The £22 billion question: how can improvement be spread in the NHS?

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.

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Comments

#548077 Bruce Gray

Learning how to do improvement, and what comes from doing improvement are two separate things. The how has to be in place for the what to happen. This is why pointing to case studies on a website, or benchmarking analyses from Consultancies, is ineffective. It's also why the 'spread at scale and pace' mantra is ineffective. What should be spread at scale and pace is the learning how to do the how, i.e. the methods, not the outputs.

#548078 Mark Henry
Managing Director
JMatch Ltd

Excellent article by Beccy. Having been a Clinician, Service Improvement Manager, SHA Head of Modernisation/Redesign and A Chief Operating Officer and patient I have witnessed successful improvement programmes and unfortunately ones that have not delivered. The combination a clinician and a service improvement team/individual can be powerful but it is essential that the core principles are adopted and practiced by the clinicians, non clinical staff and managers to sustain the gains made. Having presented at numerous workshops/events some of the same staff who had attended would be back in the audience 6 months later having not implemented any change at all - it was apparent that their organisations struggled to support what they were trying to do and there was little executive support. In the NHS we have experienced several significant reorganisations and policy changes. When this happened organisational structures, networks and national programmes were significantly effected leading to the slowing down on the progress that had been made when the Modernisation Agency and the NHS Institute for Innovation and Improvement Service Improvement were disbanded. We have returned to short term financial gains and letting slip the the constitutional right to be seen within 18 weeks and treatment to begin. Where has the patient voice and involvement gone? Since Mid Staffs the NHS has become more transparent but there is still a long way to go. I can't see a sustainable solution currently to supporting service improvement at a local level with STPs facing signicamt financial issues but with the pressure of transforming thier respective health communities with all the politics and organisational barriers that come into play. A recent example of this was in Pathology. Trying to get several organisations to come together with a solution and the sustaining and delivering the change has been fraught with difficulties in some networks leading to one major organisation withdrawing from their local network. Service Improvementd have occurred and will continue to do so despite the lack of clarity at a national level primarily stimulated by the NHS modernisation agency movement and continued on by the National Institute for Innovation and Improvement. On a final note prior to these organisations I worked at an organisation that really attempted to adopt the principles of Total Quality Managent and achieved significant improvements in performance and patient experience over a five year period resulting in the organisation achieving National Charter Mark status for the hospital. Staff and patients were heavily engaged and the Executive leadership was highly evident. I am sue there are similar organisations out there today achieving similar results. Quality of services has to remain the essential requirement of any provider:commissioning organisation.

#548085 John Hartly
Project Manager for the Changing Care Program
Northampton General Hospital

Beccy,

I couldn't agree more with your assessment. Trusts need to support and Invest in their workforce in order to empower frontline staff to realise continual quality improvements.

I'd like to share my story as an example of why service/quality improvement programs have failed to gain traction at national level. And whys it's so important it is to invest in people, from consultant to cleaner.

My story begins 6yr ago, when as a newly qualified bushy tailed cardiac physiologist , I approached my line manager and HR department, inquiring about doing an MBA and was virtually laughed out of the door. So, I scuttled off tail between legs. Less then 6 months later I left the trust to Locum, over the period of 6 years, I've self funded an MBA, project manager and lean six sigma certs but still struggled to pick up service improvement projects through the NHS jobs board.

The story does have a happy ending, Recently I was recruited through an agent and am starting a new role with Northhampton General as the 'changing Care' PMO.

The lesson of my story boils down to Human Resources: In my experiences there seems to be a disconnect between how trusts develop their workforce and what "Human Resource" departments actually do in the NHS.

John Hartley
Changing Care - PMO

#548159 Rosanna
Horizons Associate
Horizons NHS England

Wise words here. Every context is different and so the outputs from an improvement process cannot be transported over to another healthcare setting. We need to develop improvement cultures, skills and knowledge. But first, look at staff energy for change and address the gaps in current vs. desired energy levels. Its amazing how much untapped, latent energy for change is out there!

#548261 Mike Stone
Retired Non Clinical
None Private Individual

‘Why won’t good practice spread?’ asks Beccy.

Looking from the outside, and with very little knowledge of how practice spreads within the NHS, I will confine myself to a comment about how beliefs seem to spread in the context of end-of-life. When I discuss the law around end-of-life with clinicians, or when I read what they write on the subject, what clinicians typically believe is not what I think the law says. So far as I can see, in the context of beliefs, it isn’t ‘what is correct’ that spreads, so much as ‘what already fits in with what most clinicians already believe’ that spreads. It isn’t like Darwinian selection: flawed but widely-held beliefs, are not rapidly killed-off by correct but possibly ‘harder-to-work-with beliefs’. In fact, if 'correct' is indeed more challenging 'day-to-day', the reverse seems intuitively possible - that 'convenient flawed beliefs' will kill-off 'inconvenient correct beliefs'.

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