Without motivated people, no new model can change the NHS

The challenges facing the health and social care sector are well documented. Understandably the urgency to respond is growing ever stronger as the fiscal constraints continue to bite and the current design flaws of our systems become ever more obvious.

‘Not enough time is being set aside to allow team members to understand the techniques of service improvement or to put them into practice’

All the talk is of the need for transformational change, with radical shifts in models of care being the answer. This is often said without following on with either the clarity or detail on what this really means in practice. Yes, the sector requires transformational change but it is, sadly, not well placed to achieve these ends and is currently in the uncomfortable position of potentially being overwhelmed by the sheer enormity of the challenges that lay ahead.

Why is the sector not well placed to respond? 

First, we believe too little attention is given to the application of system design or improvement science principles to understand where the opportunities exist to deliver the required three wins: quality gains, productivity increases and improved motivation.

Second, the skills and knowledge base simply do not exist with sufficient critical mass in our clinical and operational teams to apply these principles. 

Third, not enough time is being set aside to allow team members to both truly understand the principles and techniques of service improvement or to put those skills into practice. 

Finally, organisations are not, generally, developing cultures of permission to allow clinical operational teams the opportunity to get on and make the changes that would lead to service improvements.

• HSJ showcases the best places to work in the NHS
• Join the debate about HSJ’s top 100 places to work using hashtag #HSJbestplaces
• David Oliver: Beware the false solutions to the NHS’s challenges
• Spreading innovation: AHSNs step up to the challenge
• Focus on collaboration not liberation to innovate the NHS

Create a revolution

If the health service is to create a revolution in how it tackles the future, it will not achieve this through a top-down approach, with the power and knowledge being confined to a few people. The revolution must start with the clinical and operational teams lighting the fires of change, working to an agenda of improved safety, flow, quality and productivity leading to better motivation. To do this they must be steeped in the science of improvement rather than that being left to a few enthusiasts.

‘The ability to deliver the large scale quality and productivity gains can be achieved by sharing and nurturing teams to take responsibility’

The ability to deliver the large scale quality and productivity gains can be achieved by sharing and nurturing individual teams to take responsibility. If enough teams do so, the necessary critical mass is more likely to happen than with a top-down approach.

But they need the training and tools to ensure a systematic approach is taken to understand how the service currently works, what outcomes it delivers for patients and what impact the new designs will have on the system outputs and outcomes. 

The discipline of improvement science has existed for over 100 years, with its roots in the manufacturing sector. However, its principles can be adapted to suit health delivery systems in a very straightforward manner.

Healthcare differs from manufacturing in several critical ways. First, the paths that patients follow through the system are not predetermined. Much of the work is diagnostic and decision making. Second, people are obviously not machines – they learn from experience and follow their own agendas, they form tribes and the behaviour of the organisation is emergent. In short, healthcare is a complex adaptive system – a factory that makes cars is not.    

Therefore there are three key elements to be considered:

• people factors or leadership requirements that create the right culture and behaviours to support, recognise and “reward” teams to deliver change;
• systems thinking where the care given, the clinical outcomes and the productivity outputs are seen in the context of the whole care and treatment pathway rather than at departmental or organisational levels; and
• process factors, which we focus on here.

The 6 M’s

What are the critical tools and knowledge that need to be adopted?

We argue for a diffusion of approaches to system redesign that share common themes. We call the approach “6M design”, requiring knowledge to map, measure, model, modify, monitor and maintain a service design. The critical factor here is to adopt a systematic and consistent approach that does not diminish any of the key stages, as this is more likely to lead to failure.

In practical terms, teams will need to be competent in: the use of basic mapping and measurement techniques such as psychological, physical and flow mapping; the use of system stream mapping, Pareto charts, process templates or Gantt charts; and the use of time series or Shewhart charts.

Too often redesign starts with a series of hunches or theories as to what the problems or causes are for the poorer outcomes, rather than an empirical approach that looks at the system behaviour to diagnose and subsequently provide an insight into what design solutions might be applied.

Treatment options

Having reached the diagnosis phase, it is only now that the team will be able to propose “treatment” or redesign options. The options are refined into a decision by the team to modify the system or pathway in a particular fashion.

‘Modelling tools need to be used to predict what impact the design change will have on safety, flow, quality and productivity outcomes’

Before implementing the change however, the modelling tools need to be used to predict what impact the design change will have on safety, flow, quality and productivity outcomes to be confident it is the right thing to do. This is the modelling stage.

If the design change is predicted to deliver the improvements required, it is time to put it into action, to modify the actual system, and then to monitor over time what the outcomes were in reality. 

If the changes are demonstrably proven to be effective, it is crucial that the design change includes a mechanism for maintaining that change, to bed it into business as usual. This will require continuous monitoring and be an opportunity for the team to reflect on the success as a way of both recognising and encouraging more improvement changes to be made.

This feedback loop is part of the maintain step and is a critical part of the design. If it is omitted the improved performance will drift back. 

The complexity of the adaptive systems with which the health and social care sector works requires an approach that can “tame” and make sense of where changes need to, and should, be made. Leaders across the sector must recognise and act on the very real situation that we have not geared our teams up to take on these challenges.

We must give them the skills in improvement science in healthcare if we are to see the necessary radical, transformational change required. Leaders of improvement have to demonstrate their commitment by taking the plunge first. 

Steve Peak is a former trust chief executive and is now a non-executive director for Worcestershire Health and Care Trust, business development director for Vanguard Healthcare Solutions and a trainee healthcare system designer; Simon Dodds is a consultant surgeon at the Heart of England Foundation Trust and complex adaptive system designer