If you want to solve a problem, it helps to know what works. It helps, for example, to know what has transformed one of the biggest NHS trusts in the country from one that has prompted terrible reports by the ombudsman to one that's now described as "exemplary". So I spent a day at Manchester Royal Infirmary, to find out.
The Central Manchester University Hospitals NHS Foundation Trust, as it's not very snappily called, employs more than 11,500 people, and treats more than a million patients a year. There's a children's hospital. There's a dental hospital. There's a women's hospital. There's an eye hospital. What it feels like, when you wander through it, is a massive university campus, on a massive industrial estate. Some of the buildings are quite old. Some are spanking new. But all the ones I visited, one cold day in December, felt full of energy, and life.
In the "command centre" of its shiny, new children's hospital, I met Gill Heaton and key members of her senior nursing team. Heaton first came here to train as a nurse in 1976. She came back 10 years ago as chief operating officer, and chief nurse. Which means she's responsible not just for every single aspect of the trust's nursing care, but for every single aspect of its "operational performance".
The first thing she noticed when she took charge, she told me over a cup of tea, was the "disempowerment" of the "senior nurse force". Their "recognition" and "power base" had, she said, been "eroded". Nurses, she said, no longer had loyalty to the hospital, but to the university where they'd trained. "We're just the placement now," she explained, "and the people who went through that system didn't have that recognition of having a presence, and a status."
"Ten years ago," said Cheryl Lenney, the trust's director of nursing for adults, "we could probably say the areas in the trust where we're not sure we'd want our families to be cared for." Now, she said, there wasn't anywhere in the organisation she wouldn't be happy for a relative to be treated. "We have", said Heaton, "a very simple philosophy. 'Is it good enough for me and my family?' We make it," she said, "very clear that we aspire to be the best trust in the country. But," she added, "we're not."
If they're not quite the best, they're very clearly near it. Their infection control, which used to be "the absolute pits", is now used as a model for other hospitals. They're the best-performing trust for colorectal cancer. Four days before my visit, they were assessed by the NHS Litigation Authority, and were awarded a level 3, which is "exceptional". And when the Care Quality Commission visited last year, they gave such a glowing assessment that Heaton actually asked them if they were sure they were that good. The answer, apparently, was yes. "They said the thing that really strikes us about here is the quality, the care, and the consistency of delivery, but also that staff are really happy."
Ten years ago, according to Heaton, there was "no consistency, no structure, and no oversight". So she set about putting all these things in place. Nurses who weren't doing their jobs well were moved into "more appropriate roles". Others were encouraged to leave. Heaton restored the nursing structure, so that there was "a clear line of accountability". She also set about making sure that everybody was clear what the management expected. "There is", she said, "an absolute flaw in making an assumption that people know what they're doing, and that they're doing their job, and that they're doing it well."
A very big part of this has been about setting standards and looking for ways to make care better. They used, for example, schemes like "productive ward", developed by an organisation called the NHS Institute for Improvement and Innovation, to look at ways to "take time out of non-patient-facing processes, and tasks". They were trying, she said, "to put a kind of performance profile" on "quality of care". They also developed their own "patient feedback devices", and built up whole banks of "quality care round data". And in the end, they decided to draw on all the different schemes they'd tried out, to develop their own.
What they came up with was the "ward accreditation" scheme, which rates each ward as gold, silver or bronze. Or, in the absence of any of these, white. "It is", said Heaton, "about mainstreaming how you work, and constantly trying to improve it.
"We said that within a couple of years we want all of our wards to be gold wards. What we are saying at the outset is that for those of you who aren't, that's OK, but continuing not to be is not an option."
The scheme looks – according to Lisa Elliott, one of the trust's "service improvement leads" – at areas like the "culture of leadership", "communication within the team", and "the ability to use the data they've collected", which staff learn over a 14-week programme, to "make decisions" and "monitor change". The culture, said Heaton, is already changing. She has even overheard nurses telling each other in the canteen that they're "going for gold".
And if they're not? If they're not gold, or silver, or bronze – if, in fact, they're white, which means they're doing pretty badly – how do they react?
"Interestingly," said Lenney, "they're devastated. I don't think", she said, "that that would have happened a year ago. We've said 'that's absolutely fine, we understand all your issues, now we are going to focus you. What is it we need to do to help you get better?'"
And do they, I asked, ever hear of terrible patient experiences? "Yes," said Heaton, "we do. Where we do have complaints where we think 'Oh my God, we could have done that a lot better,' if the patients or their relatives are willing, we'll ask them to come in and talk to the wider team. We have used complaints and experiences in DVDs. Often using that visually is very powerful."
It all sounds pretty damn good. Nurses who are constantly trying to do better. Patients who are invited in to meet the chief exec. Ward leaders who are "devastated" if they get a poor rating, and vow to do better next time. So I decided to see for myself.
The first ward I visited was the renal ward. It was bright. It was clean. It was cheerful. On the wall were lists and charts. One board had the heading "Improving Quality". Another had "activity clocks", which show how much time the nurses on the ward have spent on direct patient care. All members of staff, said Emily Raybould, the ward sister, have a personal development plan. About 90 per cent of the staff, she said, were "very positive" about the data collection, and had "taken it on board".
