Frontline staff working together to achieve better joined-up care

Challenges

• Frontline staff are operating in a challenging environment and may be suffering from change fatigue.
• There can be multiple uncertainties about how and when their roles may change.
• Staff may feel that they lack control over change.

Key actions

• Ensure clear, honest communication to maintain trust throughout the change process.
• Co-produce a shared agenda for change with staff. A good example is Salford Royal Hospital, where high levels of staff engagement have helped ensure improved outcomes for both workforce and patients.
• Recognise the role of frontline staff as active participants in developing joined-up care, not passive recipients of top-down plans.
• Empower staff to find the best ways of making change happen (see Leadership Qualities Framework - Skills for Care).
• Use networks of professional leaders as a link with frontline staff and to promote the value of joined-up care, e.g. the Adult Principal Social Workers Network has produced an advice note that spells out the distinctive contribution of social workers to integrated care.
• Consider the six building blocks for a highly engaged workforce.

There is now an overwhelming body of evidence to show that engaged staff really do deliver better health care. The NHS providers with high levels of staff engagement (as measured in the annual NHS Staff Survey) tend to have lower levels of patient mortality, make better use of resources and deliver stronger financial performance.

The King’s Fund, Leadership and engagement for improvement in the NHS (2012)

Engaged staff are more likely to have the emotional resources to show empathy and compassion, despite the pressures they work under. So it is no surprise that trusts with more engaged staff tend to have higher patient satisfaction, with more patients reporting that they were treated with dignity and respect.

Improving NHS care by engaging staff and devolving decision-making – Report of the Review of Staff Engagement and Empowerment in the NHS (2014)

The value of people from different disciplines and organisations working together across traditional boundaries cannot be over stated. This helps instil person-centred approaches, embracing co-production and a ‘one team’ ethos which focuses on best pathways, with the right blend of care and support services to achieve their outcomes and enjoy best possible quality of life.

Martin Farran, Corporate Director Health, Housing and Adult Social Care, City of York Council

Frontline staff: the key point of contact

Frontline staff are crucial to successfully delivering good joined-up care. They are the key point of contact between individuals, and carers and families, services and systems, so their perspective, experience and knowledge is indispensable.

Frontline staff need to work together with colleagues from other services, professional groups and organisations. This will involve a shift away from working in separate ‘silos’ and creating effective interprofessional relationships based on collaboration and teamwork.

Joint working may involve a number of changes, including adapting to new team members and styles of working, understanding new terminology and processes, and moving to a new workplace. It can be a difficult and emotional time for staff, who may be anxious about the impact the change will have on them. Strong engagement with staff is important, not just in terms of workforce motivation, but also in terms of outcomes for people using services.

This section explores the range of levers that can be used to support a move to joint working for frontline staff. It takes the perspective of a frontline worker, and people working and interacting with frontline workers. It provides practical advice about how to approach joint working as well as examples of what has worked and why.

Change fatigue

We know that this is a time of significant reform in the sector and that staff may be suffering from ‘change fatigue’. Many staff in health and social care have experienced serial reorganisations throughout their careers. They may not have been involved in shaping the proposals, or they may have limited understanding of the rationale for the changes or the potential benefits. They may even disagree with the changes. Professionals with heavy workloads might see major change as an unhelpful distraction.

An environment in which workers feel safe and confident to raise questions, express concerns, talk about their experiences and make suggestions for service improvement based on their experience and relationships with people they support will create trust and help them and colleagues to feel supported.

Skills for Care 2014

When budgets are tight and jobs are at risk, adapting existing working practices to enable joint working may feel like a step too far.

It is important to understand how staff feel about changes to their working arrangements. Some may be excited by the prospect of joint working, whereas others may be apprehensive or worried about the proposed change, and there may be a mix of reactions within the team.

Examples of some common concerns include:

• facing and juggling multiple uncertainties, both personal and organisational
• working in a complex system where no one person or single organisation can come up with a solution on their own
• feeling powerless to influence or be involved in the change process.

Understanding and appreciating these concerns is the starting point for a strategy for addressing them as part of the implementation of joined-up working.

• Case study: Salford Royal NHS Foundation Trust Open

  Salford Royal NHS Foundation Trust has consistently high levels of employee engagement and it scored highest out of the 142 acute trusts in England in all of the national surveys of the last three years. Staff satisfaction is high across the board. Out of the 28 key findings in the staff survey, the high levels of employee engagement are matched by exceptional performance. Patient satisfaction is very high at the trust and it performed very well on the inpatient survey. Salford Royal aims to be the safest trust in the NHS and it currently has the fifth lowest mortality in the country.

