Stakeholder Engagement in NHS Grampian

1.Actions Recommended

The Board is asked to:

1.1Note the requirements for the Board in relation to stakeholder engagement

1.2Note the approach to patient, public, staff and other stakeholder engagement summarised in this paper

1.3Consider the next steps required to maximise the organisational learning from stakeholder engagement

1.4Consider the opportunities presented by health and social care integration to work collaboratively with partner organisations and maximise the opportunities for joint engagement

2.Strategic Context

As our organisational values, “Caring, Listening, Improving”are core to the way business is carried out in NHS Grampian. To live by these values we need to listen carefully to patients, families, carers, the public and staff, on an ongoing basis and at every stage of their interaction with the organisation. We need to make it easier for people to share their experiences, ideas and opinions and to be genuinely engaged in decision making at all levels. Most importantly we need to demonstrate more consistent and system-wide learning and action as a result of the feedback we receive.

NHS Grampian is responsible for improving the health of the local population and for delivering healthcare services. However, significant change is needed in the way that health and healthcare services are provided to ensure that we deliver our Healthfit 2020 vision. Engagement with patients, families, carers, the public,our staff and all other stakeholders is integral to this.

We can already evidence a strong organisational commitment to stakeholder engagement, through our values of “Caring, Listening, Improving” and our strategic themes of “involving our patients, public staff and partners” and “developing and empowering our staff”.

We also have governance structures in place through the Board Committees - Patient Focus and Public Involvement (PFPI), Clinical Governance and Staff Governance, and through the Grampian Area Partnership Forum, all of which aim to provide strategic direction as well as quality assurance and monitoring roles.

NHS Grampian was recently assessed as achieving the highest level of the national Participation Standard. However, although components of stakeholder engagement have been in place in Grampian for many years, we should not be complacent. Board and Executive leadership and active commitment are needed if we are to fully embed stakeholder engagement into our organisational culture and realise our Healthfit 2020 vision which aspires to “our staff working jointly with the public, communities, local authorities and other partners …being clear and honest about the challenges, the needs of the population, the opportunities available and working together to agree and deliver the changes required.” We also need to ensure that the good practice, commitment and belief in the value of engagement that is evident across a wide range of areas of the organisation and is consistently applied.

  1. Key matters relevant to recommendations

Stakeholder engagement encompasses engagement at the point of care, following care and in service redesign and strategy development. Staff are key stakeholders and should be engaged at all these levels.

Stakeholder engagement at point of care

There is an increasing need for NHS organisations to capture and use real time or point of care patient and staff experience information for improvement. The National Person-Centred Health and Care Collaborative includes structural measures for leadership in person-centred care. These are:

  1. By December 2015, 100% of services/departments will have real time feedback systems in place for service users.
  2. By December 2015, 100% of services/departments will have real time feedback systems in place for staff.

Recent reports into poor standards of care in hospitals in England have made frequent references to the need to listen to the stories and experiences of patients and to the fact that such information is a good indicator of quality of care. Further, there is an increasing body of evidence which links patient and staff experience to patient outcomes, wellbeing, length of stay and patient mortality (West (2013)). Doyle et al, publishing in BMJ Open (2013) concluded that:

The data presented display that patient experience is positively associated with clinical effectiveness and patient safety, and support the case for the inclusion of patient experience as one of the central pillars of quality in healthcare.

The experience, in NHS Grampian, of collecting patient experience information has led to the conclusion that when we ask patients about their experiences, they often tell us about safety and effectiveness issues. For example:

After leaving hospital from my operation I did not receive any pain killers or leaflets regarding removal of stitches. Due to this, the stitches in my left side became infected and had made a large hole in my abdomen. I was readmitted to hospital to make this go away. Better Together Free Text 2012

The Keogh Report (2013) reported on the findings of an investigation into the performance of 14 hospitals in England and highlighted some common themes or barriers to delivering high quality care. One of these was the limited understanding of how important and how simple it can be to genuinely listen to the views of patients and staff and engage them in how to improve services. Keogh states that we know from academic research that there is a strong correlation between the extent to which staff feel engaged and mortality rates”. Keogh recommends that:

Realtime patient feedback and comment must become a normal part of provider organisations’ customer service...

The Francis Report (2013) also has much to say about patient and public experience, describing it an enormous resource... “waiting to be exploited” and states that “nothing is more likely to focus the mind on the impact of decisions on patients than to listen to patients’ experiences”.

