models and
drives integration across boundaries, with
expertise in culture change, effective
teams and enabling
• Access to clinical expertise across system
and wherever it is needed & flexible
referral system
• Integrated collaborative interprofessional teamwork & partnership
working (including first responders and
service users)
• Continuity of service and advice in
different contexts
STAFF RECRUITMENT, COMPETENCE,
ROLE CLARITY, EMPOWERMENT,
SUPPORT
• Appropriate staff levels, role clarity,
competence development and use,
• Strategy to grow and retain staff for a
stable workforce by:
– Career progression framework
– Learning & development incentives
• Appropriate empowerment for effective
decision making
• Commitment to using the workplace as
the main resource for learning,
development, improvement and inquiry
• Strong administrative expertise and
support
PUBLIC INFORMATION
• Public education, and information to
navigate the system
• Clinical expertise, credibility for a specific client group (with
case management) 50-60% of time in direct provision
• Leadership to achieve culture change through working with
shared purposes achieving integrated ways of working and
effective teamwork across primary and secondary care and
partner organisations
• Creating a learning culture that uses the workplace as the
main resource for learning, to maximise opportunities for
learning and development, competence development and
innovation
• Enabling expertise to be accessed by as many people in the
systems as possible through advanced consultancy
approaches
Making the complexity of
community nursing visible
The Cassandra Project
Carrie Jackson, Prof Alison Leary, Tricia
Leadbetter, Prof Kim Manley, Anne Martin, Dr
Toni Wright
False Assumptions about (Community)
Nursing
• We can rely on historical patterns to predict the
future requirements
• Nursing is linear
• Nursing is a series of primarily physical tasks that
occupy time- time and motion
• Nursing is the application of a task based skillset with
little decision making
• Data collection mostly linear-measuring
• Most current IT systems e.g. RIO, System One are
diary based linear tools
Worrying facts
• Robust systematic workforce data is not available for
planning for future needs
• Workload calculations are based on time it takes to
complete a task
• Caseloads vary greatly in number and complexity
• Variation of contact time from 15-20 minutes
• Skill mix varies and current models will not sustain us
going forwards
• How can we really know the cost and impact of care
left undone?
Project Summary
• 18 month research project (funded NHSE,
HEKSS at regional level)
• To find a workload activity tool that would
enable us to understand the complex work of
community nurses
• To develop a method of capturing and
analysing these data
• To test a model (Cassandra) previously
developed for the specialist nurse/case
managing community
Activity of specialist advanced practice nurses
Things that
specialists do
Outcomes
Emotional
effort
Physical
Psychological
Intervention
Social
Things that
Cassandra
records
time
context
Admin
Care
management
numbers
date
form
What does the Cassandra Tool do?
• Minimum 70-100 hours activity per
practitioner
• Intervention, context, time, people, care left
undone/activity left undone
• Instant report generation at 70 hours
• Organisational report providing detailed
analysis of workload activity across bands
Findings so far from pilot
• Approx. 11,000 points of data
• 7,629 interventions collected in 58 regularly
used categories
• Issues with collection (not enough for a “big
data” study) but shows complexity of care.
• 112 examples of care left undone
Spread across the intervention
spectrum (2x context)
Modelling is about building a representative “whole
system” rather than trying to measure bits
Our model gives good insight
Garbage
data
Great
model
Garbage
results
Poor
decisions
Great
data
Garbage
model
Garbage
results
Poor
decisions
Great
data
Great
model
Great
results
INSIGHT!
Next Steps in Cassandra
• Develop data ontology for community nursing
• Data collection allowing for pattern
recognition through NIHR bid
• Optimum caseload calculations using
stochastic methods
• Detailed analysis of workforce resourcing
patterns and gap analysis
• Economic impact assessment through Burdett
Trust programme at RCN
Transcending organisational & workplace
cultures in mental health- the Sophia Project
• 12 months developing a mental health workload
activity tool for community MH teams
• Working with front line staff to develop from scratch
• Using principles underpinning Cassandra Project
• Conceptual model built, Sophia (Goddess of
Wisdom) chosen by staff in open competition
• Ready to test May
• If you are interested in being a pilot site contact us!
Developing skills in culture change
• In house programmes – to develop a critical
community
–
–
–
–
e. Aspiring Consultant programme
Inter-disciplinary clinical leadership programmes
Facilitating individual effectiveness programmes
Medical Clinical leadership programmes
• Communities of practice to develop leadership and
also empowered professionals who can implement
what is required in an integrated way e.g., Health
Visiting
Community of Practice Health Visiting
Research Themes
BEGINNING
END
Getting to know group and networking
Working as a group towards collaborative action
What is a cop?
Developing HV practice as a CoP collectively
Learning about self
Becoming more confident
Clarifying and valuing role
Confidence and clarity with role and contributing
to future health care – more political
Learning about tools to use in practice with teams
Beginning to use tools with others
Developing reflection and enabling skills to reflect
on practice
Becoming reflective and enabling others to reflect,
challenge and support recognising the importance
of feedback
Developing theoretical insights to practice
Theorizing from their own practice
Health Visiting Community of Practice Kent & Medway Action Research Study 2015
England Centre for Practice Development
@CoPKandM
Developing a culture of effectiveness in Health
Visiting placements
Unreceptive/
underdeveloped
Culture
Triggers
•
•
•
•
•
•
•
No shared vision about
Student HV or Newly
qualified HV
Poor retention of newly
qualified staff
Service needs vs. students
needs
Different opinions on
supporting students in
consolidated practice
placement
No team meetings
Staff are not retained
Staff leaving to undertake
specialist roles
START
Source of evidence
PRACTICAL STRATEGIES
 Set up team meetings
 Clarify with Team Leader
the guidance on students in
Consolidated Practice
 Talking to students about
how they are feeling
 Best evidence about
supporting students is
implemented
 Reconnect with values of
the service user contract
between 10-16 weeks
 Developing a learning
culture
 Asking students for
feedback on challenge and
support
AN EFFECTIVE
WORKPLACE
CULTURE
• Retain newly
qualified HV on
qualification
• Students and staff
perceive that the
culture is positive
• Shared vision held
and implemented
about supporting
HV placements and
practice learning
• Team working
• Team strategy for
retaining students
and staff
END
Source of evidence
CPD Impact Tool for quality care: context,
mechanisms, outcome and impact
•
•
•
•
HEE Education Outcomes Framework
Realist synthesis and evaluation over 12 months
2 phases of development
Result an impact tool to measure impact of CPD
learning on patient experience outcomes in the
workplace
• Indicators of effectiveness for individuals, teams,
service and organisations
• IMMINENT RELEASE!
Take home messages
• Future workforce planning and development
requires a whole systems approach
• Focus on development of leadership capacity
across the whole system
• Workforce development requires robust
modelling that takes time
• Innovation should be based on best evidence
rather than fad and fashion for sustainability
• Growing a critical mass of culture change
agents at the front line really matters
Thank you from the England Centre
for Practice Development
@ECPDCarolyn, @KimManley8
@ECPD3
#
WePracticeDevelopers
www.canterbury.ac.uk/englandcentreforp
racticedevelopment
www.facebook.com/groups/ecpd1
• IPDJ free online access journal at
www.fons.org