Nursing, midwifery and care staff make up the largest proportion of the workforce across the NHS. In the UK, there are more than 698 000 registered nurses and midwives (Nursing and Midwifery Council, 2018) and more than 1000 registered nursing associates (Health Education England (HEE), 2019), all striving to prevent and tackle health inequalities and improve the care experience for patients, individuals and populations.
The role that nursing, midwifery and care staff play in improving the health and wellbeing of the population and reducing health inequalities should not be underestimated. Between May 2016 and March 2019, the Leading Change, Adding Value (LCAV) framework (NHS England, 2016) aimed to demonstrate and share the leadership and practice that these professionals undertake every day in this time of transformation across all health and care sectors in England.
A key aim of the framework, from co-development, launch and landing to co-implementation in practice was to demonstrate strong partnership working and stakeholder engagement. There was whole-system endorsement of this shared national framework for nursing, midwifery and care staff, in addition to alignment with other national policy initiatives, including All Our Health (Public Health England (PHE), 2019), ‘The Shape of Caring’ (HEE, 2015), NHS RightCare (https://www.england.nhs.uk/rightcare) and the Getting It Right First Time programme (https://gettingitrightfirsttime.co.uk).
The framework was significant in explaining how staff—whatever their role, wherever they work—can look at what needs to change or could be changed to improve services, experiences and outcomes for patients and residents, individuals, families and populations.
The ambition of the LCAV framework was to support and guide nursing, midwifery and care staff to demonstrate and quantify the professions' contribution to national, regional and local programmes of work, exploring ways to support staff to apply an evidence base to making changes in practice at whatever level or role within the system.
This approach aimed to support the professions to look at reducing ‘unwarranted variation’, highlighting the need to quantify the impact of their work in relation to the triple aim of improved outcomes, experience and better use of resources (Zubairu et al, 2018). In fact, since the launch of the national framework in May 2016, it has been clear that many colleagues are now (or were already) identifying unwarranted variation as a part of their everyday practice.
Just before the conclusion of the 3-year LCAV programme there was the publication of The NHS Long Term Plan (NHS England and NHS Improvement, 2019) and the Long Term Plan Implementation Plan (NHS England, 2019). It was quickly recognised that there is now an opportunity to build on the foundation work achieved by LCAV and position the professions at the centre of the delivery of the Long Term Plan.
Resources
Three products were developed as part of the LCAV framework to support colleagues to lead transformational change:
E-learning tool
This was developed by HEE, NHS England and LCAV partners, including e-learning for Healthcare (https://tinyurl.com/y6mbz5hm).
The tool aims to provide an opportunity to build or strengthen current knowledge and skills in the understanding of the impact of ‘unwarranted variation’ on individuals and populations and then help lead the change required to address this. It consists of a 20–25-minute e-learning session for all nursing, midwifery and care staff to access. A pdf version was also developed, and this was distributed to nursing, midwifery and care staff working across both health and care at the request of care sector colleagues during the final formal year of LCAV implementation.
National Atlas of Shared Learning
The AoSL demonstrates how nursing, midwifery and care staff across the system have led and contributed to narrowing the gaps that exist in health and wellbeing, care and quality, funding and efficiency—and their essential input to national, regional and local programmes of transformation.
With over 180 small and large-scale quality-assured case studies published online to date, the AoSL enables colleagues to share practice and learning on how unwarranted variation in practice has been identified and addressed through nursing, midwifery and care staff leadership and the resulting improvements. These pieces of work are also directly aligned to some of the key areas in the Long Term Plan, for example mental health, learning disabilities and cancer. In just 12 months alone, case studies on the AoSL portal have received over 85 000 unique page views.
The Research Portfolio
This is the third and final product of the framework. Developed in collaboration with partners across the health and care system, the portfolio aims to increase the visibility and promote nursing, midwifery and care staff research. A range of nursing and midwifery research leads from higher education institutes (HEIs) across England attended a task and finish group, representing wide-ranging excellence in nursing and midwifery, co-chaired by NHS England and the Council of Deans of Health.
Small and large-scale research pieces are included to provide a snapshot of the robust evidence base for clinical practice, care provision and policy development that exist and continue to evolve. Indeed, the studies cover a range of health and care areas and clinical priorities. The research portfolio is not an all-encompassing database of research, rather it is a resource to clearly help articulate components of the research agenda within nursing and midwifery, and to act as a stepping stone in continuing to promote research and the principles of research to a wider audience.
The research portfolio aims to demonstrate how the professions' leadership position can help lead and deliver the Long Term Plan. The portfolio is complementary to the AoSL.
Service evaluation: could the principles of LCAV be adopted as business as usual?
Throughout the course of the implementation phase of the LCAV framework, Edge Hill University conducted an independent, academic service evaluation at year 1 (https://tinyurl.com/y6djx7h7), year 2 (https://tinyurl.com/y5w9o8l2) and year 3 (https://tinyurl.com/y3udsxbg) to explore whether LCAV could be adopted as ‘business as usual’ by nursing, midwifery and care staff.
In the final year, through focus groups and surveys, this included considerations of how the framework had been disseminated and to collate information on the implementation of the framework. Four focus groups were conducted between September and October 2018, comprising a representative population of nursing, midwifery and care staff. Being cognisant of the challenges across the system from the outset, it was acknowledged that the number of focus group sites would be small, but that this would still provide early insight into the dissemination, landing and implementation of the LCAV framework.
