Putting values first – creating a different kind of front line

The starting point for preparing workforces for person-centred, community focused care is with value systems.

The movement in local areas towards coordinated, place-based and out of hospital care will create new demands on existing roles, new roles, and new ways of working in redesigned multidisciplinary teams (MDTs).

GPs, practice nurses, community health workers, social care staff, pharmacists and others will be on a different kind of front line providing a different type of care, especially for people with complex needs and multiple long term conditions (who already take up a third of primary care consultations).

Hospital based staff may also confront new challenges with, for example, consultants starting to work as part of community hubs or joining community MDTs to advise on case management; and nurses who have so far been tied to wards starting to rotate out to community practice.

And there are likely to be newcomers on the scene: volunteers, befrienders, link workers, navigators, care coordinators, community health trainers will be part of the ‘extended MDT’ reaching into community provision.

They too will need training, support and supervision; while professionals may need to learn how to relate to, trust and empower a swathe of non- or semi-professional co-workers.

We know that there are identifiable skill sets that can equip clinicians to provide person-centred and coordinated care. Reflective listening, risk communication, health coaching and shared decision making skills, all help increase partnership with patients.

But any future workforce planning that concentrates only on embedding skill sets into curricula and qualifications will miss the point.

Behaviours are inculcated in many ways, and do not necessarily change because we learn new skills. A clinician may get a bit better at communicating risks and benefits; but if his or her value set is based on minimising risk for people with frailty, rather than maximising their ability to manage by building on their and their community’s assets, a dependency culture will continue.

The work of the Realising the Value programme (funded by NHS England and led by Nesta and the Health Foundation, working in partnership with Voluntary Voices) is beginning to suggest ways in which the value framework of health and care will need to change, if challenges such as those set out in the Five Year Forward View in England are to be met.

Over and above clinical and service oriented outcomes, we need to value the personal and self-defined outcomes and goals of people with care and support needs.

The health service needs to be better at looking beyond the immediate outcomes of treatment, at the cumulative impact of interventions and services acting together.

At the moment it doesn’t see, for example, that repeated episodes of (good quality but preventable) urgent medical treatment in hospital environments can weaken an older person’s capacity to walk and push them towards a frailty that they might otherwise work to avoid.

At National Voices, we support the long term push to introduce relevant skills into formal education, and welcome the commitment of the Royal College of General Practitioners, for example, to train future doctors for care planning consultations.

But most of the future workforce is already in the workforce. To redirect a local care system following the Five Year Forward View will mean tackling the values challenge up front:

• setting and sticking to a compelling vision of how people’s satisfaction with work will improve as they see the benefits to people
• creating ‘lightbulb moments’ for health care professionals about the meaning and implications of person centred care (which most think they are already providing)
• bonding teams around shared goals
• creating trust in the value of each other’s skill sets to deliver better personal outcomes for people.

As Realising the Value’s further outputs are completed – on population behaviour change, for example, and on the key ingredients that make successful person-centred, community based care happen – we would expect the importance of commissioner, provider and health care professional values and orientation to be further highlighted.

Finally, addressing the issue of values needs to be handled with care.  It mustn’t be experienced by those working in the service as an attack on their values, since this will be alienating.  Rather it needs to be framed as an appeal to the values that brought them into health care in the first place, and a challenge to go further.

Jeremy Taylor is CEO of National Voices and Chair of the People and Communities Board of the NHS Five Year Forward View