Framework for change: supporting you to drive improvement

The Leading Change, Adding Value framework for nursing, midwifery and  care staff  is halfway through its three-year programme. With its unprecedented emphasis on staff as leaders its initial impact was greatest with senior managers. But the focus is now on how front-line staff can make a difference.

The Leading Change, Adding Value framework for nursing, midwifery and care staff is halfway through its three-year programme. With its unprecedented emphasis on staff as leaders its initial impact was greatest with senior managers. But the focus is now on how front-line staff can make a difference

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Nursing, midwifery and care staff often have ideas on how to improve care and provide it more efficiently – but often don't get the chance to put them into action.

Lack of support, lack of knowledge on how to bring about change and sometimes even a sense that no one will listen to them, or that it is not their job, can stop them taking ideas further.

It shouldn’t be like that, and one of the aims of Leading Change, Adding Value – the framework for nursing, midwifery and care staff, launched in 2016 by England’s chief nursing officer (CNO) Jane Cummings – is that they should be enabled to play their part in making the NHS a better place by delivering the triple aim of better outcomes, better experience and better use of resources. These reflect the priorities in NHS England’s overarching strategy for the NHS, the Five Year Forward View.

‘It is often about stopping things that they have done historically that don’t add value to people’s experience and care’

Stacey McCann

Improving outcomes and experience are, of course, the mainstay of nursing, midwifery and care staff's working lives and have featured in previous strategies. What is new is the emphasis on their role as leaders and their ability to influence how resources are used.

Key to all of this is the idea of reducing ‘unwarranted variation’, where practices differ between organisations and even within organisations for no good reason. Reducing this – and adopting the best practice universally – is seen as a key way to help the health and care sector improve outcomes, experience and make better use of resources.

It would be easy to view this as just about better use of funding but that would be wrong, says Stacey McCann, head of nursing strategy and commissioning at NHS England. ‘It is often about stopping things that they have done historically that don’t add value to individual or population's experience and care, and freeing up some time to do things differently,’ she says.

Ten points to help stay focused

The ten commitments in the Leading Change, Adding Value framework are intended to help everyone focus on its aims
1. We will promote a culture where improving the population’s health is a core component of the practice of all nursing, midwifery and care staff.
2. We will increase the visibility of nursing and midwifery leadership and input into prevention.
3. We will work with individuals, families and communities to equip them to make informed choices and manage their own health.
4. We will be centred on individuals experiencing high-value care.
5. We will work in partnership with individuals, their families, carers and others important to them.
6. We will actively respond to what matters most to our staff and colleagues.
7. We will lead and drive research to evidence the impact of what we do.
8. We will have the right education, training and development to enhance our skills, knowledge and understanding.
9. We will have the right staff in the right places and at the right time.
10. We will champion the use of technology and informatics to improve practice, address unwarranted variations and enhance outcomes.

In reality, of course, nursing, midwifery and care staff  do this all the time but may not be using the vocabulary around unneccessary variation to describe their actions – and may not even identify that what they are doing is about reducing variation, says NHS England director of nursing and professional development Susan Aitkenhead.

It’s a new direction for the chief nurse’s campaigns but it does not mean that care and compassion – and the 6Cs – have been left behind. They are still integral to the vision of care. But the message now is also ‘you can make a quantifiable difference’.

Demonstrate outcomes

There is also a focus on measurement of what is done and the difference it makes, which makes the framework stand out from previous strategies. ‘Nursing, midwifery and care staff do a huge amount of changing practice and we needed to capture that and work out what was the contribution of the profession,’ says Ms Aitkenhead. ‘We do the quality stuff really well, but in the current climate we need to also quantify what we do and demonstrate the outcomes.’

For some nurses that could lead to greater involvement in research. ‘A lot of nurses feel it is quite difficult to start doing research and looking at evidence, but this framework gives them support to take things forward,’ says Ms McCann. ‘It is time to dispel the myths and encourage staff to think how they can undertake research.’

‘If they use the framework they would be able to free up some time’

Stacey McCann

LCAV is now over halfway through its three-year programme. One major output of it will be the publication of an Atlas of Shared Learning, with around 200 case studies of how nursing, midwifery and care staff have influenced and improved care. More than 50 case studies have already been submitted from across the range of settings. These can stop staff reinventing the wheel – some solutions could be adopted or adapted in different organisations.

