Getting clinical leaders on board

With nearly two decades’ experience working on the front line in the NHS, Simon Watson is passionate about patient safety. A Consultant Nephrologist at the Royal Infirmary of Edinburgh and Clinical Lead for the Scottish Patient Safety Fellowship Programme, Simon is also a Health Foundation Clinical Associate. He talks about why clinicians need to influence change in their health organisations and the importance of clinical engagement following the Francis Inquiry.

What is clinical engagement?

It’s about healthcare managers and clinical staff (anyone providing hands-on care) maintaining ongoing conversations about how their organisation works and runs. Ideally, both sides listen and respond to the ideas, concerns and aspirations of their colleagues.

Senior leaders need to be visible and accessible to engage clinical staff. This can be done informally, such as on walk arounds, or through regular meetings discussing important on-going issues. Topics could include how clinical care budgets are spent or organisational responses to adverse events. 

Why is it important for managers to engage with clinicians around safety and improvement issues?

Patients deserve the best, most compassionate care. This only happens if all healthcare staff focus on continuous improvement.

Clinical engagement drives improvement in a number of ways. Firstly, people that feel valued and listened to are more motivated at work. Secondly, clinicians who have been involved in developing organisational plans feel more committed to them. Finally, it’s often the frontline clinical staff who have a clearer understanding of how care is actually provided. That real world perspective is vital – it ensures managerial plans and decisions are well-informed.

Could you give an example of clinical engagement work that has led to successful improvements in care?

I worked on a two-year programme with colleagues in NHS Lothian that aimed to ensure clinicians had the right patient information at the right time. Patients were sometimes at risk when clinical records were fragmented, incomplete or inaccessible.

The project involved staff from all levels: executives, clinical and non-clinical directors, doctors, nurses, IT and clerical staff. This collaboration helped us understand the problems and make changes. Results were impressive: errors in records reduced by over 90% and improvements were sustained because so many people had invested in them. 

What do you think the Francis Inquiry recommendations will mean for clinical engagement?

Well there are 290 recommendations, so that’s quite a big question. But the clear themes seem to be increased candour, transparency and organisational learning. All of those require – but also encourage – good levels of clinical engagement. 

It really depends on how the recommendations are applied at a local level. Some are very likely to become national level policies. For the rest, I think that in hospitals across the UK, Boards, clinicians, managers and patients should spend some time absorbing the report, agreeing the key implications for them locally, and then co-creating high value, high impact plans for improvement.

However, clinicians will be wary of knee-jerk action plans generated at the top of their organisations, which apparently tick off the Francis recommendations before being cascaded down to the sharp end for implementation. No stronger signal that ‘nothing has changed’ could be sent to clinicians in organisations where better engagement is badly needed.

The report recommends a legal duty of candour for people to be personally and legally responsible for the care they offer patients. What’s your view on this?

I definitely think there should be a duty of candour; I’m not sure whether or when sanctions should be used to enforce it. Furthermore, organisations should actively support a wider reporting culture which values learning for improvement. Staff should not fear retribution or expect reports to fall on deaf ears. I’m not convinced that many organisations have achieved that ideal reporting culture. Working towards it should be a high priority for the NHS. I'm optimistic that things can keep improving.

How can clinical leaders constructively challenge the culture of an organisation?

Clinicians usually have high professional credibility and are often in post for longer than senior management: we can have a lot of influence in an organisation. If we aren’t happy with a pattern of organisational or individual behaviour, we should raise concerns, ideally backed up by data and patient stories.

In some instances, things may have gone beyond the point where they can be managed internally. Then clinicians need to go to professional bodies and regulators. 

Recruitment, retention and promotion procedures are more robust now than decades ago. So, on that level, challenging behaviour shouldn't be career limiting. I and others I know have been appointed to jobs partly because, not in spite of, us doing things differently.

What do you hope to achieve in your role at Health Improvement Scotland regarding clinical engagement for improvement?

Our Fellowship Programme gives frontline clinicians, from Scotland and other countries, the confidence and ability to influence colleagues and organisational patient safety culture. It’s been a great success over the first four years – my ambition is to continue to develop more world class patient safety champions.

I’d like to see more collaborative quality improvement, with clinicians working with patients, commissioners, senior leaders and managers. And for clinical engagement to become the routine way of working, not a ‘special’ activity. 

Find out more

The Health Foundation and Healthcare Improvement Scotland have practical guides to help organisations develop clinical engagement strategies.

• Health Foundation research report: Are clinicians engaged in quality improvement?
• Healthcare Improvement Scotland Clinical Engagement Strategy