In July, we spoke with a group of Q members to explore the current challenges for people working to address backlogs in care and improve access to services. We heard that members wanted to understand more about what others were doing. They specifically wanted to draw out learning about how to balance short-term needs and long-term goals; make better use of data to support improvement; and apply systematic improvement tools, methods and approaches to address both the technical and human side of change.

Since then, we have been working collaboratively with members to develop six case studies to explore these in more detail. This blog reflects what we have heard across the case studies, to explore what this learning means for improvers undertaking work to support health and care service recovery. We hope that, like us, you find inspiration and encouragement from the learning that has been shared. The case studies provide a partial view of improvement work currently happening to address the multifaceted challenges with backlogs in care. Individually, they explore learning from projects from service level through to a system-level perspective. Taken together, we think they create a picture of the different actions needed in the system.

It has been a privilege to speak to the people involved in these projects. With the impact of seasonal illnesses, cases of COVID-19 rising once more, and the cumulative effect of the past 18 months on staff, we appreciate just how hard it is to be working in health and care right now. As one session participant shared in July: ‘People are shattered, and it makes your heart sink to think about ramping up elective work.’ But what we have heard shows that even in the most challenging of contexts, there is the opportunity, imperative and will to make a positive difference on long-standing priorities for health and care improvement – such as enabling better access, tackling inequalities and supporting staff wellbeing – made more critical by the effects of the pandemic.

What did we hear?

1. The quality of data needs to be improved

The problem isn’t that we don’t have data. The problem is that it isn’t organised in a way that helps people to get actionable insight

A consistent theme running through the case studies is the importance of improving existing data, so staff understand who is waiting for treatment and care, and where the pressure points are in the system. The case studies explore different angles of this.

A data validation exercise is often essential to understand the true scale and complexity of the lists. This is challenging from both a clinical perspective (in terms of how to prioritise people by clinical need) and operationally due to the work involved in contacting thousands of patients. We have heard different routes into this, from using the opportunity of rolling out a Patient-Initiated-Follow-up (PIFU) as a validation exercise, to ICS-level strategic analysis and collaboration.

We have heard attempts to address long-standing cultural issues of target-driven output monitoring within organisational silos. This has been done by developing internal analytical and improvement capability to improve staff access, capability and ‘permission’ to explore data and embed this into improvement work.

We also heard the importance of applying an equity lens to this work. As our Health Foundation colleagues’ analysis explores, interventions to support service recovery may be exacerbating existing inequalities. This is a concern also reflected in the case studies. However, we heard of proactive work in Birmingham to prioritise surgical patients by taking into account the social determinants of health; and the benefits of co-design for developing an inclusive and accessible supported self-management service.

2. Wellbeing must be at the heart of this work

It is all about staff. It is staff, staff, staff, like everything at the minute

We heard from Q members that if organisations focus on getting the waiting lists down at the expense of staff health and wellbeing, this work will fail.

“There is a huge programme of work around staff wellbeing and support. […] I just don’t know how much of it is enough, having gone through that for the last 18 months. Obviously, we would love to just stop everything and let everyone have a break. Actually, we can’t.”

While we haven’t singled out a specific staff wellbeing intervention to feature as a case study, the six show how staff wellbeing motivates improvement. We heard that open, visible, compassionate leadership, and staff seeing the results of improvements, in terms of patient benefits and value added to their roles, both go a long way towards improving staff wellbeing and experience.

“[Our project has resulted in] staff feeling more comfortable coming to work, with the workload being manageable.”

3. The value of learning and working collaboratively

We try to soak up what other people are doing as much as possible because we haven’t got any really good ideas

The interdependency of the work needed for recovery requires system-wide collaboration and openness to sharing learning. Through two of the case studies, we heard the benefits of working in a more joined up way and the challenges when cross-organisational collaboration is not in place. When working collaboratively teams can identify priorities at a system level, make best use of resources and enable innovation. When this is not in place, teams are limited by what can be changed at an organisational level.

We have heard how the context of the pandemic was a catalyst for increasing both informal collaborations for generating improvement ideas and formal collaborations and partnerships. We heard how improvers are building on the blueprints from how teams, services, and organisations shared learning and came together in mutual aid during the pandemic, enabling all parts of the health system to work better together to make the most of their expertise and capacity.

There is, inevitably, still work to be done, and potential strains and issues will surface at different phases of the recovery. While structural and financial changes have formalised more local system collaboration, changing embedded ways of working and mindsets will not always be easy.

“… [There] is reluctance to appear weak when you’ve got organisations badged as ‘high performing’, and then others in same region that don’t want to hold themselves up as not high performing. The element of competition within [the] NHS has raised reluctance to share and be open.”

What does this mean for improvers?

Different faces and forms of improvement

“How do you engage with people who are so busy and overworked? QI is always seen as the thing you could drop.”

The context of the pandemic and what is needed to enable recovery has created an urgency to get things done. We know from members that this creates opportunities for service and local-system-level innovation, but the ideal place and role for improvement tools and approaches will be different in different organisational and team contexts, or at different stages of project implementation.

The case studies provide examples of improvement principles in action: from relational and data-driven approaches for implementing organisation-wide initiatives to more ‘purist’ approaches in the application of Lean or embedded co-design. We hope there is useful learning for everyone, particularly in how others have flexed their tactics and approach. This pragmatism, to avoid ‘overdoing’ improvement to ensure that busy clinical and non-clinical staff can take an active role in improving services, is shown to be a skill that is particularly useful in the current context.

Leadership and improvement capability at all levels of the system

The case studies reinforce the importance of strategic, operational leadership and credible clinical leadership, working alongside people with a ‘tenacious’ improvement capability. They demonstrate that when these capabilities are embedded at all levels, it creates the conditions for improvement to flourish. What this means in practice is that the role of leaders is not just to make big decisions, but to be present and visible to create an enabling culture for improvement. The case studies suggest that for improvement to be core to recovery efforts, we need to help staff feel seen and listened to, to involve them in meaningful and lasting change, and to work towards fundamental changes to how data is shared and applied.

What next?

These case studies shine a light on the different ways in which improvers are approaching their work on health system recovery. They reinforce the essential role of improvement approaches for empowering staff, for proactively turning attention to equity, and for putting staff and patient experience and wellbeing at the heart of the work.

Explore the case examples in more detail to discover the challenges and advice from each of the six projects that you could apply to your improvement work. There is a lot more to learn from this work, and it will likely prompt many more questions. What resonated with you? We’d love to hear your thoughts in the comments or get in touch via email.