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In the mid-1990s, the service improvement methodologies developed by Don Berwick at the Institute for Healthcare Improvement in Boston, US, were first used in the NHS. In 2001 the Department of Health established the Modernisation Agency to develop and spread service improvement skills more widely throughout the NHS. And yet there is still a mountain to climb in terms of both service improvement and productivity, and there is significant variation across the country. Why is it that the best ideas are so hard to spread?
It has been 15 years since I ran one of the first Modernisation Agency mental health service improvement pilots in an inpatient psychiatric unit in Essex. I was inducted into the mysteries of service improvement methodologies, the PDSA (plan, do, study, act) cycle, process mapping and statistical process control charts.
Fast forward a few years and I was working in a cancer network, leading a team of service improvement facilitators – some placed in acute trusts and one in primary care – concentrating on how to improve waiting times for cancer diagnosis and treatment. These facilitators were really able to get under the skin of what was going on, to improve services for patients. In one trust the facilitator uncovered around 120 different queues for a diagnostic test, with each clinician carrying out the test having a number of separate queues for varying levels of urgency – these were organised on paper in shoeboxes, and unsurprisingly there were very long waits for this test. In another, they found that patients arriving at the chemotherapy suite for treatment were then sent all the way to the other side of the hospital for blood tests to check that they were well enough to receive chemotherapy that day. The service improvement facilitator was told that was fine, because by the time patients had walked back to the unit their results would have arrived so they could start treatment (or be sent home). The facilitators worked with the clinical teams to deal with the issues that were uncovered, whether it was streamlining queues or moving a phlebotomist into the chemotherapy unit. Working in partnership with clinical teams they made great strides, both in relation to waiting times and also improving patients’ experiences of care. I think we even managed to meet the 62-day waiting times target for cancer services across the entire network for a few months.
But fast forward again to the present day – the 62-day waiting times target for cancer hasn’t been met in three years and diagnostic waiting times are still increasing. Not all of this is down to process – undoubtedly demand has risen and resources have not kept pace – but talking to people on the front line, many of the issues that were being addressed back in the early 2000s are still there. Why is it that one breast cancer unit has virtually no wait for treatment, but the unit at the trust next door has very long waits, even with the same demand and the same level of resources? Why wouldn’t the unit experiencing problems examine and learn from the practices of the successful one? Why won’t good practice spread?
There are innumerable service improvement resources online, endless case studies, myriad tools (for example, these are just the some of the ones for endoscopy). But however good, these tools and resources do not produce change on their own. What really made the difference back in the days of the Modernisation Agency was people. People whose job it was to become skilled in improvement methods, who could work in partnership with clinicians and patients, and who had the time to examine each issue forensically.
The National Nursing Research Unit at King's College recently evaluated the sustainability and spread of a quality improvement approach (experience-based co-design) in a cancer centre and found that clinical engagement, committed leadership and 'externally-positioned quality improvement staff' working together with frontline staff are very important for introducing and securing change. Virginia Mason Hospital in Seattle, often held up as a beacon of good practice in quality improvement, constantly invests in training its staff in improvement skills and embeds the methodologies throughout its organisation. It does not rely on sending people to a website to see how others have done it.
In my mind there is just no replacement for actively implementing service improvement, from the bottom up, with trained expert facilitators working with frontline teams again, and again and again. It’s not cheap. But it works. The Fund has previously argued for a coherent strategy for quality improvement. As we noted in that report, ‘Improvements in the quality of care do not occur by chance. They come from the intentional actions of staff equipped with the skills needed to bring about changes in care, directly and constantly supported by leaders at all levels. They do not come free and will require a substantial and sustained commitment of time and resources.’
The NHS must invest in improvement skills and use staff dedicated to improvement to support frontline staff, not just in acute trusts but also in general practice, mental health and community health services, if it is going to have a hope of implementing the recommendations of the Carter review, or the ambitious steps being outlined in sustainability and transformation plans. The national improvement and leadership strategy due to be published by NHS Improvement in the autumn will be vital in driving this forward.