Rapid innovation and learning have been at the heart of our immediate response to coronavirus (COVID-19). In order to maintain and embed positive changes over the coming months, leaders will need to pay attention to the conditions and ways of working that have enabled innovation to thrive.

This webinar was hosted by the Health Foundation’s Q community, delivered in partnership with the NHS Confederation and the AHSN Network as part of the NHS Reset campaign. It provided an opportunity to step back and think clearly about what the significant changes are and what’s enabled them, so that we can make the most of the beneficial changes that are emerging.

“Leaders have seen extraordinary change going on, and there is a real desire to bottle and capture and make that change sustainable where it can be.”

Niall Dickson, Chief Executive of the NHS Confederation

Overview

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Chaired by Niall Dickson, Chief Executive of the NHS Confederation, the webinar brought together a panel from across the health and care sector:

• Penny Pereira, Q Initiative Director, the Health Foundation
• Zoe Lelliot, Chief Executive of the Health Innovation Network
• Raj Jain, Group Chief Executive of Northern Care Alliance
• Hugh McCaughey, National Director of Improvement and NHS England and Improvement.

Penny Pereira began by presenting an overview of two pieces of work from the Health Foundation:

• Understanding and sustaining the health care service shifts accelerated by COVID-19: analysis that explores what has enabled rapid shifts in the delivery and use of NHS services during the pandemic, and what will be needed to sustain beneficial changes in the future.
• Frontline insights on the rapid implementation of video consultations: a Q insight project that focused on one high profile service change – the rapid uptake of video consultations.

The panel discussed these two publications, focusing on three themes, each of which is summarised in more detail below:

1. Enabling leadership through ‘top down clarity and bottom up agency’
2. Cross-boundary collaboration
3. Imperative to act now

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1. Enabling leadership through ‘top down clarity and bottom up agency’

One of the findings from the Health Foundation’s work that resonated strongly with the panel was the importance of ‘top down clarity and bottom up agency.’ As Penny highlighted, “we’ve heard people talk positively about the combination of clarity from the top, together with agency to solve problems at the frontline, with regulation and financial rules relaxed in ways that made innovation easier. […]  If the system reverts under pressure to a more centralised way of directing change, with multiple expectations on providers and little protected time for introducing changes, this will limit what’s possible at the frontline.”

Raj brought this to life with his experience in the Northern Care Alliance, where they’ve seen innovative work achieving positive outcomes for patients and staff as the result of improved job satisfaction. While some changes will need more evaluation or investment, Raj reflected: “some innovations have their own momentum. They don’t need a lot of leadership attention – they just need infrastructure and support to continue with the great stuff that has happened. […] For us, it’s about understanding how not to get in the way.”

The discussion from the panel considered what is needed from leaders to ensure the system doesn’t revert to a more centralised way of directing change. This suggested that leaders need to take an active role in “[getting] out of the way” by focusing more on outcomes and providing the right processes and support.

Hugh shared what he had learnt from this period: the importance of organisation and system leaders providing a more ‘permissive environment’ that focuses on the end goal rather than exactly how to get there.

“Successful organisations have clarity around the objectives and outcomes to be achieved, but there is local determination of the ‘how’. We need to move much more to creating the clarity, the framework of the objective of what needs to be achieved, but supporting devolvement of the how much more.”

Hugh McCaughey, National Director of Improvement and NHS England and Improvement

Zoe also commented that a shift in thinking is required: rather than focussing on a specific innovation – such as one digital tool – focus should be on the outcomes the innovation is trying to achieve. She reflected that this enables different organisations and localities to come up with different solutions that meet their needs. This was seen in the different ways in which innovations that were accelerated during COVID were taken up.

The panel acknowledged that this isn’t always easy for leaders: behaviour change, a different attitude to risk and embedding this into processes and systems are all required to make this shift a reality.

2. Cross-boundary collaboration

Another key theme that resonated with the panel was the importance of cross-boundary collaborations and what is needed to maintain them as the next phase of the pandemic unfolds.

Raj shared that what surprised him in the crisis response was not that staff and members of the community had great ideas about how to do things better, but the pace of change and decision making. This was enabled by organisational boundaries falling away, which resulted in “decisions being made at a pace that I would never have imagined.”

This type of cross-organisational collaboration is already disappearing. Raj highlighted the example of work that enabled safe discharge during the height of the crisis at a pace they’d never seen before.

“We’ve seen some of this work regressing. Our key focus now has to be on governance and risk tolerance between primary, community and secondary care [to clarify, for example, who] is accountable for patients in that mixed care pathway. We need to work on that to enable the clinical teams to work more effectively as they did in the surge.”

Raj Jain, Group Chief Executive of Northern Care Alliance

The discussion drew attention to the importance of changing the way financial decisions are made – particularly around investing in digital infrastructure and digital innovation, and place-based services. Zoe cautioned that “what will put the boundaries up quickly will be competing for budgets, and costs and rewards that fall in different places.”

The discussion also highlighted the importance of a common purpose and having fewer priorities to ensure concentrated efforts. Raj shared that “[a focus for the senior team and board is] how we collectively move to a place where we have fewer priorities and fewer lines of improvements so we can concentrate our efforts on things that are going to be most important.”

3. Imperative to act now

The panel members discussed the valuable leadership focus on learning from COVID-19. However, Hugh reflected on how quickly progress can stall or be reversed:

“When things stabilise, the emergence of governance and audit and managing risk will re-emerge and will be an anchor on that approach we’ve had over the last few months that allowed us to work quickly. There will be a tendency to draw back – we really need to use this period and opportunity to make sure we embed different mechanisms on ‘the how’, not just focus on the positive changes over the last few months.”

Hugh McCaughey, National Director of Improvement and NHS England and Improvement

The panel was clear that the time to act is now; to make the radical changes that are needed to change the finance, compliance and risk cultures that will hold us back from applying the learning from COVID-19. But the discussion also highlighted how important it is to take the time to understand and cultivate the conditions and behaviours that enabled staff to deliver service shifts. This is needed both to enable staff to continue working in this way but also, as webinar attendees reflected in the chat, to prevent ‘locking in’ changes that worked well in an emergency period but need amendment or redesign for a more ‘normal’ environment. Hugh articulated that there needs to be a focus on the intended outcomes, with more substantial service and pathway redesign to enable them to be achieved:

“We don’t want to digitalise the current model. We need to use digital to help us transform the model […] the danger is that we look at video consultations as the solution – it’s not. We have to change the model of delivery.”

Hugh McCaughey, National Director of Improvement and NHS England and Improvement

This highlighted an important role for evaluation and ongoing learning. Zoe stressed that what’s needed is both pragmatic, rapid evaluation and long-term research to fully understand the impacts of service changes.

What next?

See the links below for the resources mentioned in the webinar and further reading. There are plenty of ways that Q can support you in your work:

• Use Q’s member directory to contact a community of almost 4000 improvers across the UK and Ireland – find members in your area, gather insight and solutions and tap into expertise that will support you to embed changes that meet your long-term priorities.
• Connect with people who are continuing to work on video consultations by joining the dedicated Special Interest Group.
• If you’re looking for opportunities and support to learn, build skills and collaborate, why not join Q?