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Using the 6Cs to improve communication

February 3, 2015

A guest blog by Duncan

Hi, I’m a Care Maker. I say that because it’s relevant to the story I’m about to tell. The last few years, our ears have been full of the 6Cs rallying cry from nursing leadership, with various claims that it “enables staff to reconnect with their values” or “the 6Cs explain what we do in a simple way”. One of the most common is: “we can use the 6Cs as a framework for improvement”. Even the Chief Nursing Officer (CNO) for England, Jane Cummings, is touting that one, despite going on record more than once in saying the 6Cs are incomplete, “…but six is about as many as anyone can remember.” (

The value of any framework or model is that it is both explanatory and predictive. To have some practical merit it has to be useful not just as a post hoc justification, but to put you on the right path before you even set off. Let’s take a look at that.

Way back in April of 2014, an eager soon-to-be student nurse (that’s me) applies to join the CNO’s ambassadorial network, the Care Makers. The route applicants were encouraged to do this by was via an online form located on the NHS Employers website. Curiously, NHS Employers are frequently found on the Department of Health side of the table in negotiations on reducing staff entitlements, but this organisation belonging to the NHS Confederation is also helping implement Action Area 6 of Compassion in Practice, “supporting positive staff experience”. Part of that is administrating the Care Maker scheme, intimately involved in the promotion of the 6Cs. Now, the web form for applicants naturally asks for personal details, including a special class of information deemed especially “sensitive”, being ethnicity, sexual orientation, religious beliefs and so on. It also asks for anecdotes of application of the 6Cs in practice, which would likely include details relating to service users. Given all that, being a savvy internet user I check for the lock icon in my browser, but it’s nowhere to be found. The web form is unencrypted. Any data sent would be visible to any party sitting between the source and its destination. This is something akin to leaving a folder of patient notes open on the front desk, if you need an analogy, or rather more like carrying it around the hospital in plain view. As a regulated professional, that’s the kind of potential breach of confidentiality that can result in at least suspension, or even being struck off.

Appearing to somewhat contravene legislation, I mention the lack of encryption as I email in my application (not much of a security improvement, to be fair). This gets me an auto-reply and nothing more. Now might be a good time to remind ourselves that “communication” and “competence” are included in the 6Cs framework that NHS Employers have been commissioned to promote.

Go forward a couple of months and an update seems in order. I email again, wondering how my application is doing (this lengthy silence is not untypical of other applicants’ experiences) and pointing out the lack of action on encrypting the applicant form. Investigating further, I discover NHS Employers are using a third-party solution for their web forms, JotForm, and take a look. Their instructions for how to enable the necessary security can be found here, and amount to simply clicking a checkbox. And also upgrading your subscription from free to $10 per month, which I think compares quite favourably with the record £325,000 fine imposed by the Information Commissioner’s Office (ICO) for losing data. This time the issue was acknowledged and I’m told it’ll be referred to the “web team” for action. Armed with my heads-up about the checkbox, I feel satisfied things will be sorted in due course. Seeing the sign off for the reply, the author of The Care Makers Song his very self is on the case and no one could doubt his Commitment starts with a capital ‘C’. What could go wrong? Nothing.

Nothing. Nothing happens.

The form remains unencrypted, but it’s not long before applications to become a Care Maker are suspended to “better support existing Care Makers” so it appears to stop being an issue regardless. Only later do I discover the application page hasn’t been deleted and remains active through direct links from third-party sites.

Roll on December. Care Makers are asked to recommit to the scheme by filling out a web form. You can guess the rest. In my experience, going full lawyer tends to get people’s backs up as much as it gets any action, but I decide now has to be the time to put that aside. I get myself put in touch with the Head of Legal and Compliance at the NHS Confederation. The next day I receive an appropriately serious reply and the web forms are encrypted, privacy notices put in place. I’m promised a substantive update on corrective actions taken, but a month goes by and I hear nothing more. Perhaps not as serious, but I’m struck by the parallels with service user experiences, where all a complainant usually wants is to be acknowledged and know things have been improved going forward, yet we fall short of that far too often and things escalate.

So I escalated things. Having given a few days extra to account for the holiday break, I got my substantive reply the day after I wrote a complaint to the Information Commissioners Office (ICO). The whole debacle has been entirely unnecessary and my patience somewhat tested. Despite my frustration, I hope my account of events has been reasonable, but I feel too close to it to really know, so please don’t judge me too harshly. I’ve written this because Care Makers are supposed to share their experience in order to promote best practice, so what can we learn?

Specifically, having a defined, robust procedure for handling complaints is a must. Someone competent in coding C# should be able to throw together a crude solution in a week of evenings with Visual Studio, to enter complaints into and track progress, it basically just needs a database and a timer and a UI. If budgets allow, suitable customer relationship management (CRM) software can be purchased, giving deeper integration, data analysis and all that good stuff. Even without a dedicated solution, Outlook and similar provide to-do functionality integrated for emails and calendars. Failing to follow up shouldn’t be an option, even if all you can say is “we’re still working on it” and it certainly shouldn’t require the intervention of senior management to get things moving. Responsibility and responsiveness should start at the front-line. If nearly two-thirds of complaints are never even made, letting the ones you do get slip through the cracks seems a desperate waste.

