Wearing two hats to improve NHS services
The last decade has seen huge changes in the way the NHS involves patients and carers not only in their own care and treatment, but in planning and redesigning NHS services and making changes to existing ones. At its best, this involvement goes way beyond simply informing users of NHS services about service changes towards the collaborative involvement of patients and the public in co-creating services.
We shouldn’t underestimate the significant shift in culture and behaviour needed to move from a historically more paternalistic and managerial approach to healthcare improvement to one which values and embraces a broader range of perspectives and approaches to improving NHS services for the benefit of all.
So let’s assume, for the moment, that we are all on board with the idea of involving a wide range of ‘stakeholders’ in activities seeking to improve NHS policies, procedures and services, be they staff or patients or other interested parties. The next question we might reasonably ask is, what do we expect and want our stakeholders to contribute to improving the NHS?
Usually, we invite people to participate in improvement and service development initiatives because they hold a particular role in relation to the NHS; they might be a patient, a nurse, a carer or a service manager. In this way, we expect that people will contribute to the improvement initiative on the basis of their knowledge and experience in that specific role. We expect that people invited to take part in an improvement event as a ‘patient’ contribute their expertise based on their experience as a patient; that people invited as a ‘ward nurse’ contribute their expertise based on their experience as a ward nurse, for example. We all understand and interpret our own experiences in light of the role or roles that we have in a given situation. Those roles can ‘filter’ or influence our understanding of our experiences and can also influence our behaviour. Our language reflects this when we say: “as a parent, I find that….”, “as a nurse, I know that….”, “as a carer, it’s often the case that…”.
In reality, people hold many different roles and responsibilities and have knowledge and experiences related to a variety of roles in their lives. That is, most people wear more than one hat.
Your experiences as a nurse in a particular service, for example, may be quite different from your experiences when you use the same health service as a patient. For example, as a nurse we may understand the importance in infection control of the 48 hour rule on children returning to childcare after a short viral illness. As a parent, we might find this rule challenging when our own child has had a bug and a lack of childcare causes us difficulties. The situation in the same, all that has changed is our perspective; in other words we are wearing a different hat.
“From an improvement perspective, having more than one role or ‘hat’, and more than one perspective or lens through which to view a situation, may be a real bonus.”
Indeed, people with dual or multiple roles insights and experiences of a situation potentially offer unique contributions to improvement activity. Are we missing a trick in not making use of all of this easily accessible knowledge and experience that people have when we involve them in improvement activity?
Working with NHS England and NHS Improvement, the Flourish team at Hope For the Community CIC have explored whether NHS improvement initiatives typically use the expertise and experiences of people wearing two (or more) hats. To find out, we searched the literature and ran focus groups. We were interested in two specific types of ‘multi-role perspective’: the perspective of NHS members of staff who also had experiences of being a patient, and the perspectives of patients as they observed the experiences of NHS staff during their use of NHS services.
It seems that we probably are missing a trick! A focus group member said that in her 20 years working in the NHS, no one had ever asked her about her experience as a patient in order to understand and drive change in NHS services. In one of our focus groups for NHS staff with long-term health conditions, the group unanimously believed that their multiple-role perspectives are unique and priceless, but seldom voiced or used. Another focus group member gave an example of a bottleneck in accessing treatment. As a patient, they had experienced the frustrations of the bottleneck to their care and treatment. As a member of staff, they understood the systems that had likely created the bottleneck and also understood how it might be resolved. Only people wearing both hats can experience the bottleneck through both those lenses simultaneously. Patients in our focus groups told us that they had never been invited to contribute to staff experience focussed improvement activity despite their willingness to contribute and their many years of observing and interacting with NHS staff.
We found very limited evidence of the deliberate identification and use of multiple-role perspectives in improving NHS services. Very rarely were people invited to participate in service improvement and development initiatives specifically because they wear ‘two hats’ as an NHS patient or carer and as an NHS member of staff. Equally, people told us that when they were involved in improvement events, they self-censored their contributions and restricted their comments to expertise consistent with their given role in the event.
What a waste of knowledge, expertise and experience! Just a small shift could make a big difference to the contributions of stakeholders in improvement activities. The NHS is a major employer in the UK, and we found that many of the people involved in patient participation groups have past experience as NHS staff. All NHS staff have some experience of being an NHS patient. This means it is possible that dual patient and staff perspectives are easily accessible. We therefore recommend that improvement project leads identify people “wearing two hats” from the outset of improvement initiatives. We should move from inviting people to contribute a single role-specific experience towards encouraging them to bring their whole range of highly valuable insights and experiences gathered through wearing at least two hats!
Blog written by:
Dr Wendy Clyne and Dr Karen Deeny, Hope For the Community CIC
Kate Milton, NHS England and NHS Improvement