One enabler would be for leaders at all levels to model their commitment to, and belief in, the NHS as a benchmark for global health to aspire to (Don did this every time he spoke about the NHS). We can also create communities in which we support each other to take some of the losses necessary to make system-level change; this will sometimes mean sacrificing our specialist interests, and sometimes making the case for changing models of work, for example, in integrated care.
Some communities are already moving in this direction. A number of quality improvement sciences, tools and techniques have been successfully pioneered in other industries and applied to health – such as the IHI methodology, which draws on a significant tradition of improvement based on Japanese Kaizen (meaning 'good change'). In our medical leadership programmes we have found that clinicians with an understanding of, and who are supported in developing ideas for, quality improvement value team-based working, which has tangible benefits for both staff and patients.
Don offered a timely reminder, in the face of the Francis Inquiry, about the public's loss of trust in our clinicians and managers and about the resulting impact on the morale and motivation of our workforce. He stated on more than one occasion that 'people who give care can change the care' and challenged leaders in health to listen to their non-clinical and clinical colleagues who are providing care. In considering the opportunities for improving the quality of service; Don suggested that leaders needed to answer two critical questions: 'What do we need to change/improve?' And 'How should we go about this?'
One model that might help leaders to answer these questions is IHI's 'triple aim': improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care. By focusing energy and attention on population health and on wellness we can both improve the experience of care and take account of per capita cost. But to achieve this, we need to change our systems.
From a system point of view, organising care around patients’ needs will require professionals to work across existing boundaries – including the interface between health and social care, for which the need has never been greater. And we need to recognise and value the achievements of professionals who lead the way in change – with a special plea to politicians to have the wisdom to build on successful ideas as oppose to dismantling and changing things for the sake of political gain.
What can we learn from other health systems? Nuka in the Alaskan health care system offers a model in which the system was transformed from one focused on health care transactions to one focused on delivering health. To achieve this entailed significant change – to job roles, buildings, systems, objectives. It involved taking care out of secondary care hospitals and locating roles and responsibilities within the community. Above all it required the executive team to have powerful conversations, be visible and so lead the culture change necessary to recreate a more sustainable care system.