The art of the possible: engaging people in improvement at a time of huge pressure

Sussex Community NHS Foundation Trust delivers a wide range of medical, nursing and therapeutic care to over 8,000 people a day across the Sussex area, employing around 4,400 people.

Siobhan Melia joined the organisation as chief executive in September 2016. We spoke to her about the improvement journey the trust is currently embarking on and the challenge of engaging the workforce at a time of huge pressure in the health and care sector.

The art of the possible

Sussex is one of the first community trusts in the country to introduce their own quality improvement capability programme. They are doing this with little extra funding and at a time of severe pressure on staff and resources.

So why did the trust feel that now was the right time?

‘Embedding systematic quality improvement as part of our culture will allow front-line staff to put patients at the centre of everything we do – an ethos we really support’, says Siobhan.

‘Our aim is to create a social movement with our staff, channelling their energy, appetite, and enthusiasm around the art of the possible, and keeping people motivated around what quality improvement means for the people that we serve. I started my post as chief executive in September and this has been my priority from day one.’

Making this a focus for the trust has meant engaging people in a new shared vision for the organisation, encouraging them to prioritise improvement despite the many challenges they face with the day-to-day running of services.

‘We’re an ambitious organisation. We were rated as good by the Care Quality Commission two years ago. And when you look at other organisations that have moved from good to outstanding, the common theme seems to be their approach to improvement. So my conversations with the board have been about becoming an outstanding organisation.’

Energy and inspiration

Talking to other chief executives who have been on this journey, Siobhan says their energy is palpable, making her even more determined to make quality improvement a priority.

‘Broadly speaking the board were supportive from the outset, and I guess I brought some extra energy to the table saying I would lead it and make sure we really engaged people along the way’, says Siobhan. ‘With the executive team, we spent a lot of time talking about how we can put this right at the centre of what we do as opposed to something that sits alongside corporate objectives or strategic goals. There’s a tangible enthusiasm among the team about where this might take us and how energised we all feel about co-creating this with staff.’

It’s helped that Siobhan’s been able to share detailed research into how other organisations across the country have successfully introduced quality improvement.

‘We’ve taken a lot of inspiration from places like South Eastern Health and Care Trust in Belfast, who were in exactly the same place as us seven years ago, with little spare resource to invest.’

Planning together

The executive team have now started talking to front-line staff about how together they can build capability and help people working at the trust to demonstrate their improvements in a way that’s enabling and not too bureaucratic.

Siobhan says the team are keen to stress that this ‘isn’t top down, and it isn’t off the shelf. This is about creating a new way of working that adds value to what you do all day, every day’.

So far the conversations have been really positive.

‘A couple of people I spoke to last week told me they’d come from trusts elsewhere in the country where quality improvement was slightly further ahead, and they absolutely believed it was the right way to go’, she says.

The trust is planning to create a small quality improvement team, to build some capability in-house. They will be the guardians of quality assurance and will be able to offer direct support to people working at the front line. People at the trust will also be offered training and access to a library of resources. But the feedback has been that people want short, intense periods of updates and training rather than longer rolling programmes. So Siobhan says the trust is starting with the shorter energised, ‘come in for a day, learn about this, go out, create a learning community’ approach – interspersed with more relaxed opportunities to talk over coffee and create more informal learning environments. Siobhan hopes this will lead to an organic and emergent approach to improvement that becomes part of the organisation’s culture.

Overcoming the challenges ahead

Conversations with staff have so far been led by the trust’s Finance Director and Chief Nurse.

‘That partnership just emerged naturally’, says Siobhan. ‘But it’s ended up being a really powerful symbol of how we are going to do this together. The finance/quality dilemma is something we face every day, but they’re not mutually exclusive.’

Siobhan predicts that the biggest challenge the trust will face is time.

‘Being able to free up people working at the front line to engage and commit is going to be tough. Current issues with the supply of workforce into the NHS are significant. We’ve got teams that aren’t at full complement and right now all their time is focused absolutely on seeing patients and reducing waiting lists.’

The trust is currently running a big recruitment campaign and hopes in the future their work around quality improvement will be a way of attracting people into the organisation, making it an even greater place to work.

Siobhan says the trust is also looking at what existing infrastructure can be adjusted to make it easier for staff to engage with improvement activity. ‘Teams already take half days three or four times a year as protected improvement time, so we can use that’, she says. ‘And then it’s about creating informal opportunities over lunch and in staff meetings. We want to shift the thinking so improvement isn’t always perceived as additional work.’

Being a bit brave

Siobhan says that one of the biggest challenges has been trying to work out how to introduce a meaningful programme without having a significant pot of money to bring a quality improvement partner in.

‘There’s been some pretty heavy government investment into quality improvement over the last few years, but a small number of big organisations have received the resources. It would be nice to see a different tier of financial support available; some smaller pots of money to help push projects like ours over the precipice a bit. Or maybe a national team of quality improvement people who could be seconded into your organisation for six months to help with expertise and resourcing.

‘Because there are so many reasons why you can’t afford to do what we’re doing, you have to be quite determined and a little bit brave to continue to say, yes we can.

‘In general though, it’s just a difficult time in the sector. It would help if there was greater focus on quality improvement coming through the national policy messaging. Something that would give us a really clear mandate to invest the time and effort in this as well as all the structural, financial and efficiency challenges going on.’