Free Nursing Essays - Critically Consider The Impact Of The Large Number Of Recent Structural Changes, Policy Initiatives And Targets Imposed On Collaborative Working Of NHS Staff
The Department of Health has laid down certain policy initiatives, targets and structural and organizational changes that can improve the quality of care received by patients through the NHS. These changes are emphasized along with the need for multi-agency and multi-organizational collaborative working across disciplinary boundaries. The four key interfaces for which collaboration and coordination measures are being suggested are health and social care; general medical and community health services; primary and secondary care; and interface with carers (DoH, 1996).
In this article we will discuss:
1. the policy measures and guidance documents provided by the Department of Health that stress on the need for collaborative working and how this approach could be implemented in the NHS
2. the targets set by the Department of Health for achieving certain levels in the quality of services and how an emphasis on collaborative working could help in enhancing quality of care
3. the structural and organizational changes that the Department of Health have specified to implement collaborative working within the NHS and how in turn these changes have influenced collaborative and multidisciplinary working within the NHS.
Our responses and analysis of the issues in consideration will involve these three major points and we will discuss the implications of strategies, policies, structural changes and targets on collaborative working and how these issues are related to the multi-organizational work culture as promoted in recent years by the Department of Health.
Collaborative working in NHS - Key Issues and Concepts
The Department of Health has identified seven areas focused on cross boundary collaborative working and these include:
(i) partnership with patients and carers;
(ii) the commissioning process;
(iii) inter- agency collaboration;
(iv) inter-professional collaboration and teamwork;
(v) professional education and training;
(vi) communication and information sharing; and
(vii) research and development.
However, in order to examine the policy and structural changes within the NHS, the main structures and processes identified are :
Organisational processes and Infrastructure, Knowledge Management processes, and Knowledge management resources. In fact collaborative working relates to knowledge management and structural and organisational changes have been suggested to facilitate information sharing across departments, and professionals as well as to facilitate interaction between patients, doctors and carers. Knowledge management indicates the optimum use of knowledge across departments to enhance quality of care provided but relates not just people, collaboration or work culture but also to technology and upgradation of services provided. Knowledge management is also directly related to improvement of staff performance and the recent empahsis on collaborative working has been based on several objectives that the Department of Health seems to have identified. These we can enumerate as follows:
- Implementing a process of change within the NHS
- Improving efficiency of services and quality of care
- Encouraging advanced and technologically superior equipment and clinical procedures as seen in the NHS Modernisation Agenda.
- Using management principles of knowledge management and coordination to achieve collaborative working and better interaction among patients, doctors, nurses and other health professionals across departments and agencies.
- Improving staff performance through performance management and optimising utilisation of processes, organisational structures and resources.
At the heart of the collaborative working approach are policies, targets and changes as implemented by the NHS. The change model given by the NHS is
External change, Problems & opportunities → Recognition of the need for change → Start of change process → Diagnosis (Review present state ↔ Identify future state) → Plan and prepare for Implementation → Implement change → Review
The 'people' or personnel aspects of change management have also been identified within the NHS and these involve: (NHS plan, DoH 2000)
power, leadership and stakeholder management;
training and development;
motivating others to change; and
support for others to help them manage their personal transitions.
Motivating others to change, support to others, and communication all refer either directly or indirectly to the need for a collaborative working approach and coordination as a means to achieving the standards and targets set. The Department of Health has given National Standards of Care and Planning Framework and in this context the NHS Improvement Plan given in 2004 is of considerable importance.
According to a DoH publication (2004), the NHS Improvement Plan, 2004, set out the next stage of the Government's plans for the modernisation of the health service. It signalled three big shifts:
putting patients and service users first through more personalised care;
a focus on the whole of health and well-being, not only illness; and
further devolution of decision-making to local organisations.
All this requires much greater joint working and partnership between PCTs (Primary Care Trusts), Las (Local Authroities), NHS Foundation Trusts, NHS Trusts, independent sector and voluntary organisations. The Department of Health shows that this is happening in many parts of the country, but needs to be made more consistent (DoH, 2004).
