Effective Demand: Assessing Needs and Managing Need Need

The political aspiration to re-orientate healthcare provision so that the patient is genuinely at the heart of healthcare originated before Devolution and has, until relatively recently, remained an aspiration rather than an achievement. Continuing variations in the efficacy of hospital catering and food service, and the qualities of

180 the food produced have nevertheless endured, despite attempts to mandate

processes and standards, which suggests that within governance, there are behavioural as well as structural conditions for change.

Although the process approach to healthcare delivery was seen to be the most effective and cost efficient means of improving the service (WAG, 2003a) it was not until the structural integration in 2009 that the necessary changes started to take practical effect. Empowering ward sisters to lead on ward management for patient experience, the introduction of the NCP and associated accountability frameworks have been instrumental in bringing about structural change by addressing needs, but, in isolation, only offers a partial explanation of reform within nutritional governance.

The ‘All Wales’ collaborative approach to the menu framework has begun to address some of those remaining structural deficiencies, both in relation to the assessment of need, and as a result of the mandated standards being structurally embedded, multiple needs. By structuring best practice within a flexible framework to meet differing clinical and cultural needs, the ‘All Wales’ menu structure reduces variation in meals, limits the number of ingredients that need to be purchased, and aggregates demand to enable economies of scale. Economies of scale are not, however, the sole consideration. With a standardised menu framework, the contracts for provisions can be optimised prior to publishing the tender, and

contracts structured to meet stakeholder needs and maximise market opportunities.

Certainty on the range and quantity of products within each framework reduces waste and minimises the risk and costs of suppliers, competition, in theory, ensuring the lowest price. Planning therefore needs to be an integral part of governance, the proposed alignment of catering and food service with regeneration technologies further evidence of a commitment to quality rather than lowest cost, and learning from experience.

Thus processual governance structures have enabled and supported the focus on sustainable development outcomes of effectiveness based upon equity, as

differentiated individual needs, and best value as efficiency through the reduction of systemic waste as variation from qualitatively defined best practice. Programmes such as ‘Transforming Care’, for instance, demonstrate how reducing systemic waste can release nursing time to provide care, suggesting time, rather than cost or staffing levels, is the material resource. Identifying best practice nevertheless requires leadership from front line practitioners, as a means of legitimising best practice and accountability models, and to enable ownership and encourage

181 compliance. Collaboration is, however, critical for success. Best practice at ward level is evident where nurses, dietitians and catering staff work together and where cross-disciplinary clinical and management teams have developed programmes within the 1000Lives programme to embed food, as nutrition, in care.

The focus on food waste has also been reignited as part of the audit process, the emphasis being on the cost of avoidable waste arising from system failures, rather than lack of patient appetite. The labour cost of continuous detailed measurement and monitoring of physical waste, bearing in mind the relatively low cost of food provisions to the NHS, suggests, however, that physical food waste will remain a peripheral concern. The setting, and relatively easy and rapid attainment of

maximum targets for food waste, irrespective of the correctness of the data, invites complacency unless the data relates to nutritional waste as part of effective service delivery to meet patient needs. The menu framework should, however, minimise waste in terms of quantitative need for purchasing, but only on the assumption that the underlying technical basis of the nutritional standards are fit for purpose. The perceived risk from practitioners is that the standards, although setting minimum quality levels, will increase overall costs without necessarily reducing food waste.

Within the process of healthcare governance, nutritional care activities within hospitals represent the assessment of nutritional needs and the management of demand that informs the sourcing and contracting role of NWSSP-PS. Actors continue to challenge current practice, with a continuing emphasis on an ‘All Wales’

approach that seeks to integrate best practice as a means of adding value,

providing consistency and improving quality as the patient experience as well as the rigour in accountability through performance management.

Critically, however, inconsistency both in terms of the quality of the meals produced and the care provided on hospital wards, suggests a number of interrelated and contingent factors might be required to explain change, but that mandating is an ineffective mechanism of behavioural change. Collaboration, leadership and learning were suggested as interrelated conditions of change within the wider governance contexts. The policy narrative within nutritional governance is, however, that of empowerment, as devolution of responsibility, authority and resources to nurses, implying that structural empowerment alone will bring about change. Whilst structural empowerment enables leadership, adoption of best practice is arguably a matter of learning, which is conditional upon collaboration rather than technical skills. The development of best practice models has also been shown to be

182 conditional upon collaboration between stakeholders, rather than just a matter of professional or nursing leadership.

Although at a strategic level, the NCP demonstrates empirically a process structure dependent upon leadership, learning and collaboration, actual change cannot be explained solely by, but is arguably conditional upon, structural empowerment.

Following the thesis that processes are ‘nested’, the NCP, within healthcare governance, is te overarching process within which procurement takes place.

Process effectiveness and efficiency therefore inform sourcing and contracting activities, which in NHS Wales take place within the NWSSP-PS.

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CHAPTER 6