At the NHS Confederation Conference Sir David Nicholson, Chief Executive of the NHS, released his outline of the new NHS Commissioning Board (see 'Developing the NHS Commissioning Board'). It’s a 28 page document which by its own admission isn’t meant to be the finished article but an outline of how Sir David sees the development of the Board, its role and outline structure. But more importantly, in his own words the document sets out to ‘concentrate on culture, style and leadership’. I read through all 28 pages, took some time off then re-read it again. It is a document in my own style, laying open thoughts and ideas before they’re concrete.
Sir David also makes clear that the role of the centre will be to support local groups, not micro manage or dominate, and he talks about alignment and cross boundary working. In fact the whole style being put forward is one of matrix management, people being able to use the right resources and teams at the right time. However, human factors science tells us it’s really hard to shake off traditional hierarchies and ways of working, both at a micro and macro level. In fact people at the micro level look to the macro level for leadership by example.
So what does this mean for patient safety? The NHS outcomes framework already makes it clear that one of the five domains for improvement is safety, to quote ‘treating and caring for people in a safe environment and protecting them from avoidable harm’. Sir David outlines the structure for the Commissioning Board and describes how the professional leads for improving outcomes on mortality, long-term conditions and acute episodes will report to the Medical Director. The leads for improving patient safety and patient experience would report to the Nursing Director.
So, what was your gut reaction to the proposed division of labour? Pleased that a Nursing Director will have significant influence on a critical issue, or concern that traditional hierarchies and values will get in the way, and that safety will be marginalised or seen purely as a nursing issue?
Human factors tells us a lot about hierarchy and its role in the fine line between safety and disaster. If we look at the previous arrangements, I was surprised to learn that there was a Chief Nursing Officer when I first got involved in healthcare. We’re all familiar with the role of Chief Medical Officer, which Sir Liam made his own. I assumed when I attended a Patient Safety Forum meeting at the DH in 2009 at which the CEO, Medical Director and CMO were normally in attendance that the CNO would be there – ‘she’s not invited’ someone told me! And at a local level I have become all too familiar with the massive ‘authority gradient’ between medical and nursing staff on the shop floor – it was one of the factors that meant my late wife’s emergency ended up with her being dead. She wasn’t ‘protected from avoidable harm’.
I firmly believe that the current Medical Director, Sir Bruce Keogh, and Sir David himself are well aware of the hierarchical problems in healthcare. I also know for a fact that Sir Bruce recognises that this is a problem in human factors terms which the medics must solve. (If I can be blunt for a moment to all you medics out there: ‘there are plenty of times when nurses know more than doctors').
But however clear the CEO’s words are on matrix management, the reality is that people will view the responsibility of patient safety shifting to the Nursing Director at a national level as being a marker, an indication that safety is not the first priority and can be delegated. I know the Medical Director’s responsibilities for clinical outcomes clearly include patient safety, but for once we need to be blunt and unequivocal if we are to send the right message, all the way from the top to the bottom.
I have two messages to end on. The holders of responsibility should be the people who have the most power to influence the outcome. So first, please make patient safety a joint responsibility of the Medical and Nursing Directors – the overall strategy should be coordinated and discussed between them, individual projects could be shared or delegated as appropriate, but this is a joint problem that needs joint working and joint solutions.
And secondly, I’m so impressed with the many nursing staff I work with on a regular basis, but at a national level the nursing profession of today has sometimes failed to stand up and be counted. Sir David talks about and demonstrates leadership by setting out his vision. His appointments (due soon) of a new CNO and a Director of Safety are also an opportunity to demonstrate leadership; by appointing strong leaders. The new CNO needs to inspire and encourage nursing organisations to lead the medical professions into areas that need attention. The CNO shouldn’t wait to be invited.
Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group.