Can a perfect week really make a difference to improving health services in the long term?

‘Evergreen’, ‘Operation Fresh Start’, ‘Spring to Green’, ‘Peak Flow’, the ‘Perfect Week’ – what do all of these phrases mean to you? Military manoeuvres? Song titles? No, these are all local names for what is centrally known as the Emergency Care Intensive Support Team’s (ECIST) Breaking the Cycle initiative which is kicking off again this month. The aim is to act as a ‘system reboot’, particularly for those areas that have persistent A&E performance issues, by rapidly improving patient flow to produce significant improvements in performance, safety and patient experience. The initiative is usually run over one week during which all local health and social care partners focus on improving the emergency care pathway.

This all sounds great in theory, but can this really make a difference in just a week? Looking at examples of where this approach has been taken it seems to have created the desired result in the short term, with reports of improved A&E performance, reduced length of stay and happier staff and patients. But more than that, the approach seems to really start enabling staff to break through what they have told us are key barriers to change.

The initiative can create a real sense of shared purpose and staff engagement focused on improving patient care by improving flow, and creating headspace and permission for frontline staff to rapidly test out and measure new but often small changes or improvements, assess success, and then adopt or discard. It can confound those who feel that improvement is beyond their grasp and helps upskill staff capability for change through practical introduction to quality improvement methodology and tools.

So can this help to create sustainable change for the long term? I think this is less clear. While it can go a long way towards creating a culture which is hospitable to and supportive of change (vital to successful change), having a perfect week is by no means a panacea for all. We know from our Flow Cost Quality programme that achieving sustained change at a system level takes time and requires careful planning, preparation and long-term commitment and effort from all partners involved. Areas that merely seek to work harder for that one week – for example by ensuring a much higher level of senior clinical presence in the emergency department and wards or having intensive command and control twice-daily huddles – will struggle to sustain that effort over the long term.

What remains a burning issue for leaders within the health and social care system is how to marry the reality of complex, large-scale change with the continued pressure to deliver against short-term performance targets. This prompts for me a set of more fundamental questions.

Despite the attractions of the ‘perfect week’, doesn’t this just intensify the pressure on an already stressed system fixated by A&E performance which, although high profile, arguably provides limited insights into the quality of patient care? Doesn’t it ultimately create even less headspace for staff to focus on those areas that are either more likely to improve health outcomes for local people or create a more sustainable local health economy for the future? Perhaps we should be having a perfect week focused on those areas that we know will create the most impact for local people – which may be focused on the diabetes pathway or maternity services – rather than those that have the most political focus and attention.

While there is growing feeling that the current targets regime is not conducive to improving quality, how can we break out of this cycle when it is such a political priority? An attempt was made at the start of this parliament, with the coalition government announcing that the A&E target would be replaced with a wider set of clinical quality indicators. However although these indicators are now published monthly, they have a much lower priority than the headline target which is still the main focus of attention.

The underlying issue here is striking the right balance between maintaining performance now and transforming care for the future. Inevitably, while ideally you’d look to do both, there has to be an element of trade-off. This issue is helpfully highlighted in a paper on creating and sustaining improvement by the Massachusetts Institute of Technology which looks at the differences between working harder versus working smarter, and the near inevitability of a dip in short-term performance when trying to create long-term improvement.

In Constructive Comfort, published in February, we argue that national policy makers need to broaden the measures they use to define success for organisations in the NHS. At present, there is a mismatch between what the centre prioritises (predominantly focused on short-term performance) and the priorities of organisations and health economies that adapt and succeed over the long term (whose priorities include capability for improvement, change and resilience).

While national targets are likely to be here to stay, a far more nuanced approach to performance could be taken. As such, we have recommended that national bodies should introduce transparent ‘improvement zones’ for those transforming their health economies: where expectations of performance are adapted to create headroom for the duration of a period of change. Such an approach could be used to accelerate change in the Forward View ‘vanguard’ sites.

If there was a set of national incentives which meant that a trust chief executive who puts building an improvement culture ahead of waiting time performance wouldn’t be putting their career at risk, wouldn’t that be truly ‘breaking the cycle’?

Clare is a Senior Policy Adviser at the Health Foundation, www.twitter.com/clareahealth