Certainly, the staff seemed happy. All the ones I spoke to said, in ways that made you think they meant it, that they loved their jobs. "I enjoy working on this ward," said one healthcare assistant, "the team is very friendly. Everybody's welcoming, and the patients are all happy."
Even the patients I talked to on the gastroenterology ward, which often has patients with chronic conditions that are hard to treat, seemed happy. "The care has been absolutely brilliant," said one who'd been on the ward two weeks. "I've always been treated with respect," said another. "It's a really nice place to be." Even a patient who'd been there 15 weeks, with complications relating to lupus, had nothing but praise. "The pain management", she said, "is excellent. And the staff have smiling faces."
Pamela Taylor, the ward sister, told me about some of the things she'd done to make a difficult and demoralised ward better. When she took it over, most of her staff were from overseas. Quite a few of them, she said, "needed a lot of help in acclimatising, and working at the pace and standard we expected". There were, she said, "communication issues". Clinically, they were "excellent", but it was "the other side of nursing, bedside manner, empathy, and problem-solving" that wasn't, she said, so strong. So they came up with a programme to address this, and now their ward has been given a silver rating. Next time, she's hoping for gold.
"When I look back to how I provided care," said Cheryl Lenney, as she walked with me back to Gill Heaton's office, "when I first trained in the early 1980s, I probably had lots of empathy, but technically there were things I might not have done, which would then have been acceptable, but today wouldn't, and patients probably died. I defy any nurse of that generation to say that didn't happen, because it did. So I think the whole social stuff about expectations, and what we expect from healthcare now, has completely changed."
I think she's right. I think she's right to say that patient care is safer than it used to be, and I think she's right to say that nursing is "tough" and you can get "compassioned out". She's also right that the way to make things better isn't "through fear and hierarchy", but through "setting the standards" and "setting the tone".
And Gill Heaton, the inspirational leader of this inspirational nursing team, is right when she says this: "You hold," she said, "such a privileged position, because you are with patients at the most vulnerable time in their lives. They will share with you things they've never shared with anybody. You have women giving birth, you have people dying, you have everything in between. You're part and parcel of all that, and you have the opportunity, whatever's going on in their life, no matter how traumatic, to make it a bit better. If you waste that opportunity," she said, and it nearly made me cry, "you can't get it back."
Nurses of the year: Raising a glass in praise of nursing excellence
"The terrible reports on nursing", said the chief nursing officer for England, Chris Beasley, "can suck the life out of you. We need", she said, "to dig deep to find some of those reserves, in order for that energy not to go. We need", she said, "to listen to what people say, and we need to think about what we can do to make those changes." She was speaking three weeks ago, at the awards ceremony for the Nursing Standard Nurse of the Year.
It was quite a night. The champagne flowed and so, at least at moments, at least for me, did the tears. We were there to "celebrate excellence in nursing", and there seemed to be a lot of it about. A total of 22 nurses had been nominated for awards. Some worked with children. Some worked with older people. Some worked with wounded soldiers in Afghanistan.
Johanne Tomlinson, the nurse who won the overall award, has developed a care plan for ex-veterans in a prison. Simon Andrews, who won the ward sister award, has transformed a trauma unit with low morale and high sickness rates into a "gold standard ward". Lisa Brown, who won the general award, has developed a scheme to reduce the high incidence of pressure ulcers. "I was a hairdresser before," she told me. "I was working with people in their own homes, and I saw that they were quite isolated, and they needed a certain level of care. I thought", she said, "I'd like to go into nursing, and try and make a difference."
Simon Andrews is her boss. "We've brought ourselves back to basics," he said. "We took ownership of our care, and patients, and improved our standards from that." And what, I asked, would he say to nurses who were struggling? Andrews smiled. "Take a step back," he said.
"Have a good relationship with your ward manager, whether you're a healthcare assistant, or a domestic on the team. And make sure that everyone feels part of the team that's trying to make the culture change."
It wouldn't, I think, have been possible to leave that ceremony and not be moved. Most of us will never have the chance to help so many people at their lowest ebb. These people do, and they do it brilliantly.
"Nursing", said Natalie Ions, who won the student nurse of the year award, "was a second career for me. It wasn't until I got a part-time job as a healthcare assistant to fund myself through university that I realised I was so much more comfortable spending my days with people, rather than sitting behind a desk.
"So I took the plunge, and quit my job, and went into nursing. It is the best decision I ever made," she said.
TOMORROW: Part 5 - a ten-point plan to cure the nursing crisis
Special report: A crisis in nursing
* Day One: Six operations, six stays in hospital – and six first-hand experiences of the care that doesn't care enough
* Christina Patterson: More nurses, better paid than ever – so why are standards going down?
* Leading article: What can and should be done about nursing
* Day Two: Reforms in the 1990s were supposed to make nursing care better. Instead, there's a widely shared sense that this was how today's compassion deficit began. How did we come to this?
* Day Three: How can a profession whose raison d'être is caring attract so much criticism for its perceived callousness? Does nursing need to be managed differently? Or is the answer to develop a new culture of compassion?
* Day Four: The nurses who taught an ailing hospital how to care