Creating a Culture of Joy in the NHS

A Culture of Joy is the biggest determinant of safe and high quality healthcare! That is such a phenomenal statement that it is worth reading over and over again, making it into a poster, sticking it on your wall and meditating on it morning and night. It feels to be simultaneously absolutely true and somehow beyond belief. I’ve previously blogged here about the need for a culture of kindness in the NHS, and I hold to that – kindness certainly doesn’t exclude joy (!), but a Culture of Joy….. I don’t know, in a day in which 50% of our staff admit to feeling burnt out, can we honestly say we have developed this throughout our health system in the UK? So, what does it take to build this? How do we have a joyful workplace? If it is really the single largest factor affecting patient safety, which research from The Mayo Clinic, The IHI and The Quality Forum tell us it is, then we better sit up, pay attention and do something about it!

 

There are 3 key ingredients to creating a culture of Joy.  The first (and this is in no sense a hierarchical order!) is leadership, the second is how
teams actually function together and the third is personal responsibility. You will see the words incorporated from the ‘culture circle’ in bold!

 

Good Leadership: Here’s a fascinating fact, I learnt from Stephen Swensen, of The Mayo Clinic – The bigger the signature of a CEO, the worse the outcomes for patients, staff and the finances of the organisation!! CEOs are responsible for setting the structures in place that allow healthy cultures to develop. Leaders create a culture of joy by having humility and developing 5 key behaviours:

 

  1. Appreciation – good leaders build joy in their teams by saying ‘Thank You’ – it is one of the things the team at my surgery consistently tells us, as partners. Of course we are grateful, but we don’t say it enough. Every member of a team knowing that they have value is so vital. I remember, as a house officer on a medical ward watching a lady called Jean, cleaning the ward and saying hello to all the patients. I went up to her and said, “Jean, I just want to thank you for everything you do on this ward, every day. The way you keep this place clean helps fight off infections and keeps people well; and the smile and kindness you bring is really comforting to people who are scared or hurting.” To my great surprise, she burst out crying. I asked her what was wrong and she told me that she had worked on this ward for 25 years and no-one had ever said ‘Thank You’ to her. My favourite hashtag on twitter is trybeinggrateful – it costs so little.
  2. Transparency – good leaders communicate openly with their teams. They don’t do ‘special huddles’ in which they invite a few ‘high level’ people to know their secrets. No. They communicate with honesty and openness and this builds trust. And with trust they are able to negotiate difficult situations and requests of their teams, because there is a belief that everyone is in it together.
  3. Ideas – They look to their teams for ideas. One of the things I loved learning about recently is that the CEO of Toyota in Derby, deliberately does not park his car in the special ‘CEO parking space’ right next to the building. Instead, he parks it at the far end of the factory, so that the walk to his office takes him through every department, (a good 30 minutes of his time), so he he can say “hi” to his staff, connect with them and ensure that he is hearing about their ideas for innovation and improvement. Toyota takes 2.5 million suggestions from its staff every year. This simply doesn’t happen enough in the NHS, and I wonder how many CEOs take time at the start of the day, to walk the corridors, listen to patient stories, understand the pressures in the ED, hear the heartbeat of the wards and get a sense of the ideas brewing in some of the most compassionate, caring and intelligent staff of any organisation in the UK. If we are to transform the NHS into a system that is truly safe, sustainable and excellent, we must listen more to the ideas of our teams and in doing so, we will cut waste, undo the reems of red tape and instead find we are working far more effectively and efficiently. To embed this into the culture, there must be psychological safety – that means that no question is too stupid, no idea is too dumb and it is safe to bring to attention concerns a person may have, without a fear of retribution. One great question for leaders to ask is, “what are the pebbles in your shoes?’ – in other words, what matters to you? Or what are the barriers for you here? What’s getting in the way? Great CEOs do not have great answers, they are willing to work with complexity and have great questions!
  4. Career Mentorship – every person needs to be able to keep learning and develop in their role. We all need mentors or coaches at different stages in our careers, and ensuring these structures are in place to support staff as the complexity and pressure we deal with increase, is vital in building joy. People who are developing in their role are naturally safer in their role.
  5. Inclusiveness – To a good leader, it doesn’t matter who you are, what you look like, what you believe, what your sexual orientation or status might be. You need to know that you are welcome and you are loved just as you are. Inclusive teams that do not scapegoat, do not sideline and do not bully are joyful teams. Joyful teams celebrate difference and thrive off it.