To complement the information gathered from the focus groups, an online survey was distributed across the same sites to all nursing, midwifery and care staff, not limited to focus group participants. The focus group, survey questions and discussion areas included:
It is beyond the scope of this article to go into detail of the service evaluation. However, analysis of the qualitative data identified five overarching themes:
It must be noted that the focus groups were held at sites that already had knowledge of LCAV, so this may have introduced a possible participant bias. Staff also explained how LCAV was helping to ensure that leadership was being advocated and that leadership at all levels was becoming the norm. Crucially, this framework was also inviting shared decision-making and joined-up working in service delivery. The following quotes come from participants in the service evaluation. They provide a flavour of the constructs discussed and how this national, co-implemented framework has begun to make an impact.
‘So, reducing unwarranted variation. People think “huh”? But if you say we're trying to do some work to make sure that care is consistent … or we're strengthening the pathways of care from inpatient to community … people start to talk that language and they can articulate the work that they are doing.’
‘I think this is a shift in the momentum because it's out there more in the culture of approaching change, thinking about change, leadership at all levels … you don't have to have leader or manager in your title to do that sort of thing, so I feel there is a change in the culture.’
‘There's a feeling in this organisation … that leadership is at all levels and so we're doing a lot more co-design, not only with service users but with staff who've got fantastic ideas on how to improve services if you just give them that space to think and to get actively involved so that co-production is at all levels.’
Continued learning and recommendations for future policy
The LCAV framework was an intentional ‘slow burn’ because, for many, it has been a new way of working. It needed to be embedded within a complex system of practice environments, particularly regarding terminology and focus, for example, with a specific call to ‘apply the same importance to quantifying our contribution as we do to the quality of care we provide’.
It is therefore unsurprising that knowledge and understanding were variables. The focus groups suggest that understanding was associated with dissemination activity, and how well the principles were cascaded across an organisation for nursing, midwifery and care staff to take on. In organisations where the framework was distributed and shared widely, there were increased examples of the framework being embedded in practice. This highlights a benefit of effective dissemination, notably a range of dissemination strategies, to engage and support staff. Often, focus group participants, who were actively implementing the principles of LCAV, identified and shared examples of the framework in action. This was with emphasis on promoting an evidence-based approach to identifying and addressing unwarranted variation and leading change within their organisation.
A key feature that emerged was advocating an environment that embraced quality improvement, leadership at all levels and established mechanisms to support staff at the point of care as drivers of change within their own areas of practice.
The discussions in the focus groups suggested that LCAV reflected a framework being ‘of its time’. This underscores the importance of incorporating and communicating key elements of earlier policies in current health and social care policies. LCAV built on previous and existing visions and demonstrated the contributions of the professions to the delivery of the Five Year Forward View (NHS England, 2014). As previously mentioned, LCAV has been recognised as being complementary to the priorities set out in the NHS Long Term Plan (NHS England and NHS Improvement, 2019).
The above finding can be shown when exploring synergies in the principles of LCAV and key ambitions of the Long Term Plan. The NHS Long Term Plan sets out ambitions for improvement over the next decade, and its implementation plan (NHS England, 2019) sets out how these will be met. It is clear that nursing, midwifery and care staff are already leading and improving work in many of these areas: for example, in person-centred care, prevention of ill health, health and wellness promotion and personal responsibility, mental health, healthy childhood and maternal health, primary care and integrated and personalised care for people with long-term conditions. There is a huge opportunity to demonstrate the key part of health and care professionals in this transformational change and ensuring their leadership position in the future. It is anticipated that this will support colleagues to continue to positively build on their quality improvement practices.
The exploratory evaluation data found that the products supported a deeper understanding of the principles of LCAV. The e-learning tool and the AoSL were already familiar to some participants, but not all—this again highlights the need for better dissemination of the tools available. The three products were well received by those who were aware of them; indeed, several participants contributed their own work to the AoSL.
The importance of demonstrating the quantifiable impact of change was illustrated in the focus group discussions. Participants recognised the significance of staff being supported to implement changes in the face of competing demands. This was also seen in parity with the need for staff to have the knowledge, skills and training to evaluate the evidence. A wider focus on staff development features in the AoSL, where case study exemplars demonstrate how they have contributed to significant improvements across organisations. Working across traditional professional boundaries and embracing multidisciplinary working have been consistent themes running concurrently through LCAV and are strongly advocated as new policies evolve—there has been an explicit shift towards joined-up working across health and social care.
The LCAV framework has provided a vehicle for colleagues to lead change in practice. It has been clear that many were already, or are currently, identifying unwarranted variation as a part of their everyday work. However, for some, support has been necessary to help understand and subsequently embody these principles, which takes time. The evidence collected through the explorative evaluation suggests that this national framework has supported nursing, midwifery and care staff to demonstrate and quantify the professions' leadership and contribution to evidence-based outcomes, as well as national, regional and local programmes of work and public health priorities.
Summing up
This article has provided an overarching summary of the LCAV framework: dissemination of the principles has enabled learning and subsequent implementation of these in practice. It is advocated that organisations continue to support their staff to apply evidence-based practice and promote strong and visible nursing, midwifery and care staff leadership. These principles also enhance multiprofessional working as they provide a positive way to deliver care across the system, and ongoing collaboration and engagement are considered beneficial to patients and residents, individuals, families and populations.
To disseminate these principles more widely it is imperative to continue the key collaborative work between HEIs and health and social care organisations to ensure universal health coverage, focus on underserved populations, reduce health inequalities and address social determinants in health and care outcomes.
We are pleased that the framework has been shown to promote leadership at all levels and encourage nursing, midwifery and care staff to use their experience and influence to continue to effect change across the health and care landscape—and to demonstrate the impact the professions can make in transforming the delivery of care.