What enables improvement at scale?

As the pressures on health services stack up, I find myself returning to some fundamental questions: What does improvement in health and care actually require, given the scale and impact we need to achieve? And how do we make the case clearly and convincingly to those who can shape the conditions for success?

The need for NHS reform is undeniable, yet we continue to be frustrated by initiatives that underdeliver.

I think the time is right to be more direct about how to achieve the scale of impact we need within health and care and how change based on sound improvement principles can unlock sustainable reform. 

Drawing on what I see happening in the Q community and what we’ve learned over the years, I’ve distilled three core factors and three enablers that we should push for – and design in to – any change effort. 

Working systematically with people to define goals, diagnose problems and identify, test and refine solutions is a critical foundation for effective improvement. 

Policies or other interventions that claim to transform care but rely on crude and incomplete assumptions about behaviour change cloud the credibility of improvement and the impact it can have. If we cut corners on diagnosing what’s needed or involving people, initiatives are unlikely to succeed.

The context within which a change is introduced is critically important to achieving lasting success – perhaps as significant as the intervention itself. 

When I started my improvement career, the focus was mostly on redesigning services. The work of our community now recognises the need to create the culture and systems that enable changes to become mainstream practice. We do a disservice to frontline teams, and sow the seeds of cynicism, unless we invest in creating the environment within which the changes they introduce can thrive.

Great solutions trapped in the place that generated them aren’t just a missed opportunity – they can actively increase inequity or introduce safety risks through inconsistency. 

We need to act as one NHS and treat sharing and scaling as a core part of improvement work. We have learnt this requires more sophisticated approaches and greater investment than it typically gets. But precisely because resources are so tight, we cannot afford to continue to solve problems one team at a time. 

Expressing these factors is one thing. Achieving them in practice is often hugely challenging, especially in the face of operational pressures, financial strain and structural upheaval. Confronting what’s needed underscores we can’t do this alone. Change efforts need to address three accompanying enablers. 

The complexity of designing for different contexts reinforces that improvement and learning go hand in hand. Change is rarely about straightforward implementation of a solution or single method. We need to be able to test and refine as we go, drawing on relevant learning across disciplines and from others on a similar journey.

No one individual or team can be expected to ensure an improvement intervention satisfies all these factors. This is well recognised by members of our community, who have for years, come to Q to learn and practice effective collaboration skills as much as conventional Quality Improvement methods. 

We need a breadth of perspectives and disciplines to deliver improvements. That means combining specialist change skills with wide staff and public engagement, supported by proactive leadership that creates the conditions for improvement. 

The pragmatism of improvement and willingness to get on with what we can within the resources and space available is a strength. 

The scale and pace of transformation needed in the NHS is daunting. We’ll only get there by being up front and bold about what is needed to deliver sustainable improvements. 

Please do tell me what you think. Do these factors and enablers resonate with you? Have you found something else that works in gaining buy-in from senior leaders and policy makers? I’m speaking on this topic at NHS Hampshire and Isle of Wight Improving Together Conference, so if you’re there, let me know your thoughts.