 

Joyful Teams:  It’s really important to understand that joy does not mean false happiness. It does not mean that we walk around with fake smiles on our faces all the time and pretend that everything is ok. Joy is much deeper than that. We deal with very sad and difficult things in our workplaces every single day. We break bad news, we hold people as they take their final breaths, we watch people make terrible life choices, we see and carry the hurt of those who suffer loss and each of us has our own burdens we carry from the lives we live outside of work. Joyful teams do not pretend like that stuff isn’t happening every day – quite the opposite. Joyful teams develop three key qualities:

  1. Camaraderie. The high school musical song – ‘We’re all in this together’ is a great theme tune for NHS teams. People need to know that they belong, that they are loved and that people care about them. On good days, we celebrate together, on bad days, we pull together. Joyful teams develop encouragement, support and kindness in how they treat each other.
  2. Purpose. Joyful teams have a real sense of shared vision and purpose. They know what they are there to do and each person knows that they are valued in that team. The posh term for this is a sense of corporate agency. This is our job to do, we are responsible for what happens here and we want to do our work with excellence. 
  3. Trust. It is really important that individuals feel trusted to do their job without feeling like they are always being watched or criticised or that they have to give an account for every action. When people feel trusted, they actually work more effectively and produce better outcomes.

 

Personal Responsibility: in order to create a culture of joy, it is not just the responsibility of the CEO or team leader, nor the atmosphere created by the team as a whole – we each have a responsibility to steward and hold to this culture. And that means taking care of our own needs. We need to be active, eat well, take notice, be mindful, sleep well, forgive those who hurt us and have good friendships. Making sure that we ‘host ourselves’ well, ensures that we play our part in building the culture of joy that is so vital to the providing care that is of the highest quality and safety. There is a personal accountability to ourselves and to those we work with to ensure this is so. There is also personal agency that rises to the challenge that each one of us can set a new trend and make a significant difference to the culture in which we work.

 

In the midst of all we are currently facing in the NHS, for the sake of our patients and their families, it is vital that we build cultures of joy now and cultivate them for the future.

 

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Here we go round the NHS Mulberry Bush!

One of my favourite songs as a 5 year old was ‘Here We Go Round the Mulberry Bush’. I’ve been involved with the NHS for 17 years now and every winter, we do this same dance around Emergency Departments and the total mess that surrounds hospital admissions, discharges and an ever growing list of missed targets. Unfortunately, it no longer applies only to winter. It really is an absolute shambles and the problems are only too obvious. In this blog, I plan to outline them, but hopefully move away from the classic “who’s to blame” arguments and push through towards thinking about solutions…..none of which are easy, but neither are they rocket science!

 

So, here is a list of problems:

  1. We have an increasingly elderly population, who have increasingly complex health needs. You might not think this really means that much, but it has a profound impact on how long someone might need to stay in hospital and the kind of care they might require both in terms of social care and health care in the community. A recent report by the King’s Fund showed the extra strain on the health service due to a rise in people having multiple conditions is substantial. (http://www.kingsfund.org.uk/publications/pressures-in-general-practice)
  2. Funding cuts in social care and ‘efficiency savings’ in the NHS are having a terrible impact on hospitals and communities alike. If, as in our locality, wards have to be closed in order to balance the books, this has a massive knock on into several areas. If you close wards, it means the hospital fills up more quickly. If the hospital is full, then where do the patients who need to go into the hospital wait? The answer is in the ED. If they are waiting in the ED, then there becomes a back log of patients who cannot be seen and there will be an automatic failure to see, treat and admit or discharge patients within the 4 hour target window, which then leads to a negative rating for the hospital under CQC and pressure from on high to ‘do something about it’. But that’s just it….what can be done? Can people just be discharged home when they are unwell? – This is happening increasingly and then they end up back in hospital the next day in a worse state. The ED departments get the blame, but there is precious little they can do. At the other end of the line are people waiting to get home, but due to the deep cuts in social care, there simply isn’t the provision to put that care in place and so they are stuck. A lack of joined up computer systems between primary and secondary care makes this even more difficult. And even where patients could be cared for at home by community teams, the correct investment has not been made in this key area, hospital staff have not been trained to work in alternative environments (and believe me, they really are different) and so the teams we need in the community simply aren’t in place in many towns, cities and rural communities.
  3. There is a lack of information flow about patients and the care packages they already have in place and so a massive amount of time is wasted due to poor communication.
  4. The ‘A&E brand’ or ED, as it is now called is incredibly strong. Everybody knows it. And so people use it totally inappropriately, sometimes out of ignorance, sometimes desperation, sometimes laziness or convenience and sometimes apathy to the strain it places on services. We either have to work with this or keep on encouraging people not to use the ED. Unfortunately studies from the USA and Canada show that the more you negatively advertise the ED, the more people will use it. The King’s Fund explain with excellent clarity some of the complexities involved. What’s going on in A&E? The key questions answered (http://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters?utm_source=twitter&utm_medium=social&utm_term=socialshare)
  5. Our residential and nursing home sector is in absolute disarray and in some areas of the country they are run like cartels, holding hospital trusts and county councils to ransom in terms of affordability.
  6. We are still unwilling to have a difficult and frank discussion about our attitude to death and how we often keep people alive for years, when we could allow them to die naturally and peacefully (I’ve blogged on this emotive subject previously).