  Devolving decision-making:

  The whole culture at Salford Royal is focused on involving employees in decision-making. This is reflected in the trust’s structure. Unlike many trusts, there is no director of operations or chief operating officer taking major operational decisions at the top of the organisation. Instead, the trust is organised into clinical divisions with responsibility for decision-making, and management devolved to the senior nurses and doctors in those areas. Senior leaders at the trust understand how important prominent clinical leadership is. Clinical leaders are seen as the experts in their services.

  Continuous improvement

  There is an established and effective methodology for continuous improvement at Salford Royal. Employees are encouraged to think about how they might be able to deliver their service more effectively and efficiently, to get teams together to work on their ideas collaboratively and then to test them in their services, measuring their impact.

  People management

  Salford Royal has a real focus on people management, ensuring line managers are really able to engage with staff. The trust invests time and money in leadership programmes for line managers, ensuring they have the skills, capability and confidence to act as effective leaders. The trust comes top of the 142 acute trusts in the country in terms of support from immediate line managers. Appraisals are a key part of this process, ensuring staff have a clear understanding of their personal goals and objectives, and how they align to those of the organisation.

  Values and purpose

  The four values – putting patients at the centre, continuous improvement, respect and accountability – were developed with extensive involvement from employees through focus groups across the trust. The values are mainstreamed throughout the trust, forming a key part in the service delivery strategy and the annual planning process, as well as informing the recruitment and appraisal systems. Increasingly, the trust is looking to align reward and advancement to individual contributions towards these goals and the values of the trust.

How can this learning be applied?

Frontline staff can only change their behaviour if they are empowered to do so. It is vital that frontline staff have defined freedoms to take initiative and test out ways to work across organisational boundaries. This needs to be clearly and consistently communicated by all managers and built into the responsibilities outlines in job descriptions.

Frontline staff need to recognise that when they do this, they assume a leadership role. Such leadership from below is grounded in everyday behaviours and must become a part of the culture in every organisation.

A team needs a champion who can constantly remind us what we are doing and why and can tell us when we are making progress and how we can do even better.

GP representative, Oxfordshire

• Example: Integrated care pioneer programme sites Open

  Skills for Care and Skills for Health have worked with integrated care pioneer programme sites, helping them to engage the workforce in developing new models of care, and supporting them to develop new ways of working that enable personalised, joined-up care.

  In Greenwich we have developed core competencies for our care navigators to nurture, develop and measure performance. I have found it helpful to distinguish between MDTs and interprofessional practice, which is more conducive to integrated care.One of the key things for us is to incorporate learning from service users, carers and staff all the time. This helps us to identify both subtle and significant service gaps and functions that are not meeting people’s needs. My advice would be to challenge, influence and nurture change with commissioners and senior managers to ensure investment and refreshed ideas.

  Wendy McDermott, former Integration Lead, Royal Borough of Greenwich

Tools and resources

• The Leadership Qualities Framework for Adult Social Care, National Skills Academy for Social Care, 2012. Open

  The Leadership Qualities Framework (LQF) describes the attitudes and behaviours needed for high-quality leadership at all levels across the social care workforce. It focuses on the values and behaviours that provide the foundations for effective leadership in social care.

  Visit: The Leadership Qualities Framework for Adult Social Care, National Skills Academy for Social Care, 2012.

• Healthcare Leadership Model, NHS Leadership Academy. Open

  The model aims to help those in the health and care sectors to understand how their leadership behaviours affect the culture and climate they and their colleagues and teams work in. The model is made up of nine leadership dimensions and the online resource describes each dimension – why it is important and ‘what it is not’.

  Visit: Healthcare Leadership Model, NHS Leadership Academy.

• The Social Work Professional Capabilities Framework, British Association of Social Workers Open

  This framework can be used as a benchmark or checklist to build on any existing local approaches.

  Visit: The Social Work Professional Capabilities Framework, British Association of Social Workers.

• The principles of workforce integration – Skills for Care Open

  The principles describe the ways in which all workers, practitioners and managers can be enabled to contribute to creating and sustaining a confident and high-quality workforce, and deliver personcentred, excellent integrated care and support.