Howver there has been considerable shifts in focus and in the way patient care services are being delivered and a procedural change from a system driven by national targets to a system in which
standards are the main driver for continuous improvements in quality;
there are fewer national targets;
there is greater scope for addressing local priorities;
incentives are in place to support the system; and
all organisations locally play their part in service modernisation. (DoH, 2004)
Despite all this, the importance of national targets cannot be downplayed and targets emphasised by the Department of Health have always been instrumental in shaping policies and have an impact on collaborative working and modernisation plans of the NHS. All NHS employers for instance have difficult targets to maintain and the targets are set for NHS employers and health service agencies. National standards are related to National targets as certain frameworks and acheivement objectives set, help in realising goals of the health department. The importance of the National Standards of Health could be stated by the facts that they
provide a common set of requirements applying across all health care organisations to ensure that health services are provided that are both safe and of an acceptable quality
provide a framework for continuous improvement in the overall
quality of care people receive. The framework ensures that the extra resources
being directed to the NHS are used to help raise the level of performance
In 2004, Health Secretary John Reid cut down the number of national targtes that should be reached by the NHS from 62 to 20. There was a grwoing recogntion to shift the focus of NHS from national targets in health care achievements to more local targets. The NHS plan given by the Department of Health in 2000 has been considered as the biggest change to helathcare since the establishment of NHS in 1948. The NHS plan
emphasised on a health service designed around the patient with more investments in NHS facilties, NHS staff and changes not oly in the systems of the NHS but changes between health and social services and changes in NHS doctors. Changes of patients, nurses, midwives and therapists have also been suggested along with changes in the relationship between the NHS and the private sector. Some of the other national targets set up by the NHS and given in the NHS plan was cutting waiting times for treatment, improving health and reducing inequality, providing dignity, security and independence in old age and setting up clinical priorities according to the reform program.
According to the Department of Health, the national targets will accelerate improvements in a small number of national priority areas.
The reduced number of national targets include:
achieving year-on-year reductions in MRSA levels and future reductions in other hospital acquired infections;
an 18 week maximum waiting target from start time to treatment by 2008;
helping people to manage their long-term conditions so they spend less time in hospital; and
improving the health of black and ethnic minority communities.
In the wake of several crticisms on the NHS regarding its lack of standards, old-fashioned demarcations between staff and barriers between services, lack of clear incentives and levers to improve performance, and over-centralisation and disempowered patients, the NHS plan was set up to improve health services in the UK.
Some of the general National Targets given in the NHS plan were:
more and better paid staff using new ways of working
reduced waiting times and high quality care centered on patients
improvements in local hospitals and surgeries.
The monitoring of progress will be overseen by several independent organizations controlling the NHS and these include the Department of Health that is responsible for setting national standards, matched by regular inspection of all local health bodies by an independent inspectorate, and the Commission for Health Improvement. The NHS plan also states the following changes and targets:
For the first time social services and the NHS will come together with new agreements to pool resources. There will be new Care Trusts to commission health and social care in a single organisation. This will help prevent patients - particularly old people - falling in the cracks between the two services or being left in hospital when they could be safely in their own home.
Pooling of resources and using a coordinating approach to bring health and social care services together seems to have been the major first step towards initiating a collaborative approach within the NHS work culture.
Most current NHS targets were agreed under the 2000 NHS Plan. Access targets (such as those on waiting times) run until 2008 while the outcome targets (such as those on cancer, coronary heart disease) run from 2000 to 2010 (DoH, 2004).
In this section we discussed the key policies, national targets, changes in the targets and the organisational changes following implementation of policies and targets. We discussed the importance of the NHS plan which seems to have initiated the need for a collaborative approach through the Modernisation agenda of the NHS that aims to optimise the levels and quality of services.
The key issues and objectives we highlighted are related to a growing need to change services provided and improve the quality of care that patients receive. The emphasis on collaborative working and multi-disciplinary approach to patient care seems also to be directed towards optimising information and knowledge management. Knowledge and information mangement have been identified as important factors in improving services, optimizing multiagency and multiprofessional collaboration and co-ordination and providing higher levels of quality of care to patients.
In the next section we will consider the evidential studies on collaborative working and the impact and influence of procedural policies and structural changes on NHS management approach and care orientation.
Collaborative working in the NHS - Evidential Clinical Studies
However despite the fact that the NHS stresses on the importance of collaborative working, as many authors have studied there are many challenges in interdisciplinary working and Barr (1997) writes that most services provided by the NHS require considerable interdisciplinary working. Yet the effectiveness of team structures and team functioning can be variable and the services provided can range in quality from very effective to poor or fragmented service coordination. Although there have been many developments in establishing productive multidisciplinary team working several key challenges as recognized in the past decade will have to be considered. Barr identifies the organizational, interpersonal, professional and personal challenges of each health care professional and team in general. These challenges and issues will have to be considered before any changes are implemented. We will consider other studies to elaborate further on these issues in collaborative practice.
