Improving quality is a long-term journey

Steven Michael is Chief Executive of South West Yorkshire Partnership NHS Foundation Trust. The organisation provides community mental health, learning disability, and forensic mental health services. We spoke to him about the trust’s activities to improve quality, reduce costs, change the way care is delivered and build partnerships for population health.

Tell us a bit about your trust’s improvement journey so far...

We are often asked to change systems at scale very fast within the NHS, but quality can’t be changed overnight. We’ve always looked at it as a long-term journey.

About three and a half years ago we decided to revisit the purpose and values of our organisation. We talked to over 2,500 local people, asking ‘what are we here for and how should we behave?’ This established a real shared sense of purpose and raised staff expectation about what we should be delivering. It was a great starting point for developing our culture and infrastructure, and we’ve continued to engage with local people to test how we’re doing on a regular basis.

How have you built capacity for improvement and improved quality within the trust?

One of the big things we adopted from quality improvement that we’d seen in Sweden at the Jönköping Academy and at the Dartmouth Institute in the US, is their whole systems approach to change.

We spent time describing our system really clearly at four levels and thinking about what could be improved:

1. At micro level – we’ve looked at what skills and qualities people and teams need to deliver the right outcomes for service users. Regular staff wellbeing surveys have also helped identify factors that stop people doing their jobs effectively.
2. At meso level – we’ve looked at where the micro systems combine to form pathways of care. We’ve improved handovers and reduced repetition and waste.
3. At macro level – we’ve focused on getting greater efficiency in our back office services, aligning everything to support delivery. We’ve made new links between workforce design, the design of the estate, and what technology teams need.
4. At meta level – we’ve improved dialogue with stakeholders and partners. These are the key partnerships that define the rules for the system.

The training and support we’re providing to staff really focuses on what the system is trying to deliver overall. For example, we’ve introduced practice governance coaches who work with front-line teams to enhance the coaching skills they use with patients, which in turn helps patients to self-manage their conditions better.

To build capacity for change at other levels of the system we’ve delivered a range of training programmes for staff in lean thinking and system improvement, working with our local university, University of Huddersfield.

Have you managed to bring down costs through your improvement work?

Overall we’ve made cost improvements of just over 5% over the past two years while still maintaining a very good quality of service. With a turnover of roughly £220m, that’s meant taking £10m–£11m out of our system each year.

Some of this has been about making changes to workforce. But we also learned a lot about cost improvement when we were trying to become a foundation trust. We developed an approach that gave understanding and control of the cost base to front-line staff wherever possible and this has worked really well.

Have you introduced any new models of care which have helped reduce costs?

Creative Minds is probably one of our better examples. The project has developed over 80 community-based partnerships that deliver creative activities in local areas. We’ve match-funded them and sought local grant funding to build capacity in the system and make sure local support is there to help people build self esteem and move on in their recovery. More recently we’ve developed peer-led recovery colleges. This all means less reliance on the statutory system.

How are you focusing on the wider challenge of improving population health?

People with long-term mental health problems die on average 18 years younger than they should, which feels like a complete scandal doesn’t it? But this won’t change if we don’t build the community infrastructure and provide access to not only good mental health care but also much broader opportunities within local communities which reduce social isolation.

That’s why we’re starting to work much more collaboratively with other parts of the health and social care system in our different districts. We used to look at our system through the eyes of an NHS provider, now we think of ourselves as part of a bigger network.

Nationally, we’re already seeing a greater emphasis on health and wellbeing. But I think real examples at local level of how care can be more joined up will really help. That’s why there’s so much potential in the vanguard work (we’ve got three vanguard initiatives on our patch here). We’re currently trying out a population-based approach to multi-specialist community provision with everyone working together as a network.

How do you think the government should support improvement in the NHS?

The Health Foundation’s right, there needs to be a better balance of approaches. If you’re going to use performance management, it needs to be for the right reasons. Four hour waits have dominated the acute sector... but the target has become an obsession in its own right, rather than a measure of actual quality or outcomes. So I think we should be wary of introducing more targets that actually aren’t about system improvement at all.

There are ways the government could help organisations to help themselves more, for example, making it easier for different parts of the system to work together. We also need a consistent approach... Over the last decade there have been so many initiatives but nothing is ever allowed to last the course.

Have any parts of the national system been particularly helpful or challenging to work with?

Sometimes there’s an overreliance on data for data’s sake. We have to submit information to regulators, to comply with policy, and to comply with commissioning requirements. None of the requests really align as well as they should do, and sometimes they don’t actually relate to our core business. It can feel at times like we’re just feeding the beast.

If we’re going to successfully develop new models of care, we can’t be drowning in information requests. That’s what we learnt from Sweden, they weren’t being asked for information all the time from the top. Instead they were delivering information to improve their own system, with local accountable bodies (sort of like our health and wellbeing boards) deciding whether services were good value for local people.

On the positive side, we’ve found ways to get regulatory frameworks to work for us, rather than us just working for them. For example, last year the Trust Board did nearly 50 visits to units as part of a quality improvement approach we were leading based on the Care Quality Commission’s five quality domains.