Our new report, The spread challenge, shines a light on the challenges facing the NHS in improving the uptake of new ideas and practices, and the need for new approaches when developing national and local programmes to support the spread of innovation. Professor Sir Mike Richards was England’s first National Cancer Director and later the Care Quality Commission's first Chief Inspector of Hospitals. We spoke to him about why spread is a challenge and what policymakers can do to tackle it.
Why do you think there is such variation in performance and quality across the NHS?
The simple answer is that although we call it the National Health Service, we do not work as one system. Historically, there has been individuality in practice and that is something we need to challenge. We also need to encourage and train people in quality improvement – nurses, managers, doctors, allied health professionals – to raise standards across the board.
It is not going to happen overnight and we cannot wait for the new generation of health professionals to come through; we have to train people already working in the system as well.
What are the best examples of spreading improvement you have seen and what do you think were the reasons for their success?
There have been improvements across whole conditions like cancer, heart disease and stroke, where major improvement was needed across the whole country.
Then there are individual hospitals that have worked hard on quality improvement. Salford Royal NHS Foundation Trust is a very good example, where they have invested in a quality improvement team and that gets it into the DNA of the hospital.
We have good examples of quality improvement in some providers but now – in the same way that we have been talking about spreading innovations – we also need to spread the quality improvement approach itself so that it is fully embedded.
In your opinion, why can spreading innovation and new ways of working in the NHS sometimes be so difficult?
The first thing to say is that people working in clinical settings are extremely busy and they want to do the best they can for patients.
Most people believe they are already doing the best they can for their patients, and so may not immediately see the case for doing things differently. There are clearly innovators at one end of the spectrum, but many people are in their comfort zone and are so busy that they cannot lift their heads to see there are different ways of doing things.
Those cultural barriers are incredibly important. It is not that people do not want to do a good job. They may also be worried that any change might have an adverse impact both on their patients and on their own working lives.
In what ways do you think national spread programmes could be designed differently?
We have lost some of the positive things we had a decade ago. At that point, we had national clinical directors who were empowered to do things, and who had support teams to help them roll out change. Perhaps you would expect me to say that, as I was the National Cancer Director back then! But whether the focus was cancer, cardiac disease, stroke, trauma or mental health, we made progress. Those programmes were supported at a high level, both by politicians and by the Department of Health.
Directors were given sufficient funding to engage with the NHS as a whole and there were regional networks to support implementation on a local level. It was important to have those regional networks driving the change locally.
Our report highlighted that adopters of innovation need support, as well as innovators; what can we do to more effectively support adopters?
We do need to support the adopters. We may also need to cajole, encourage and maybe sometimes use the carrot and stick approach. When we are talking about making change on a major scale, it is not only the clinical teams that need to be convinced, it is hospital managers as well – they want to understand the financial implications. We often don’t do the health economic analysis at the start.
There is no magic wand for spreading innovation; it requires a combination of factors. The evidence base needs to be as strong as it can be, but evidence on its own is not enough – you need opinion leaders, engagement with clinical teams, encouragement, training and also measurement, to identify which parts of the country are doing things faster and which ones are lagging behind. Effort and resource need to be put into that process.
Against a backdrop of funding pressures, what practical steps can policymakers take to address the challenge of spread in the future?
It is really important that the NHS long-term plan takes account of the need for culture change, for engagement with staff, and for quality improvement methodology. There is a temptation when drawing up plans to say, ‘we will do A, B and C’ and not to think about how we do those things.
Policymakers need to invest in leadership and support the spread of change – these things do not happen spontaneously. If something is ultimately going to be good for patients and save the NHS money, then we need to invest in getting it into place.
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