I’ll be honest. I don’t think incremental quality improvement or the specific improvement tools will result in the reorientation and transformation that we need in our health and care systems. It is definitely not why I wanted to join Q. Some people mention the UK cyclist team as an example of how small incremental improvements can result in a big win, but this analogy is not the right one for the NHS. It presupposes that we have the right track, are going in the right direction and have the right equipment. I’m pretty sure we have none of these. There’s no point tweaking the Titanic, we need a major overhaul.
Instead my motivation for joining Q was because I believe the mindset and culture required for quality improvement is the same one required to transform our health and care system. Improvement needs openness to new ideas, the ability to test and learn, the permission for anyone in a hierarchy to have an idea and central to all of this is the patience and skill to listen.
Why? Because I believe we have to fundamentally re-imagine our NHS and system change will happen at the micro level and spread.
We work in complex systems and complex systems cannot be controlled. We have set up a complex web of units of delivery governed by specialisms, that work interdependently without necessarily acknowledging that this is the case (normally because of specialist sensitivities) and demand continues to rise at a faster rate than that expected purely through demographic change. Something must be going pretty wrong. Our corrective responses try to control this complexity, tweaking and adapting the web of service provision in small pockets, with the focus depending on the fiefdom doing the tweaking. And where these tweaks don’t work, we tend to try and shout louder, stamp our feet harder and get a bit grumpier! It sort of reminds me of comedy sketches involving an Englishman trying to have himself understood in a foreign country!
To try and control is unwise and a bit daft because each attempt at control either adds further complexity or the environment has changed by the time the policy change has had time to truly embed. I believe the Kings Fund paper on place based systems of care expresses the way forward:
“The view of the 2014 BBC Reith lecturer, Atul Gawande, who argued that we are living in the ‘century of the system’ (Gawande 2014). By this he means that individuals and organisations cannot solve the problems facing today’s society on their own. Instead, we must design new ways in which individuals can work together in teams and across systems to make the best use of collective skills and knowledge.”
At the heart of this is not central control or a traditional policy development cycle, but in the words of Helen Bevan, a new order of power where individuals with health and care (staff) are empowered equally with citizens (patients) to quickly turn around, test and learn and adapt.
The power of Q 
Q is a collective of individuals that are motivated by change, by finding new ways of tackling challenges affecting our health and care systems and, I hope, understand that we simply cannot control complex systems through structures or top down diktat.
On the 29th March I went to the South West welcome event and out of the 117 new Q members there must have been over 90 in the room. I thought this showed amazing commitment and the day didn’t disappoint. The energy in the room was incredible and I went home buzzing!
This energy and passion to improve our NHS filled me with optimism. Stepping into the AHSN from running a charity is giving me an insight into a whole new world that I didn’t know existed. At the welcome event I learnt about job roles who’s (very important) function was to ensure a trusts 700 patient information leaflets about clinical procedures was kept up to date with the latest national guidance. And on the same day I was talking with clinicians about outpatients, primary care, diabetes, medicine optimisation, with management consultants and with a micro care provider! All of whom are dedicated to improving the NHS.
We need to harness and build the power
By supporting one another to get passed the polite conversations with one another to be able to challenge. To do this we need to cultivate an ability to listen both to one another, but also to those not in the ‘circle’.
Listening is central to how we receive and give to one another, but it’s not easy!
I can only talk about this from a first person perspective. I have no academic background in being able to confidently state the role listening takes in our relationships. As someone that used to lead a charity and now in a position to influence change in the NHS all I know is what I have experienced.
When I know I am genuinely listening, there is a complicated internal dialogue going on. I am constantly checking back to my understanding of the world and my own view point and translating what I am hearing to what I already think I know. When I get it right, it promotes an empathy towards the other person, an identification with what they are saying, I recognise the other person and respect them for who they are and values them. It also prompts questions for my own world view, maybe challenging a view I need to adapt. Where it becomes a real struggle is where the other persons perspective is so different that the translation is almost impossible. This creates a distance, but I also know it is absolutely when I need to try my hardest to listen. Loads of people I know seem to be really good at this, but I’m sure I’m not alone in know that it takes additional effort to listen and recognise someone who has very different views from me.
So in my view whilst saying listening is important, I also think we need to be patient with one another because it is a very challenging skills to get right.
Listening is common sense, but not common practice.
How many times do we hear comments about our services not listening, that people have to keep repeating themselves, that they don’t hear the whole story. And even within the systems themselves they don’t listen to one another. We hear just as often that one profession doesn’t listen to another, that one rates it’s world view as more important than another.
Empowerment and strength come from being able to truly listen.
Again, from my experience, listening requires someone to be able to hold trust in that process and that whatever the result, the ‘I’ in it will be the grace with which the listening is conducted and the authenticity of care and love that a response is given with both ‘I’ and ‘them’ in balance with one another. To do this requires, for me, incredible discipline. To listen I have to put ‘I’ to one side, but still know what I want and need for myself. At the points at which this is hardest to do is exactly when I have to listen the most intently. Pretty tough.
“The hardest time to practice kindness is, of course, during a fight – but this is also the most important time to be kind.”
“The hardest time to practice kindness is, of course, during a fight – but this is also the most important time to be kind.”
This quote came from an article about lasting relationships. Studies have shown that kindness and generosity were critical traits to successful and long lasting relationships. It all suggests listening | giving attention | empathy | whatever it is termed, is fundamental to our relationships.
If Q is to be successful it must not only build a network with a culture of listening, but invite diversity in.
Just to heap the challenges on, my view is that once established, the next wave of new Q fellows must not become complacent in networking just between NHS organisations. Patients, charities, social enterprises and industry must be invited in. Otherwise we will simply be listening to views and opinions that broadly match our own and won’t help challenge us to think as differently as possible. We will need to identify bridges and connectors out of the NHS system.
So in a nutshell, the Qmmunity has the potential to fundamentally reshape the NHS by diligently developing the ability for fellows to listen to one another, and then to those outside the NHS because system change will not come from top down, but bottom up.