An important aspect of collaborative working is that it not only utilizes issues of knowledge management but also brings in the necessity to use the management perspectives, managerial decisions and skills of clinicians as they are the ones who coordinate and shape the working approach within a clinical setting. In fact there are several controversies as to whether it is proper to draw in medical consultant and doctors into managerial decision making in clinical settings. Fitzgerald and Sturt (1992) examine the influences and reactions on doctors when they are asked to perform managerial tasks. The doctors have been found to be reluctant to accept managerial roles and responsibilities. The authors argue that the adoption of the clinical directorate model as a favoured mode of organization in acute units has led to clinicians assuming general manager roles purely on the basis of imitation rather than real understanding. Fitzgerald and Sturt raise the debate as to whether asking clinicians to be managers is a good decision and whether this is the best way to use the unique skills and time of the clinicians. The authors suggest that collaborative working between doctors and the general managers is essential in health care and it is advisable not to give the doctors too many responsibilities related to management. The set of tasks that should be exclusively for managers and tasks exclusively for doctors are delineated and separated although several researchers have realized the need for good clinical managers and have identified tasks that clinicians will have to perform and might require training support and development for effective performance of the tasks.
According to some authors the competition based market would slowly give away to more collaborative working approach in which partnerships and alliances would be important. This is the new management trend whether within the health sector or within any other industrial sector for that matter. Children's nurses for example have a much greater role to play as they are placed to respond not just as counselors and responds to NHS calls; they are also involved in commissioning and service development decision making processes. Giving the picture of a new NHS, Warne (1998) suggests that primary care groups builds upon existing practice and offer opportunities to GPs and nurses who work in the community to spread the benefits of working on a wider scale more effectively.
Elston and Holloway (2001) performed another relevant study in which they examined the perspectives of professionals in primary care and studied their opinions regarding the impact of the changes in its organisation and interprofessional collaboration in the UK. For the study, general practitioners (GPs), nurses and practice managers were interviewed in three primary cares and after the interviews, the data or results were analysed using various theoretical perspectives. The study indicated that subcultures of GPs, ideologies in the care environment as well perceptions of nurses and other healthcare workers influenced reforms in primary care. Professional identities were found to be at loggerheads with traditional power structures and this fact generated some conflict between the three groups of GPs, nurses and practice managers. This was found to be one of the factors affecting collaboration and subsequently there were many problems and obstacles in implementing the reforms. According to Elston and Holloway a completely new approach to care, collaboration and management is necessary. The authors conclude that it seems completely possible that 'it will take a new generation of health professionals to bring about an interprofessional culture in the NHS'.
However some other obstacles to the development of an inter-professional culture have been identified since the beginning of services by the National Health Service (NHS). Atwal and Caldwell (2005) did an influential study on the improvement of collaborative working practice if any within the context of changes in policy and current policy focus. The study was based on direct observational method and the tool used was Bales Interaction Process Analysis. This was carried out on two older persons teams to explore patterns of interaction in multidisciplinary team meetings to understand the underlying dynamics of team collaboration and practice. There were however major differences ion the way people of different professions interacted and communicated with members of other professions and this was revealed by using the analysis tool. Certain people in distinct professions showed different approaches altogether as Occupational therapists, physiotherapists, social workers (SW) and nurses rarely asked for opinions and orientation. Yet the consultant or the person in charge of the medical team asked for orientation, gave orientation and also personal opinions and this trait was also found in some nurses who gave orientation, and training. The data also indicated that therapists, nurses and Social workers are usually reluctant to voice out their opinions in multidisciplinary teams and thus collaborative working approach may have traditional issues of power structure, domination by managers and doctors and a hierarchical work culture that may be a major obstacle to its complete development. Several research studies have shown that therapists, social workers, and nurses need to feel more comfortable with collaborative working and strive to facilitate a culture based on equality and cooperation by voicing out their opinions and being more dominating in order to be competent and committed patient centered practitioners.
