Professor Carol Peden is Associate Medical Director for Quality Improvement at the Royal United Hospital Bath and a Health Foundation Quality Improvement Fellow. She spoke to us about her experience of making change in the NHS, and how national actions affect change at local level.
How does our report on accelerating change in the NHS resonate with your own experience of change in the NHS?
It hits the mark in appealing for clarity about the ‘how’. We have the NHS Five year forward view, now we need to talk about how we get to where we’re aiming for.
People are so busy doing their jobs, and they need headspace to think about how things can be done differently. For example, I developed a series of ‘mini collaboratives’ in our hospital. We bring multidisciplinary teams together for a couple of hours to look at a specific issue, such as pressure ulcers. Even in such a short space of time, bringing people together outside their busy clinical environments is incredibly effective. It’s an opportunity for them to get some headspace and think creatively.
What do you think is the main factor influencing whether an improvement project succeeds?
Having data is hugely important. In my work to improve outcomes for emergency surgery, our first big task is always to help people understand their data, so that they recognise the need for change.
At the Royal United Hospital in Bath, we’re introducing ward ‘dashboards’ to help make data more accessible to ward staff. You might find that your ward has an issue with falls, for example. Once you’ve identified that, you can ask, ‘who’s doing this better?’, and go and find out what they’re doing differently.
Clinical teams want regular access to high quality data. Another big project I’m working on is EPOCH (Enhanced peri-operative care for high risk patients). It’s an NIHR-funded research project, looking at improving outcomes for high-risk patients in emergency surgery. We bring people in different roles (surgeons, anaesthetists, nurses) and from several hospitals together in one place. Then we give them their data and help them to understand it. It’s just so inspiring. It really gives them time out to engage with what’s happening in their area, but also some structure to help them understand and use that information.
How have you tried to overcome some of the barriers to change identified in our report?
People working in the NHS want to do the best for patients, and sometimes really simple things can be barriers. Things that might seem trivial – like IT problems, or a problem with a photocopier – can be a significant barrier. Rather than assuming you know what people need to make change happen, it’s good to ask. The answer might be surprisingly simple.
Another barrier is capability to execute change. People are generally beginning to understand the language of quality improvement but I’m always asked, ‘where can I go on a course?’ and there is a gap. How can we give people opportunities to learn and build capability to execute change?
In my hospital we’ve done things like half-day classes for clinicians and middle managers, introducing them to basic tools and methodologies like the Model for Improvement and Lean. It's just an introduction, but it gives them an awareness of what is being done.
Do you think the NHS is ‘bad’ at change?
I think the NHS is actually really good at change! In the last few years, there have been huge positive clinical changes. For example, under the enhanced recovery programme, people can now go home two days after a hip replacement.
The issue is not that we’re bad at change, it’s that we could do better at recognising and celebrating success. Sometimes I go to international conferences and see something presented and I think ‘we’ve been doing that for years!’ We need to celebrate the NHS – and learn from people who are doing things well.
However, although we can do change really well, staff can feel ground down. You work really hard and try your best, but keep reading bad things about the NHS – it’s dispiriting.
Do you think national action helps or hinders change?
Both really. For example, with the four-hour A&E targets, the incentive is placed on getting people through the front door. We need to think about how we incentivise targets throughout the whole pathway. It’s important that incentives are aligned to clinical pathways. For example, the best-practice tariffs for hip fracture care really helped improvement.
I think you do need incentives around change and quality improvement. A clear strategy is important, but it also needs to be agreed on a local level.