Releasing innovation from the constraints of improvement

Quality improvement as a management approach has gained widespread currency within the NHS. But does it go far enough? Helen Howson argues that we need to be more ambitious and look beyond iterative gains to make a more transformational change to benefit the lives of patients, staff and communities.

The NHS as we know it is not sustainable. With large and possibly insurmountable challenges looming, including workforce recruitment, ageing population and complex conditions, we are now in desperate need of some radical thinking in order to ensure that future generations will benefit from a universal, comprehensive and free health service.

Missing radical solutions

The concept of ‘quality improvement’ makes sense to many healthcare professionals and, aided by evidence-based targets and protocols, enables them to make iterative improvements to everyday tasks and services. These improvements can be measured and communicated, providing satisfying proof to senior staff and members of the public (“We reduced waiting times, reduced length of stays, improved ambulance response times” etc.).

However, what quality improvement may fail to fundamentally question is why these tasks and services are in place and do we really need them? If we do, could better outcomes be delivered in entirely different ways? Within a mainly transactional, target and process-driven environment, it would be easy to miss the much more radical solutions that could make a real difference to health outcomes, patient experiences and better suit people’s needs.

Revolution not evolution

At the Bevan Commission, we argue for a much more ambitious approach to address the constantly stretched, unsustainable NHS: transformational change, not just improving what already exists. In essence, we are calling for “revolution not evolution” – a more radical position advocated by the Parliamentary Review for Health and Social Care in Wales.

Our Bevan Exemplars scheme, which recently demonstrated a consistent 79% success rate, gives NHS professionals the support they need to think differently and try and test out their own innovative ideas. However, this is only part of the story – these innovators need to be working within supportive environments which encourage transformational change. If not, they risk not being able to properly sustain and scale-up their ideas beyond the initial stages.

Supporting change agents

To challenge ways of working we have been running transformational change sessions with Health Boards and Trusts within Wales. These sessions aim to transform organisational cultures so that they can identify and support change agents. We want to see staff and patients involved in designing solutions and taking responsibility for delivering these.

We bring together clinical and non-clinical staff (from different departments and at all levels) to identify key barriers and enablers to transformational change. Barriers to transformational change identified in our sessions include: lack of engagement from senior staff; over-burdensome bureaucracy; culture of risk avoidance (instead of managed risk); and resource limitations used as a barrier instead of an opportunity for innovation and change.

Enablers for transformational change include: creating informal staff networks, where people can collaborate and find practical help (such as a change toolkit which includes advice on writing job descriptions, business cases); and establishing a generic mailbox to collect staff ideas.

Sharing risks and opportunities

Transformational change is about strong collaboration, trust and empowering people to do what is right for the patient, not just what the process or target demands. It involves everyone taking responsibility for change: supporting a wider learning environment where risks are managed and shared, and opportunities are explored and supported.

We may not get it right in the first instance but we need to trust colleagues to have a go and to effectively manage that risk, not hide behind it.

We hope that by combining approaches – creating a network of innovators in our Bevan Exemplars and Health Boards and Trusts supportive of them – will help us deliver the radical solutions from within that the NHS requires for its future sustainability. It is no longer enough to just make incremental gains and hope for the best: who will be brave enough to release their organisation from the constraints of improvement to embrace transformational change?

Helen Howson is Director of the Bevan Commission, Wales’ premier think tank for health and care, hosted and supported by Swansea University School of Management.

The views contained within this blog are those of the author and do not necessarily represent the views of the Bevan Commission.

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