  Visit: The principles of workforce integration – Skills for Care.

Create a shared agenda

Having started to explore the issues and anxieties surrounding joint working, the next stage is to develop a common understanding about the purpose and objectives of joined-up working. A shared ambition around making things better for local people, developed in open partnership, such as at a team awayday, gives staff from across different organisations the opportunity to come together and start developing relationships, while influencing the design and priorities of the future service.

Use guidance from specialist bodies

Another approach is to refer back to the guidance from the main professional bodies in health and social care who hold a shared view that working across organisational boundaries is crucial to providing effective care and support. This is helpful because clinical and professional staff are influenced by, and work to adhere to the values of their professional group.

All professionals have a duty to work collaboratively with patients, families, carers and other teams to deliver person-centred care that meets physical, psychological and social needs. Professionals should work across traditional organisational boundaries in order to coordinate care and meet people’s needs.

Joint statement from the Royal College of Physicians (London) and the Royal College of General Practitioners supported by the Academy and Medical Royal Colleges

The key roles and contributions that social workers make to an integrated health and care system are: to improve outcomes for people; protect people appropriately; and maximise the effectiveness of expenditure across health and care overall by undertaking a rights, strengths, and co-production approach to creative and innovative ways of improving people’s lives.

Social Work: Essential to Integration Advice note by Department of Health, Adult Principal Social Workers Network & Association of Directors of Social Services

Engage staff in joint working

In the first instance, the intended changes should be communicated in person, with a clear explanation of their rationale and what the changes are intended to achieve, along with and a clear plan for how staff can codesign the new joint working structure and processes. To overcome the barriers to joint working it is important to harness the energy, ideas and expertise of a range of people across the system, including frontline staff, who should be engaged with the change process from the outset. After this there are a variety of different engagement approaches that can be taken, including:

• Weekly sessions to discuss the change, either run as ‘drop-ins’ or focused on specific issues, with the option of one-toone meetings.
• Asking teams to nominate a representative to attend working group meetings, where key issues are discussed and resolved.
• Mass anonymised engagement through surveys and consultation, ensuring a clear feedback loop so that staff understand how their views have informed the new model.

The biggest changes I have been a part of have only been delivered by working as a team across boundaries. Moving outcomes for stroke care from bottom quartile performance to top decile in 18 months [in Oxfordshire] was only achieved by GPs working with specialists and both working with nurses, social workers and senior managers. The whole team accepted that what had been happening was not good enough for patients and was frustrating for all parties. There was a real “feel-good factor” when we saw outcomes improve and no new money was required! It felt good when what we had done was shared in big meetings across the region.

My patients just do not understand why we are not working as a team on their behalf. Why don’t I know the community nurse, the social worker and the specialist? Why can’t I just pick up a phone to any of them and make something happen today and not in a month’s time?

Dr Stephen Richards, GP, former Chief Executive of Oxfordshire CCG

Listening to each other: Including everyone in the conversation

Good workforce development means learning from everyone's experience and valuing what all stakeholders have to say.

To view a larger version of chart, download a copy of the full report.

As allied health professionals [AHPs] we need to work together towards services that we aspire to provide rather than being constrained by organisational boundaries. We all have common goals in improving care and this needs to work in both acute and community [settings] without being limited by the structure that services are provided in.

Dr Stephen Richards, GP, former Chief Executive of Oxfordshire CCG

Source: Direct quote (Anon) from Allied health professionals into action, NHS England (2017). AHPs into Action commits allied health professionals to supporting integration, emphasising their role in care coordination, rehabilitation and reablement.

Failure occurs when staff aren’t involved from the beginning in designing how integrated care will be implemented. Imposed change with ‘consultation’ doesn’t enable the necessary relationships to start developing between the different professional groups. The narrative has to resonate with people’s everyday work. If it consists of only data and stats and finance it won’t. Change also doesn’t work if people believe it is just this year’s fashion and not here to stay. Integrated care is a necessity for the majority of people we now have to care for, and for the sustainability of the health and care system. That is why every main political party backs the concept and why it will happen irrespective of government.

Sir John Oldham, former Chair, Independent Commission for Whole Person Care

Checklist

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Checklist adapted from: The principles of workforce integration, Skills for Care, Think Local Act Personal, Skills for Health, the Local Government Association, NHS Employers and the Association of Directors of Adult Social Services (2014)