And the changes they make are not just about improving outcomes for patients or individuals they care for. It can be about making a difference to their working lives and those of their colleagues. For example, stopping doing things that don’t improve care can mean more time to do those things which staff know make a difference and which contribute to better outcomes.

‘If they use the framework I think they would be able to free up some time – I think that is where staff are getting the message,’ says Ms McCann.

Human touch

Another strand is how front-line staff can use technology and IT in delivering care. Examples include telehealth connections to care homes to reduce admissions and the use of tablets for bedside monitoring. These can reduce the amount of time staff have to spend on ‘basics’ but without compromising on the caring aspect of their roles. ‘It doesn’t take away the human touch,’ says Ms McCann.

But has it resonated with nursing, midwifery and care staff on the front line? Ms McCann suggests initially it probably had more impact on senior managers, but argues that more recently it has started to gain traction with more staff. ‘This is a new way of working for front-line staff,’ she says. ‘This year we have had an emphasis on engaging with front-line staff and starting to engage with them on how they use the framework.’

‘Don’t think you can only makes changes if you are in a senior position’

Susan Aitkenhead

An e-learning module is being developed which will build capacity and capability for staff to make changes. Higher education institutions are also involved, and ultimately the theme of reducing unwarranted variation could become part of the curriculum for nursing, midwifery and other healthcare students.

The LCAV framework is also providing the backdrop for nursing strategies in many trusts. And as Ms Aitkenhead says: ‘Don’t think you can only makes changes if you are in a senior position. If you see something with your patients that is not making a difference you can change it.’

The potential to transform lives

Tommy Whitelaw’s story of how his mother developed vascular dementia and their experience as he cared for her during the disease brings a very personal note to the LCAV framework.

Mr Whitelaw, who is UK project lead on dementia carers voices for the Health and Social Care Alliance Scotland, has spoken to health and care organisations across the UK about his experience and invited individuals to make pledges. So far 17,000 have done so, inspired by his Tommy on Tour campaign.

Baseline to work from

He sees the LCAV as offering nursing, midwifery and care staff a framework to support turning their pledges into action, with pledges often linking into the ten commitments.

‘It’s people who bring them to life,’ he says. ‘But it gives them a baseline to work from if they are all linked into the framework. The framework gives them an opportunity to embed the pledge.

‘No matter what your role, you have the potential to transform the lives of the people you care for. I have found out how incredible and passionate people are to care for others.’


We can reduce inequalities, improve outcomes and demonstrate our impact

England's chief nursing officer Jane Cummings on how the framework for nursing, midwifery and care staff is empowering staff to tackle unwarranted variation

Leading Change, Adding Value (LCAV) has built on the success of Compassion in Practice but takes us further and turns our collective attention to demonstrating how we as a profession lead in reducing the three gaps of health and well-being, in care and quality, and in funding and efficiency.

Using measurement as a powerful tool for improvement, it is helping turn our attention to demonstrating our impact through the achievement of the triple aim outcomes.

It is important that nursing, midwifery and care staff continue to build capacity and capability to work with unwarranted variation to drive improvements and demonstrate impact.

Biggest impact

So many colleagues are already using LCAV to position their leadership, and most are doing this locally, which is essential. But we also have major LCAV programmes that demonstrate where the professions as a whole can have the biggest impact.

One example is the leadership that nursing and care staff can demonstrate in managing winter pressures. Working with the care sector to improve hospital flow, creating environments for cohorting patients medically fit for discharge and driving the #endpjparalysis initiative are just a few examples. All are framed within LCAV, and we will measure the difference this makes in relation to outcomes, experience and use of resources.

I hope we continue to use LCAV to realise and articulate the collective impact we have and the difference we make as individuals, as teams and as whole professions.

Everyone a leader

Leading Change, Adding Value shows that all nursing, midwifery and care staff are leaders – so whether by yourself or as part of a team, you can improve outcomes for people in your care. Leadership is not always about managing teams – it is about looking at what needs to change or could be changed to improve services and outcomes for patients.

Please have a look at the LCAV webpages and see examples for yourself of how colleagues have identified ‘unwarranted variation’ – where care is not equal. By seeing where differences are and changing them, you can help make sure that everyone receives the same high standards of care.

If you have a great example of how you have identified and addressed unwarranted variation in practice please contact the LCAV operational team at england.leading-change@nhs.net so they can help share your work and ideas.


Alison Moore is a freelance journalist

Further information

Leading Change, Adding Value

Five Year Forward View

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