In my conversation with Amar about his new role, I asked him about his reasons for wanting to take up the post, and to share his thoughts on how we can all play a part in shaping and embedding improvement, while learning from each other.

This conversation has been edited and condensed for clarity.

PP: What inspired you to take up your new role at NHS England and what are your ambitions for it?

AS: I trained as a clinician and my introduction to improvement was relatively late, near the end of my higher specialist training. Having the opportunity to think about the use of improvement science made me look at how it might help me as a clinician. It has really changed my outlook on how I can impact on people’s lives.

I’m still a practicing clinician, but the introduction to improvement has led to me spending more of my time thinking about how system design can be improved.
I guess becoming National Clinical Director for Improvement is an opportunity is to apply that way of thinking to the whole of the health and care system in England.

This looked to be an opportunity that was important to be a part of, particularly given how much improvement has changed my career and my outlook on how to improve people’s health and wellbeing.

We’ve come a long way in the past fifteen years. When I started training as a forensic psychiatrist, improvement was being used in only a very rudimentary way within the mental health field. Today, most health care organisations in England are applying improvement in the best way they can. Having seen the value of improvement, we can demonstrate the impact it’s made.

We now need to consider what it takes to embed and build on the fabulous work that’s happening across England’s complex health and care system.

PP: NHS IMPACT has set some big ambitions and as with anything in improvement, I guess we’ll need to learn and iterate. Are there any risks or elephant traps you see, and do you have advice on how to avoid or manage any of those risks as this work evolves?

AS: This is not the first improvement framework that England has developed, so one thing we should be wary of is putting too much weight on any framework.

Frameworks are helpful, but the hard work of improvement is figuring out how to do it yourself. People learn from what is around them, and from forging their own path and making it their own journey.

If people seize the real opportunity to explore the principles of improvement and how we can adopt those in our daily practice, and build a system that enables this within our organisations, we’ll be able to work towards realising the ambition.

PP: What would you like to see from Q members to realise the role and value of NHS IMPACT, especially in the current context of financial and resource constraint?

AS: Q is a rich community of people with a wide spectrum of experience and expertise, from those who are experienced to those just starting out on their journey. We should be excited that there is this ambition to see improvement as a specialism and seize the opportunity to shape it and strengthen it as its own field.

We need to think about how we apply scientific rigour to our work, and how we bring clarity to what we actually mean by improvement. We need to ask ourselves what sort of skills and capabilities are required to deliver the results that we want to see.

Equally, I think we need to challenge ourselves as improvers to really understand what is being asked of us, and that we are equipping ourselves continually through learning and developing the field of improvement.

We also need to consider how we organise and mobilise ourselves to support the delivery of priorities across the health and care system. There are many examples of where that already happens. If we are not right at the centre of solving today’s and tomorrow’s complex challenges, we’re not going to stand the test of time. We need to be involved in both framing and supporting the delivery of results that are going to meet those challenges.

We have a community of people in Q and beyond who have learned how to do this work and are delivering results. We have a responsibility to make sure that this knowledge base is being put to good use.

PP: NHS IMPACT focuses on embedding improvement throughout the system; ambitions which are recognised as globally unique in a report that we commissioned from Chris Ham recently. This reminded me of Don Berwick’s vision – the origin of the inspiration for Q – of the NHS needing to become a continuous learning and improvement organisation, from top to bottom. How far do you think we are along that journey?

AS: It’s a really hard question to answer because we’re in lots of different places at the same time. There are those that are further along with improvement, both in terms of time and also the maturity of their approach. These organisations have stronger collective belief in improvement because they have seen results. That collective belief reinforces behaviours like curiosity and learning, which change the nature of the organisation.

In other parts of the country, we are at an earlier point in the journey and belief is variable. Sometimes that plays out in terms of interactions or approaches to problem solving, where we may not be seeing as much of an improvement mindset. Part of what we want to be doing is learning from the variation across the country.

One of the most effective things we could be trying to do is creating a climate that enables organisations to take a learning approach, and removing barriers that make it harder to cultivate a spirit of innovation and testing.

PP: Often I think of Q as creating safe spaces to enable some of that learning, and connecting people across provider and system boundaries as well as influencing mainstream improvement practice more widely. What do you think is the same and what’s different when you’re delivering improvement across providers and systems?

AS: It’s definitely harder applying improvement across system boundaries. About half of our improvement work at ELFT now involves partner agencies, and some of our work is entirely outside of our boundaries. We’re just one of many partners involved in the work.

I suppose the most important aspect is the opportunity is to bring people together around a shared purpose. The second aspect is to bring a systematic approach to problem solving. That’s where a lot of us can trip up. Language and choice of methods can be seen as making improvement inaccessible or inappropriate or difficult to do. We have to really be careful about how we engage with partner agencies and organisations.

One of the skills we need is to be able to introduce the world of improvement in a non-threatening way that does not suggest that we have all the answers or the methodology that will work. Working in partnership with colleagues is about learning together and applying the principles of quality improvement in a really simple, accessible way.

We need to ask ourselves how we will enable people to learn and apply a method to their problem, generating a single shared purpose especially when different organisations have different needs.

That is hard work, and sometimes takes longer than we want. But those early steps around leadership and engagement with partners are key to how we commit to solving a problem together.

PP: Collaboration is core to improvement, especially as our ambitions take us into cross-boundary work. You will be co-chairing the International Forum on Quality and Safety in Healthcare in April for which Q and the Health Foundation are host partners. What do you think we can learn from other countries on how to approach improvement?

AS: I may have learned more from outside than inside England over the last fifteen years. I’ve learned so much from approaches in other countries – like that taken by Scotland. That was one of the first places I went to learn about how people were doing improvement. I’ve also learned from looking at how more resource-constrained environments have adopted the principles of quality improvement to deliver results. Some of the work that’s been done in South Africa, Uganda and, more recently, Bangladesh, has been really inspirational to me.

These places have a lot to teach us about how to bring improvement to life in the practice of daily clinical work, without an enormous infrastructure around it to support them. I see these as opportunities to learn about agile approaches that can be scaled up through systematic methods to achieve results. I still have relationships around the world that allow me to connect and learn.

This conference is a chance to stop and look at the world of improvement just as you would if you were a cardiologist and you went to a conference looking at the latest medical advances. We should be looking for best practice in the field, wherever that is in the world, and learning from it.

And if we are to view improvement as a specialism, we need to be actively focusing on our own professional development. We should be thinking about where the best places in the world are to learn from and forging connections and relationships with them.

I’m hopeful that this forum, at which we expect attendees from 80 different countries, will allow us to share our work in England, whilst also learning and supporting others from other countries.

Equally, we can forge relationships that allow us to learn, because ultimately this work is all about learning and adapting how we deliver care. We need to be continually reflecting on how we are doing and if we could do it better.