The real point I’d like people to take away though is on the 6Cs as a framework for service delivery. Whatever else they might be good for, joining the dots between incredibly broad, reductive statements of values all the way to “you must encrypt collection of sensitive user data with SSL/TLS” and all the many other wrinkles “communication” can throw up just isn’t reasonable. The real world is a complicated place. Without predictive value the 6Cs aren’t a usable framework for practice and I sincerely worry that the danger here isn’t being seen as they’re increasingly embedded in institutional training and recruitment, as well-intentioned as I’m sure that is. The 6Cs didn’t safeguard anyone’s information here, the fact that people are accountable to an ombudsman with real teeth under an Act of Parliament did. I didn’t use the 6Cs to address the problem, I used my familiarity with the law. If those closest to the promotion of the 6Cs can’t make it happen, what hope for everyone else?

Hi, my name is Duncan, and I’m withdrawing from the Care Maker scheme.

The NHS Confederation were sent an earlier draft of this article for comment, any response will be updated here.

  1. lesley58 permalink

    Well done for pursuing this.

    I am a nurse but have made a complaint about breaches of family confidentiality that have caused a breakdown in relationships with a family member who has mental health issues. This has resulted in a distressing deterioration in her health.

    My experience is that Trusts use confidentiality to protect themselves but at the same time abuse the requirements of the data protection act when it suits them.

    The 6 C’s like the hello my name is campaign allow managers to jump on a band waggon. There is a pretence that issues are being addressed but in reality it allows the real problems the NHS faces to be ignored.

  2. Duncan permalink

    Thanks for commenting, and well done you too, confidentiality seems to be a thing that gets overlooked a bit readily in my experience. When I first started as an HCA I was one of the first to get a newer style induction with more comprehensive training, so the Practice Development Lead made a bit of a face when I asked about confidentiality and she realised the induction checklist had been round all the ward sisters for comment with no one noticing that area missing.

    I’ve seen the 6Cs really energise a room at a conference so I know they have value to people, but equally there must be places they maybe shouldn’t be invoked as our catch-all answer.

  3. Maggie Evans, NHS Confederation permalink

    We are very sorry that Duncan has had this experience with registering for the Care Makers scheme. When he wrote to us in December we immediately ensured the web pages were encrypted. The fact that they were not encrypted previously was a simple, but serious error. That Duncan did not receive a response when he first brought this matter to our attention is not acceptable. The way we managed this falls short of the high standards we set ourselves in the organisation and we are deeply sorry about this. We do not hold patient data but the personal data we do have is equally important and we are carrying out an urgent review of how we adhere to both the letter and spirit of the Data Protection Act in NHS Employers and across the NHS Confederation.

  4. Duncan permalink

    Thank you for your comment Ms Evans, and for putting a comprehensive response into action, I sincerely appreciate the work you’ve put into this as it came to your attention.

  5. Marieke permalink

    The shame about the whole thing in my opinion is this: it would have been so much better if it had been/remained a true grassroots thing. By putting it with NHS Employers, it became muddled with targets, budgets, KPIs and whatever else. Look at #hellomynameis: it got taken on from the bottom up because people just started saying it to patients (if they didn’t already). Trusts followed what their staff was doing, rather than someone at the national NHS saying: WE SHOULD BE ALL OVER THIS. There are no targets, regulations, budgets and so on attached to it. People feel the direct impact. There are no meetings of people who gather at conference centres just to congratulate each other in how great it is that they introduce themselves to patients. They just get on with it because there is no pressure to write a report on how often they say it, how they say it and how they made others say it.

    If the NHS really wants change, the 6Cs should REALLY be applied everywhere, in all layers of the organisation and not just telling clinical staff they have to do it.

  6. Duncan permalink

    That’s a really good point Marieke, I hadn’t really considered that before but trying to create a cultural movement top-down must be like trying to bottle lightning. Just look at how the music video created by senior staff at ULHT alienated some:

    • lesley58 permalink

      That must be the worst of the patronising videos that are being circulated. It sums up the problems the NHS faces. Marieke is right. Those of us on the shop floor as it were, get on with doing our jobs to the best of our ability incorporating quietly the values that those who don’t really give a damn have to make a song and dance about.

      • Marieke permalink

        I don’t think those at the top don’t give a damn. I just think that they do not understand that values like that apply not just to how people look after PATIENTS. Because their aim is to improve things for patients, their focus is ONLY on how things affect patients. And since clinical staff are the people in direct contact with patients, they focus exclusively on telling clinical staff how to do the 6Cs etc. It is only a recent thing (and I mean a few years) since the importance of staff being happy in order to provide friendly and compassionate care has been begun to be understood. So those in higher positions have not been ‘trained’ with the knowledge that staff satisfaction is not just good for staff retention but that actually, patient satisfaction can ONLY be improved by happy staff.

        So, all in all, I don’t think they don’t care. I think they don’t KNOW. I am perfectly happy for patient improvement initiatives being introduced by management as long as they involve staff, rather than impose, and as long as these values are applied to ALL people.
        I think the 6Cs are not about patient care. I think they are much more about just how people should deal with each other in general. And thus they apply equally to how the HR Director treats your request for paternity leave, as to how you talk to that awkward patient. I just think ‘they’ don’t understand that.

      • lesley58 permalink

        I am probably more of a cynic than you. I just think all these videos are an utter waste of money. The 6 cs is a diversion. How I would like to see Jane Cummings putting a nurses uniform on and doing a few proper shifts in todays nursing world instead of preaching to the rest of us. Does she speak out about better pay for us?

        You are right that all these “staff friendly” initiatives and award ceremonies have only been around for a couple of years. It all seems so false though. You say they don’t understand, surely as managers who attend leadership courses and events they should know, that is their role. Maybe they are being led in the wrong direction?

        Roy Lilleys article today hits the nail on the head!

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