Within a few days, the team had reached agreement with the local Spire Healthcare hospital to take over its staff and operating theatres. Within three weeks, it had transferred the majority its ophthalmology operations, orthopaedic operations and breast surgery and other cancer operations to Covid-free ‘green zones’ on the Spire site. Within twelve weeks, it had transferred cardiovascular services, including an intensive therapy unit, to the new site.
The team also made substantial changes to how services plan and deliver elective operations, in particular making better use of waiting time to prepare patients for successful operations, ensuring that patients arrive for surgery fully pre-assessed, and establishing dedicated and self-contained clinical teams to deliver surgery pathways, rather than sharing staff with other services.
Staff reported that they have not needed to cancel cardiothoracic surgery or any level 1 or level 2 cancer surgery and have completed most level 3 surgery. They also explained that there have been no cases of Covid-19 or MRSA (methicillin-resistant Staphylococcus aureus) at the sites. On-the-day cancellations have fallen to 0.7 per cent because of better planning and because other services no longer disrupt elective operations. The average length of stay has also gone down.
Although the pandemic has inevitably led to a deterioration in access to services, there are other similar stories across the UK, where staff have achieved astonishing transformation and an unprecedented pace. Anecdotally, it seems that those who made the most progress were those who had already laid the foundations for effective system working. In Cardiff and Vale, leaders have been investing in system-wide approaches to improvement, building on the model from Canterbury, New Zealand, for the last five years.
In the near future, we hope, health and care services will be able to consider which of these service changes to retain in future and where things should return to a ‘new normal’. Many members of the public are delighted to be able to access routine services online, rather than taking time off work to queue in primary care waiting rooms or outpatient clinics. Many surgeons at Cardiff and Vale are determined to retain the benefits of self-contained cold sites for elective surgery. Of course, there is a need for comparable rigour in deciding what changes, even those that reduce costs or might make life easier for staff, are not in the long term interests of patients and communities – not least as the voice of patients and the community has been largely missing from these changes. Understandable when faced with Covid-19, but this is something that must be addressed in decisions about what changes to keep.
It is possible, though, that there are even more important lessons from these examples, relating the ways of working and processes that staff follow to achieve service change. In Cardiff and Vale, staff leading this and other projects put aside the traditional approach of developing extensive business cases for board approval. Rather than developing a detailed service model on paper, they adopted an iterative, ‘test and refine’ approach to redesign: defining objectives, making a rapid set of initial design decisions, getting a service up and running, reviewing the impact and refining the model. Instead of detailed planning, many of the complexities of service redesign were addressed simply by getting the main teams in the same room twice or three times a day to manage interdependencies.
None of these ways of working seem compatible with a traditional model of senior oversight of major projects. Instead, the staff leading the projects took much greater direct responsibility for decision-making, albeit within a model of teamworking that provided a different form of oversight and challenge. While it is too soon to assess the full impact of these projects, some do appear to have achieved important service change in weeks that would otherwise have taken years, or not happen at all. One of the downsides, of course, has sometimes been limited engagement with patients and communities on service change.
It seems critical that we learn the lessons from these examples of rapid cycle innovation while the memory is fresh in our minds. If we don’t, decades of established ways of working will surely trump the year-long experience of the pandemic. In Cardiff and Vale, this work has begun with a learning report on working through Covid-19 and the establishment of a new Dragon’s Heart Institute, which will become a centre for sharing learning and collaboration. The Royal Society of Arts provides a useful framework for reviewing crisis response measures – what should we let go, re-start or retain and build on? – and for considering how leaders can tilt local systems towards positive change.
This blog draws from two recent papers from The King's Fund commissioned by Cardiff and Vale University Health Board on system leadership and innovation and improvement within the Cardiff and Vale health and care system.