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Smörgåsbord, à la carte or working in the Q kitchen? Q members engage positively but in many different ways.

Tom Ling of Q's independent evaluators RAND Europe shares insights from the most recent survey of Q community members.

As many of you will know, we at RAND Europe are currently conducting an independent evaluation of Q from 2016-2020. We’re a not-for-profit research organisation, based in Cambridge, and independent of The Health Foundation – and so our role is one of a ‘critical friend’, to provide learning to inform the development of Q, but also to provide a summative assessment of Q’s progress to 2020 early next year.

As part of this, we have been conducting member surveys of the Q membership body. Many of you will remember receiving an email from us – and a great thank you to those of you who filled this in – and we’d like to share below some emerging themes from the evaluation survey and data collection.

There are many different views of Q depending upon your values and experiences

Hokusai Katsushika, Thirty-six Views of Mt. Fuji – Koshu

Like Hokusai’s thirty-six views of Mount Fuji, members have many different views of Q. As Mannion and Davies note ‘Healthcare organisations are best viewed as comprising multiple subcultures, which may be driving forces for change or may undermine quality improvement initiatives’.[1] They go on to point out that culture has often been identified as a barrier to improving quality[2] but also warn against an overly simplistic understanding of what culture is. A simple survey will not allow us to explore ‘multiple subcultures’ deeply – but responses suggest that Q may be understood and, most likely, acted upon differently by different ‘tribes’ within the NHS. For instance, we found differences between pharmacists, doctors, nurses and people in allied health roles in the way that they felt about Q. For example, pharmacists and doctors tended to express lower levels of agreement about the value of different aspects of Q in most cases than respondents identifying as nurses and allied health professionals (although it should be caveated that some professional categories had a low number of responses).

While Q continues to be valued by most members, these differences argue against an overly homogenised view of how Q ‘lands’ in the health and care system. Across the board, there is a sense that flexibility (how to engage and how often) is a valued feature of Q in its present form. For many, the idea of a smörgåsbord is attractive, where a range of options can be combined to meet the needs of each individual and many members especially appreciate the flexibility that Q offers. In my view, there is then a clear group that are passionate about working in the Q kitchen with a view to shaping and helping deliver the offer. There are also others who have a clear focus on getting just one thing and using it while still others appreciate the range of choice and enjoy picking and choosing to make up their preferred combinations. Personally, I think this is a good range but we should worry if there are either too few or, indeed, too many cooks in the kitchen!

A community is defined not only by the choices on offer but also the values and relationships it promotes and espouses. The strength of affection and commitment to Q may outstrip the consumerist use of its services.

Thoughts for Q members to consider

There is clearly some basis for considering a smörgåsbord approach to Q, given that many members like the flexibility this offers. This might lead to more of an à la carte offering for Q members and in a busy world this could add value. This might also be tailored towards different groups. However, understanding what lies behind this would be important; is it that members are simply not very curious about what more Q might have to offer, or is it that they are curious but unsatisfied with what they find, or lack the time to be more involved?

However, there are risks in going too far down this road. A community is defined not only by the choices on offer but also the values and relationships it promotes and espouses. The strength of affection and commitment to Q may outstrip the consumerist use of its services. A small group of members report that they want to be involved in helping to organise activities and events. I think of this group as working in the Q kitchen rather than diners waiting to be served. Helping this group to engage with Q as a whole – and in particular with the senior management of Q – might help mobilise both good ideas and energy. In general, making it as easy as possible to move between these different approaches is likely to be more sustainable than brigading groups into one sort of Q member or another.

What next for the evaluation?

As we work towards the final evaluation report in early 2020, we’ll be exploring these differences in more depth and the Q team will be doing some wider thinking around an analytical lens to understand the experiences of different groups. We’d love to hear from you about what you feel Q offers – or doesn’t offer – for your particular profession. At some point in the autumn, you’ll receive another invitation from us to participate in our final survey – and we’d be very grateful if you do so!

Until then, you can always reach the evaluation team at

[1] Mannion R, Davies H. Understanding organisational culture for healthcare quality improvement. BMJ 2018; 363 :k4907
[2] Francis R. The Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013. Kennedy I. The Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995. Learning from Bristol. 2001.

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