Improving quality in the English NHS: A strategy for action

I think it’s really important to say that I am a product of years and years and years of investment, not just financial investment but investment from people and so back in the day 15 years ago now I was successful in getting an MRC training fellowship and that set me on a new track. I was a clinician who begun to think differently. And thanks to the Health Foundation and the Institute for Health Care Improvement I was able to spend a year out I Boston in 2006 a decade ago studying health systems and really learning things that I have never been privy to before despite the fact that I was trained clinically and I was also a researcher.

And the question that I have often asked myself is how did I arrive where I am today? So today I sit in the Salford System as an equal partner in the leadership of the changed work that we’re doing. So I work with the chief execs of all the major organisations, the City Council, the Clinical Commissioning Group, the university and the hospital now embrace me as part of that senior leadership team. I think that’s really important but I also think it’s really unusual.

I just want to reflect on how did I get here and are we really engineered within our system to develop people in the way that I’ve been developed? Because actually right now I'm one of a small number, maybe 20 or 30 people in the UK footprint who are in a privileged position of having had this training and who is seen as somewhat maverick actually, we’re not seen as mainstream we’re seen as a little bit on the edge.

So what does that mean? I think what that means is that we have to get better at understanding how we can create a profession of improvers. So yes absolutely it has to be part of every clinician’s day job but it also has to be a place where we can develop excellence, where we can develop people who can really lead through tough times. So to sit shoulder to shoulder with those system leaders under the pressure they’re under and understand where they’re coming from is the work of improvement. We can't dance about, this is not about cosy corners of the world, dark shadows, this is about being real and being visible and being present.

So coming back to the report when I read it, I read it from my viewpoint, from where I sit. And I was wondering how this would differ from the last decade of reports. So I remember sitting out in the IHI when Ara Darzi was doing his work and reading the NHS constitution, and the aim of the NHS constitution and thinking that’s why I want to go back to England, that’s why I want to work in the NHS. That sense of feeling pride in the entity that I belong to is something that I think is really important. And if we need a strategy to do that let’s get on and get one. Let’s agree about what we want to do. And why is that important? Because what we know is that the most successful change programmes, Don alluded to them earlier, really have that sense of coming together.

So many of you will know the three by five campaign that the World Health Organisation ran to get three million people on antiretrovirals by 2005, an audacious goal, one that seemed unachievable in the timescales that they were set. The 100,000 lives campaign headed up by Don and Jo McCannon at the IHI, set an audacious goal to reduce harm in the health care systems across America and beyond. And we’ve had examples here in the UK, the London Stroke Reform work headed up by Ruth Carnall and her collegiate of professionals. They all had something, they all had a really focused goal, they knew where they were going and they knew what they had to achieve, and they mobilised relentlessly at every level. Leadership level, grass roots level.

I'm not sure I know what our goal is. The other thing that they had was a very visible leadership. So we know when we looked at the three by five campaign that Jim, Kim and the team there were leading it. We knew in the 100,000 lives campaign that Don and Jo McCannon were at the helm, we were all part of it, but they were there. The keystone project in Michigan, central line infection, Peter Pronovost he was at the helm. I don’t actually who leads improvement in the NHS and I work in it. So we need some clear leadership and why do we need that? Because I think there’s a sense that improvement is all good and in fact it can be good but it can have unintended consequences, it comes at a cost and it’s actually really hard to do. You need resilience, you need an environment that’s nurturing and supportive, and you need to feel that when the chips are down somebody has got your back. And that requires us to have a very clearly articulated strategy and a very clearly articulated leadership system. Because improvement is about failure as much as it’s about success and I think sometimes we forget that that bears a person toll on people who are trying to lead from the edge.

And so having an environment that’s nurturing, that grows people, that invests and develops people as leaders and change agents, for me is just a no-brainer. And when I read this report again last night on the train I just had to put it down for a minute because I looked at the central system that has been organised and re-organised for more than a decade and I was just in awe of the people that are in it because despite the fact that colleagues of mine have been in turmoil for ten years or more, they’re still in the game, they’re still on the pitch. But just imagine how much they could do if we set up a system around them that really supported and nurtured them. It feels really important to me that we get this strategy right, that we get the system right and that we mobilise immediately with this central agency who I think can provide that safe place, that safe home for me and colleagues like mine.

Just a couple more points. I think there’s something interesting about this report when I read it, there was one word that I kept bumping up against that I couldn’t quite get because it didn’t feel like it grafted with where I am, and it’s the word organisation. So in Salford when we start to think about improvement there we’re starting to think about improving systems and I think about the system and the learning system and the improving system because with the devolution agenda in Greater Manchester we’re starting to think much more about people and place rather than organisations and professions. And I think there’s something about maybe thinking about that in the development of this work.

One of the things that I’ve learned is that there’s an awful lot to be gained from, not just looking outside at other health care organisations, but looking across public sector reform. So I’ve been leading a piece of work in Manchester looking at how we can improve dementia services and actually what’s been really interesting is looking at how, for example, the fire service has moved in terms of its mind-set from rescue which has been their core business into prevention and they’ve managed to shift the whole system. And in fact when you look at public service, public service is all about rescue, it invites people who enjoy the rescue, and I think we have to get a system that is much more entertained and interested in the mundane actually, and the fire service offers us a great example.

The other thing that public sector reform has done for me is made me really serious about cost benefit analysis. So I think improvement has a lot to learn from the work that is happening in the public sector and in particular in looking at how we might inject different sources of funding, for example social finance into the improvement work we’re doing. So there’s a lot of learning to be had.

One of the things that’s not mentioned in this report and I think is almost a daily issue within our health system is how do we mobilise primary care? Because if primary care fails we all fail. And so thinking about our work as improvers I think we have to start to foreground primary care, public health and prevention in a much more significant way and I think that’s also something we could think about in next iterations of this report.

But I’m just going to finish with a quote actually. Theodore Roosevelt in 1910 presented a speech called Citizenship in a Republic and many of you will know that this has been termed daring greatly, but he said, “It’s not the critic who counts, not the man who points out how many strong men stumble or where the doer of deeds could have done them better. The credit belongs to the man who’s actually in the arena, whose face is marred by dust and sweat and blood, who strides valiantly, who errs, who comes short again and again because there is no effort without error and shortcoming but who does actually strive to do the deeds, who knows great enthusiasm, the great devotions, who spends himself in a worthy cause, who at best knows in the end that the triumph of high achievement but who at worst if he fails at least fails while daring greatly so that his place shall never be with those cold and timid souls who neither know victory nor defeat”. So I think this report actually begs us to go out and dare greatly, we have to get behind it, we have to bring it to life and we have to make sure that every single one of us gets involved.

Thank you.