Staff culture can really help unlock improvements in the care of older people – Eddie Docherty

Last year, Scotland’s population was estimated to be 5,424,800 – a record high and an increase of 6% on 2017. The largest increase was in the 75 and over age group (+31%). It is, of course, good news that we are all living longer. However that increase in older age groups is hugely significant for our health and social care system.

The likelihood of being admitted to hospital is, as expected, highly correlated with the age of the population. Around one person in three of the Scottish population aged over 75 was admitted at least once to hospital in 2016/17. By way of contrast, just under one in 11 people aged 25-44 were admitted.

At the same time as we have an increasing demand in our hospitals, we have other pressures to manage which can impact on care, for example ongoing difficulties in recruiting to a range of posts, and a perennially challenging financial context.

Acute hospital care In Dumfries and Galloway had some of the dynamics no doubt many boards and hospitals have: staff who were doing their utmost, in sometimes very difficult conditions, endeavouring to give the best care they possibly could.

So when the inspections on the care of older people in two of our hospitals highlighted a number of concerns and challenges, it was a very difficult message for staff to manage – even though we knew the findings were accurate.

There is a natural emotional response that comes from staff who are working hard, doing their best and feeling like the criticism is unfair. After all, no-one was coming to work to do a bad job. I have no doubt many who have received challenging inspection reports have felt the same.

Yet, after that initial, understandable, emotional response, what has happened since those inspection reports were published has been hugely positive. That subsequent reaction has been down to the staff themselves who chose to respond to the challenges in a way that that has empowered them and benefited patients.

Culture was the key

The key to the positive response was in managers and staff using the feedback, taking stock and ‘owning’ the areas that needed improvement. There was no one silver bullet to the improvements taking place but a combination of factors which included:

• An understanding that answers to improvements lay ‘in the room’
• Teams delivering care were empowered to make the changes they needed to make (eg if paperwork was not helping manage care then they could change it to something that did)
• We had a strong group of individuals who wanted to make the changes
• The key thing to change was culture (of person-centred care) and it was staff who could shape this
• Staff felt strongly connected with the patients and their families as the hospitals and their workforces were an integral part of the local community.

So, having weathered the challenge, staff developed an action plan and used improvement methodology from Healthcare Improvement Scotland’s ihub to support the improvements, look at best practice from elsewhere to understand how to make change happen.

It has taken at least 6-8 months for changes to feel tangible and there have also been some personnel changes which have added impetus to the cultural change. However, it is important to say that it is the teams themselves that have taken responsibility for change.

The impact

The latest inspection reports in to the two hospitals concerned are in stark contrast to the initial reports – inspectors positively commenting on team work, ethos and person-centred care. It has been a major turning point for staff. It feels like there has been a clear psychological change – and a change to a more positive perception of inspections themselves. Staff will now welcome the inspectors and the inspection process, knowing that this is an opportunity to get better. And they know that they can make the most of the improvement support that is available from Healthcare Improvement Scotland and feel they are able to embrace both aspects.

Added benefits

One of the added benefits of the changes was that, across the service in Dumfries and Galloway there has been a less fragmented feeling, and more of a feeling of a team ethos.  In addition, it also feels like there has been change in the working environment to one that is a more open, learning environment.

No resting on laurels

There remains room for improvement and I’m not saying we have solved all issues.  But it feel like we are more confident and in a better place to use challenges from inspections, and the improvement support available, to improve care in a way that might not have happened before. And for that, the staff in Dumfries and Galloway hospitals can take a huge amount of credit.

Eddie Docherty is Director of Nursing at NHS Dumfries and Galloway.