Historically, the NHS Grampian Quality Dashboard has displayed data on compliments and complaints as a proxy measure for patient experience. However, there is a keen awareness that this does not give the whole picture of patient experience. More recently, real time staff and patient experience has been captured as part of the NHS Grampian “pledges” work. This has involved members of the person-centred team collecting information in paper format and uploading it to a database for later analysis. As well as some statistical data on experience, patients and staff are also asked:

  • What went well today?
  • What did not go well?
  • What would have made your experience better?

The qualitative nature of the responses to these questions is what helps us understand the experiences of both staff and patients and leads to ideas for improvement. Currently, 20 clinical areas across Grampian are engaged with real time staff and patient experience work however there is a need to be more systematic and comprehensive in how we collect and use real time experience data.

Stakeholder engagement following care

NHS bodies have a responsibility (Can I help you? Guidance 2012)to ensure that staff are competent and confident in dealing with feedback, in a manner that is person-centred, and aim to resolve issues as they arise. The focus should be on early and local resolution, wherever possible, and learning and improvement from all forms of feedback received should be promoted and monitored.

Whilst assuring compliance with complaint handling arrangements, in line with the Patient Rights (Scotland) Act 2011, and in particular ensuring that action is taken as necessary following the outcome or any feedback, the feedback system must develop mechanisms for encouraging fast, effective and efficient responses across NHS Grampian. Specialist advice and support must continue to be given to patients and staff on the management of this process, including a commitment to delivering local training and awareness-raising. This is done by the centralised Feedback Team who also:

  • Encourage, welcome and view feedback, comments, suggestions, concerns and complaints as opportunities for ensuring the NHS provides person-centred care.
  • Promote the additional independent support services such as the Patient Advice and Support Service (PASS), and raise awareness of advocacy, communication, translation and alternative dispute resolution services.
  • Liaise between service teams and corporate services to facilitate greater levels of collaboration.
  • Support staff to capture, respond to, and learn from feedback, whilst ensuring responsibility for this remains within the service, allowing appropriately focused, continual improvements in the delivery of quality care.

Being open and ensuring communication flows freely, makes valuable knowledge available across the organisation, from front-line staff to strategic decision makers. Key issues and opinions of service users raise awareness and illustrate key areas for improvement that may not be immediately obvious to service providers, and personal perspectives often reflect issues of collective concern (Grumbles, Gripes and Grievance - the role of complaints in transforming public services 2013)

Good communication and openness actively encourages and welcomes service users’ views and will embed a culture that values both positive and negative feedback. The development and improvement of these skills must be a high priority for those delivering NHS services. This will be achieved by introducing 5modules across NHS Grampian on the 1st February 2014. These were developed by the Scottish Public Services Ombudsman (SPSO), to enable staff to encourage and deal with feedback effectively. Support is also being provided by the new complaints training role, which was introduced within the Feedback Team last year. This allows one to one support to identified Complaint Leads, and encourages effective flow of feedback across the organisation.

Complaint Statistics

From1January to 31December 2013, NHS Grampian received 1672 complaints. Of these, 434 were fully upheld (26%), 455 were partially upheld (27%) and 13 of these have so far been referred to the SPSO (0.8%). We achieved our 20 day target with 38% of complaints responded to over that time and 28 days being our average response time to date.

Stakeholder engagement in service redesign and delivery and strategy development

NHS Boards have a statutory duty to involve patients and the public in planning and developing health services, and in decisions which will significantly affect the operation of these services (NHS Reform (Scotland) Act 2004). CEL 4 (2010), ‘Informing, Engaging and Consulting People in Developing Health and Community Care Services’ sets out the process that Boards have to follow when considering making changes.

But stakeholder engagement is not just about complying with guidance to enable change. Fundamentally it is about increasing public understanding of why change is necessary and ensuring the views and experiences of those most affected are at the heart of any redesign.

NHS Grampian uses a wide range of methods to inform, engage and consult from patient and carer interviews and focus groups to public meetings and representatives on committees. The range of tools and techniques available is reviewed and adjusted to suit circumstances and client groups. For example staff have developed expertise in engaging with children, including those with complex needs, young people, ethnic minority communities and people who have a sensory impairment. This helps ensure that anyone with an interest has the opportunity to be engaged, including those who are less confident or able to take part in traditional ways.

