Conclusions

The following conclusions have been drawn from the research findings presented in Chapter 4. They are presented in what the author considers to be descending importance.

Embedding SMS/SDM is a high priority for front-line staff, demonstrating clear alignment between PCFT staff’s attitudes and beliefs and national health and social care strategy. Staff report overwhelmingly that this way of working is important to them, (implying a high degree of clinical relevance to their practice), represents an opportunity to enhance quality outcomes, and is a desirable way for them to work, whatever their discipline/area of work. This finding provides the Trust with a significant opportunity to support staff’s ambition to embed SMS/SDM by enabling front-line clinical leadership mechanisms. Staff report this agenda has had piecemeal support to date, saying this approach will not deliver the scale of culture change the Trust and its front-line staff want to see. Staff are also clear about some ways they could change their practice to better support SMS/SDM.

There is evidence of limited self-awareness of what ‘good’ SMS/SDM actually looks like, leading to lack of engagement, poor insight, reduced recognition of personal development needs, and a sub-optimal drive to redesign service delivery models. There is also evidence that raising awareness through self-

assessment and training opportunities raises motivation and confidence to make changes in practice.

Staff report barriers such as poor access to training, and limited resources to develop and embed new ways of working. The training already on offer is not recognised as being supportive of the SMS/SDM agenda.

Whilst this is a Trust priority, there is little physical evidence of the Trust enabling delivery of the strategy through some of its usual mechanisms e.g. offering and promoting training opportunities, setting objectives through IPDR and implementing systems of recognition and reward for those who exemplify this way of working. Whilst it appears this agenda is frequently discussed in senior Trust interactions, the lack of aforementioned physical evidence may be a causal factor in reduced awareness that this is a priority.

Immediate line managers of front-line staff appear to support SMS/SDM practices, and are supportive in enabling their teams to make changes to practice. However, there appears to be a disconnect at the Trust’s middle management tier, where it is believed that delivery of day to day operations precludes managers from driving the development of new ways of working in SMS/SDM. There appears to be a view that innovation in general is not easy to implement, with no systematic mechanisms in place for staff and teams.

The findings demonstrate that achieving engagement with front-line staff was a challenge. The centralised communication channels are not fully effective in

reaching the target audience, who may not access their emails regularly, or may not see the relevance of a particular communication to themselves. Using a more personalised invitation method did not enhance engagement for this research. Engagement through current mechanisms appears to be a particular challenge in nursing compared to the Allied Health Professionals, and a differentiated approach may be required. Middle leadership support is essential in achieving local engagement, however with respect to the SMS/SDM agenda, the apparent disconnect could diminish widespread implementation.

The findings suggest staff need support to engage in positive risk taking, with some staff being reluctant to ‘let go’ of patient control for fear of repercussions such as litigation. Whilst they recognise patients will take their own actions and make their own choices about how they choose to live their lives, some staff would prefer not to engage in such discussions as they don’t have the skills and confidence to implement and document positive risk taking through shared decision making processes. Whilst there are well-recognised NHS strategies and policy drivers that theoretically would negate these behaviours, for example “Liberating the NHS: No decision about me without me”, (Department of Health 2012), and the Mental Capacity Act (Department of Health, 2005), there is evidence that these are not fully embedded into front- line practice across the Trust.

Evidence of sub-culture within the organisation with respect to delivering SMS/SDM, suggests a sense of increased knowledge of the strategy within

community services, there is also a sense that mental health services might be in a stronger position to embrace these new ways of working due to the fundamental nature of their work. A similar view is held with respect to the Allied Health Professions, who are perceived by some to be more culturally aligned to working in partnership with patients than their nursing colleagues by way of their training experiences and rehabilitation/recovery focus. Additionally, there is a sense that whilst the respondents’ teams are prioritising SMS/SDM, other Trust teams are not. This might indicate a self- selecting sample who are already embedding these ways of working. Whilst these findings are suggestive of differences in beliefs, attitudes and practices across the organisation, the research is not conclusive and does not provide sufficient clarity to inform any differentiation of approach to the implementation of SMS/SDM in a particular staff group/locality.

The findings suggest that front-line staff believe that the Trust take additional steps to support the external environment to be increasingly conducive of SMS/SDM, although were unable to articulate what these steps might be. With current austerity staff report a positive drive to work differently and release resources by supporting patients to take more responsibility for their own care, where safe, however, it is not clear that staff know how to do this for themselves. The findings proposed that contracting and performance management mechanisms might be an enabler to system change.

Areas for further research

Whilst undertaking this research, a number of other areas for further interest were identified. Whilst these were beyond the remit of this research dissertation, further investigation may prove to be worthwhile in supporting the delivery of the Trust’s agenda. The importance of the support of middle management was not explored; these staff were not surveyed or interviewed about their opinions and perceptions of priority of SMS/SDM. Clarifying whether there is any disconnect, and undertaking a diagnostic to inform corrective actions would be worthwhile.

The lexicon of SMS/SDM can be confusing; within the Trust there are several approaches to supporting patients to have a holistic experience of care that supports their confidence and capability to take control of their own health and wellbeing, for example whole person care, co-produced care, self-care, self- management, shared decision making, and person-centred care to name but a few. Identifying the differences and similarities and agreeing a common language to describe the strategy is likely to lead to a greater impact of any communications and attempts to increase engagement in the agenda. A common language might also strengthen cultural ties to this way of working as part of a value set.

In addition, whilst this research has asked about clinicians’ beliefs and attitudes to SMS/SDM, the specifics of what this means have not been tested.

Using the CS-PAM (Hibbert et al 2010) would provide a more targeted diagnostic of individual and collective areas for development.

With respect to sub-cultures, it is worthwhile exploring why engaging with nursing communities is more challenging than AHPs. Nursing staff form the largest professional group across the organisation and are recognised as having particular challenges, with morale, recruitment and retention being national problems. Understanding the basis for these issues would provide the Trust with an opportunity to differentiate its engagement approach according to need, achieving greater involvement of this important group of Trust stakeholders.

Communication within the organisation is critical to the success of any strategy, and a final area for further research is to explore the effectiveness of our current communication mechanisms, identify gaps and opportunities for improvement to ensure all staff have effective two-way methods to engage with the organisation.

CHAPTER 6