There are thus issues of hierarchy, power and traditional roles of nurses and this difference in the category of roles that nurses and doctors are categorised by or even health managers are identified by which may be both a deterrent and an advantage. In the one hand collaborative working approaches may bring in new roles for nurses and health workers and give them more responsibilities and managerial roles. This may be unnecessarily time consuming for nurses and healthcare workers who are already busy. On the other hand these roles of clinical managers imparted through collaborative working make new expectations and stretch professional possibilities of doctors and nurses and by being the new age clinical managers they are able to coordinate in a successful manner to improve care and quality of services. With administrative and management powers a well, the new nurse manger or doctor mangers are able to improve the environment of clinical setting and provide more patient centered care suited for the 21st century.
Jefferies and Chan (2004) have indicated that multidisciplinary team working (MDT) or inter-professional and collaborative working has been the main mechanism that ensures holistic care of patients as professionals form all field use their expertise to provide a truly complete service of healthcare. A seamless service for patients is thus given through disease trajectory and merging boundaries of primary, tertiary and secondary care. The effectiveness of each team of professionals however needs to be separately evaluated according to Jefferies so that it is ensured that all relevant disciplines and the relevant professionals are able to participate equally in the management and care of the patients. The authors use examples of Cancer Services Collaborative at Birmingham Women's hospital in the UK where a holistic model of care has been developed along with a medical model of disease cure. Thus providing collaborative services in which inter-professional coordination and information sharing is affected, can help improve the quality of care by providing complete holistic services as all aspects of patient problems are considered and taken care of. This is on of the unique clinical advantages of collaborative working that is not available in compartmentalized traditional method of clinical practice.
The importance of knowledge management through collaborative working practice has been emphasized by Booth et al (2003) who emphasize that project staff and nursing staff must develop a wide range of skills in order to work effectively in collaboration. According to them , Project staff must acquire rapidly a wide range of task-related skills. The concern of these studies is that conventional methods of training may not properly train staff to use the various skills required for collaborative practice. For example in collaborative working approaches, the nurses and doctors may not be trained to be managers in a clinical setting if the situation demands. Action learning as mentioned by Booth et al (2003) provides a group based means of meeting the skills demands in modern collaborative practice and is an effective part of any knowledge management project within a clinical setting. Action learning is thus one of the alternative methods of training that can be used for learning and be useful and enjoyable at the same time. The content of action learning approaches have been analyzed and has been found to meet the diverse needs of project staff in a modern clinical setting that is based on collaborative approaches of working. This type of learning also facilitates sharing of knowledge within a virtual environment which can be transferred to a real clinical setting. Booth et al conclude by suggesting that, 'Knowledge management does not merely involve management and delivery within innovative projects but also requires exploiting shared learning across projects' (p.229).
There are also several studies that have highlighted the many changes that have been found within the nursing practice in the past decade and some of thee relate to movement of nursing education into higher educational section and nursing being properly recognized as a respectable profession and higher degrees are also being awarded in nursing like any other profession. These changes are within the educational aspects of nursing studies. However considering the fact that educational recognition of nursing being late to develop when compared with medical profession, the development of senior nursing roles have in many cases led to isolation and there have been some controversies on the role of nurses in the clinical setting. However the new government directive on collaborative working has only proved that any demarcation between professions and putting professionals along a hierarchy in a power structure is not only detrimental but also ineffective in a modern clinical setting. Mutual support and encouragement are expected and this has especially increased after the concept of collaborative working which according to Cushen et al (2002) can bring in possibilities of transformational partnership which complement any personal inadequacies. Transformational leadership also provides effective clinical support and there are any advantages to this form of practice including professional and personal development and reflections on practice. The validity of the concept of professional support across traditional boundaries has been emphasized.
In this essay we discussed the implications of the new policy initiatives and structural changes within the NHS as proposed by the Department of Health on collaborative working and how these policies and strategies have had an impact on collaborative working and have shaped a completely different work culture within the modernized clinical setting. We have analyzed the policies given by the Department of Health, the strategies and targets identified by the DoH and we analysed whether these targets have been reached and if not what changes have been made to the clinical and healthcare system. In this context we have discussed the role of collaborative practice and mutual work relations and have discussed the importance of transformational leadership, learning and recognition of the nursing profession in bringing major changes to not just procedural methods but also policy and organizational structures that have been able to go beyond hierarchical limitations to provide a truly holistic quality to care services.
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Downloadable version at www.dh.gov.uk
For DoH references,