Creating an organisation where improvement can flourish

These days you don’t have to wait long for a new call for the NHS to up its game. Hardly a month goes by without the emergence of a fresh challenge, usually financial or demand related, which requires service leaders’ urgent attention. Sometimes it feels that we’ve run out of adjectives to describe how grave the situation is, or how pressing the need is for faster and more far-reaching change. The pressure to do more and do it better, preferably within months, not years, is intense.  

The breakneck pace at which local health and care systems in England are being asked to develop their Sustainability and Transformation Plans this year is a case in point. In Scotland, meanwhile, councils and NHS boards have found it hard to put everything in place to meet the challenging timetable for getting Integration Authorities up and running by 1 April. 

It is little wonder, therefore, that some organisations find themselves caught in an improvement ‘acceleration trap’. Desperate to avoid an even deeper financial abyss and to satisfy central bodies’ appetite for action, as well as their own productivity and quality goals, they may be tempted to implement a blizzard of initiatives at every level without first getting people on board or working out whether they have the right skills, behaviours or infrastructure to deliver them. Delivering any meaningful change in such circumstances is difficult, to put it mildly. The risk with this is that all you end up with is stressed and demotivated people exhausted by the pace of change and burdened by an unrealistic and disconnected set of objectives. As Repenning and Sterman have argued, the benefits of simply working harder are usually very short-lived.

Nonetheless, there are some welcome signs at national level that the risks posed by change fatigue and improvement overload, are being recognised. In England an improvement and leadership development strategy is now being drafted by the newly established NHS Improvement and Health Education England. It’s likely to highlight the importance of building a supportive environment in which central bodies give organisations and systems the ‘headspace’ to plan improvement and hold back from intervening too soon. It’s an ambition that we would strongly support - one that’s wholly in keeping with the main lessons from our improvement work over the last decade. The challenge, of course, will be to translate this ambition into action. Saying it is one thing, doing it is quite another; especially as the pressure on the centre to be seen to ‘act’ in response to local performance issues, is unlikely to relent.

Hopefully, the example of providers such as East London NHS Foundation Trust, which has carved out the time and space it needs to implement an impressive organisation-wide improvement programme, will give the centre the confidence to rein in any interventionist tendencies. In this newsletter we look at the progress the trust has made in the year since we profiled their programme in our Building the foundations for improvement report.

Tricia Woodhead, who co-wrote the report, also offers her reflections on the checklist published in the report for organisations looking to build improvement capability at scale. An updated checklist, which she has tested with health care providers across the UK over the last 12 months, along with her five top tips for using it effectively, is also included.     

In a similar vein, we also highlight a  new project that we’re running in partnership with The King’s Fund that aims to help providers assess their ‘readiness to change’; or, more specifically, whether they have the right behaviours, expertise and resources to implement innovation successfully. The project, and the rationale behind it, is discussed in a new blog by Professor Michael West, the project lead.

Our final piece is an interview with Deborah McBeal, the Deputy Chief Officer of Enfield CCG, and one of our Leadership Fellows. In her interview Deborah talks about some of the challenges involved in driving and sustaining improvement outside the acute sphere in primary care settings.

A common thread running through all these articles is an appreciation that for improvement activity to flourish, organisations need the freedom to focus on what matters most to them and their service users. If organisations are to get the most from any ready to change checklist, for instance, then we have to ensure that it is not used as a stick to beat them for all the things they are not doing: Its chief value is as a means for organisations to hold an open and constructive conversation about what’s needed to enable and drive change. As ever with quality improvement, the chances of making an impact and sustaining over time are much greater if people are given the time, space and trust to work out what’s right for them: it’s a lesson all leaders would do well to remember.