 

So what happens is we have a circular blame culture in which everybody will blame somebody else, but nobody will take responsibility and so we will continue our dance around the mulberry bush! But if you have just a tiny bit of faith, you can say to this mulberry bush, “Be uprooted and be thrown into the Sea”. Where systems become oppressive and toxic,  we must pluck up the complex root structure and find a new way.

 

Without real commitment from the government to invest rather than cut at this crucial time of transition, spending now to make huge savings in the long term, we might just continue this dance ad infinitum. The solutions cannot deliver change by the next parliament, but the transition must be honoured as vital and therefore allowed to happen over the next 10-20 years. We need a whole systems approach and it needs to involve the following (we’re trying this in Morecambe Bay):
Firstly, we need the development of Integrated Care Communities (ICCs). ICCs are geographically based, multidisciplinary teams, led and co-ordinated by a GP and a nurse but also include the vital mix of the fire service, police, mental health teams, social services, community matrons/long term conditions nurses, district nurses, community therapy teams and representatives of 3rd sector organisations. The idea of these teams to to keep care closer to home, share information, prevent admissions to hospital, but where admissions happen, ensure they happen in a coordinated way, bringing people back home as quickly as possible. We already have some great stories emerging here of this working really successfully. These teams have the potential to change the modus operandi and bring a culture change to how care is delivered. 
However, these teams will fail for the same three key reasons the NHS is currently on the ropes. Resource, recruitment and IT. 

These teams will be managing complex care in the community. With not too much extra funding, GPs and the care coordinators could do some incredibly effective work, but right now, general practice is at full stretch and so convincing community teams to take on this work will not be straight forward. This resource would be best invested in two areas – recruitment of staff, or retraining of staff and secondment of them from the hospital setting into the community and the strengthening of social care teams, (which to my mind are more accountable and more effective when under the same management as the NHS and provided by the state). The investment in it would also not be huge but it does involve some upfront cash. If each GP/Care Coordinator could have a laptop with Emis Web imbedded in it, with full access to their patients notes, they could go into the hospital setting once a week, do a ward round of their patients, who they know far better than the hospital teams and get them home. With the right team investment in the community this initiative would literally save millions of bed days and save an enormous amount of resource. But the better and more important benefit will be for patients themselves However, there is a warning for the government. In order for this to be effective and have the desired impact, it MUST be double-run, rather than expecting this to be done on top of what is already the status quo. The capacity is simply not in the system, but it could so easily be and this could be utterly transformational.
Secondly, the government must reverse the perverse cuts to funding. It simply bad mathematics to think that you can shrink the size of a hospital and shrink the social care provision available in the community at the same time. We need a serious reinvestment in social care. A strong and well paid social sector will bring more people into work, which btw builds a stronger economy.

Thirdly, we need to ensure all people in residential and nursing care, and those living with complex health conditions in the community have detailed care plans in place to avoid hospital admissions, except when absolutely necessary AND in line with the persons own wishes.

Fourthly, we must co-create urgent care strategies, not designed from on high, but collaboratively between ED departments, mental health teams, the police, GPs, community nursing teams and social services. If we cannot undo fifty years of public mindset about the ED, then let’s work with this rather than against it. We need more people recruited to work in the emergency setting and the pay needs to reflect the complexity and unsocial nature of the work.

Fifthly, we must stop the nonsense around data sharing, make patient records available to patients themselves and front end our EDs, Acute Medical and Surgical Units, Outpatient Departments with the same systems as we find in the GPs, all of whom should agree to share their records. In our area this would be with Emis Web, a very straight forward system to use. It would mean far faster diagnostics, more joined up, effective care for patients and investment now by the government across the UK would save them plenty of money within just a few years. It would also make data gathering, audit and governance easier and safer. The idea of spending literally millions of pounds on apps that can input data straight into patients notes, before we have this far more vital infrastructure in place is quite frankly ridiculous!
Lastly, we must work creatively with communities on public health strategies that can have a lasting impact and so stave off the growing health crises we see emerging for the future.

I don’t know about you, but to me the dance around this mulberry bush has become pretty boring, a colossal waste of time and energy and so in my opinion, we should quite simply stop it and do something different. The solutions are right in front of us. Will the government have the guts to stop what they are doing and make the right investments now for the sake of the health and wellbeing of the population at large and the health and social care system as a whole. They might not get the glory at the next election, but in ten years time, we will see that the right choices were made for the good of all. 
 

 

 

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