For more complex and difficult change processes, we need to invest in engaging properly to increase public understanding of the case for change and to ensure that communities can effectively and realistically influence future direction. At the same time, we need to be honest about the boundaries of the engagement i.e. what cannot be changed, for example because of statutory or regulatory factors. Equally we need to ensure that feedback is always provided, which explains the changes that have resulted from the input, but is also honest about the views that have not been taken on board and why. Staff engagement at this level will also lead to more successful implementation, because there will be a sense of ownership around the changes. Frontline staff are in many ways our greatest ambassadors in relation to involvement and engagement. In many cases they will have developed positive relationships with their patients, over an extended period. They are also likely to understand any concerns and anxieties expressed by patients and to be able to feed these into involvement processes. All stakeholders will have similar contacts and relationships and it is through these routes that engagement should be channelled, with support and expertise around methodologies and techniques provided as appropriate.

As we move into an integrated health and social care environment, integrated involvement is essential. Nationally work is underway to streamline the guidelines that health and local authorities currently use. Locally, meanwhile, we need to continue to work with our local authority and third sector partners to build on existing good practice. For example we already have input to the local Aberdeen Citizens Panel questionnaires around Healthfit 2020 and work closely with local authority colleagues on projects such as the Inverurie pathfinder.

The Community Empowerment Bill, which is out to consultation, “seeks views on a range of proposals intended to give people in communities, and those supporting them in the public sector, a range of new ways to help deliver a better Scotland.” The Bill aims to empower communities by giving them the lead in starting discussions with the public sector on their own terms to:

  • ensure communities have a say in the issues that matter to them
  • improve transparency in public sector decision making
  • provide opportunities to make the most of the knowledge and talent that lies in communities
  • foster positive relationships between community bodies and the public sector

Staff Engagement

To improve patient and carer experience we must maximise staff experience. We know from evidence that where staff feel valued and treated well both patient care and the system performance are improved. We have the potential, through our 2020 Workforce vision, to markedly improve staff experience which will ultimately enhance employee engagement, by working to a common set of values and giving staff the tools and guidance to enhance their own invaluable skills.

NHS Grampian is working to enable all staff to feel empowered in changing and shaping the NHS Scotland healthcare system. Investment in staff is a direct investment in patient care.

Clear evidence links high performing teams with lower rates of patient mortality (West et al 2006). A study of partnership working in NHS Scotland showed that genuine partnership working enabled all to develop and deliver key health policies and initiatives to improve patient services, drive organisational change and develop and implement appropriate workforce policies (Bacon et al 2012). The same evidence is echoed in the recommendations of the Francis and Keogh reports (2013).

In NHS Scotland, the staff governance framework places a legal requirement on all NHS boards to ensure that staff are well informed, involved in decisions, provided with a safe working environment, treated fairly and consistently and provided with adequate training to undertake their role. These requirements have now been enhanced to include reciprocal staff responsibilities.

Understanding staff governance and individuals’ roles and responsibilities is crucial for the engagement of staff infurther planned initiatives such as the dignified workplace, development of an action plan following results of national Staff Survey 2013 and the roll out of the iMatter staff experience project. There is increasing emphasis on staff experience as a measurable tool to ensure quality staff, in a quality service, providing quality care for patients, carers and the public.

  1. Risk Mitigation

Risk 601: There is a risk that, if there is insufficient involvement and engagement of the public, patients, partners, carers and staff in our Healthfit 2020 vision, it will be harder to deliver.

Risks Identified

  • Not measuring real time experience risks organisational lack of awareness of the quality of services.
  • Not listening systematically to staff and patients risks missing opportunities to improve the effectiveness and safety of care and services.
  • Not listening, involving and engaging staff in issues of service delivery may lead to the wrong decisions being made, as all of the relevant information may not have been considered.
  • By not taking the necessary actions to improve experience for all staff in NHS Grampian we run the risk of not delivering the best possible patient care.
  • By failing to comply with national guidance around Informing, Engaging and Consulting, we will be unable to deliver the scale and pace of change required.
  • Whilst we continue to improve how we engage, until we do this routinely and then consistently act on feedback we run the risk of public and staff apathy and, at worst, loss of confidence and trust.

Mitigating Risks

  • Staff must be supported by their managers to ensure the investigation and administration of feedback, including the complaints process, and be held accountable for their role in terms of its effective management.
  • It is essential that the wealth of management information provided through feedback and experience data is recorded and acted on locally via robust governance processes and procedures. An annual publication will be produced to demonstrate to the public that appropriate action has been taken as a result of feedback, to improve services.
  • A whole systems approach to stakeholder engagement at every level will ensure that the Board places an appropriate level of scrutiny to these matters, but does so in a context that is embedded in the work of the Board.
  • The Board will be provided with specific assurance reports which will update it on progress in this area.
  1. Responsible Executive Director and contact for further information

If you require any further information in advance of the Board meeting, please contact: