Service or quality improvement is a small club in the NHS. It feels rather intimate and you keep bumping into people you’ve worked with before or know through others.
It has its own language and almost has the feel of a secret society because that language acts as a barrier to the uninitiated. Knowledge they say is power and the know-how associated with service improvement certainly gives the wielder kudos and influence of a sort.
For those of us ‘in the club’ it feels very good. We are almost like Improvoman, the quality improvement superhero. We get asked into a service or department to fix things. We whoosh in, with some nifty gadgets and tools, dispense wisdom, sort the problem, and then whoosh out again
But there is a problem with relying on Improvoman. All the mainstream improvement methodologies emphasise that it’s on the shop floor – in the ward, the clinic, and the GP surgery – that real, sustainable change takes place. And the best change ideas come from those who actually do the work. Nowhere in the improvement literature does it say that the route to success is through a band of caped superheroes.
Relying on a small group to fix everything doesn’t work, because such a small group, however well skilled, can only do so much at once. This strategy has led to some great showcase areas but surely all services and their customers deserve better don’t they? To get this happening everywhere means enabling all NHS staff in the tools and techniques of quality improvement.
Last year I trained around 200 staff (covering around 40-50 projects) in improvement techniques. I don’t know how many projects it would take to cover the whole of NHS Wales but I do know how many staff it employs, around 85,000, so let’s start there.
If I continued to train at last year’s rate then it would take me 425 years to cover all the existing staff. That of course is a ridiculous calculation; it’s not just me that can train staff. Within the central improvement function there are many more. At 20 such staff, the time scale becomes 21 years, at 30 such staff, 14 years. To cover all existing staff within 5 years would need around 85 staff. Whichever way you cut it, employing a centralist strategy takes a long time to get the coverage you want.
There is another problem with the expert group approach. Like many people who have worked for some time in the NHS I have been through several reorganisations. And small expert groups are particularly vulnerable at such times. The capacity that has been built up to effect real change is dissipated. The knowledge is scattered. The impetus is lost.
The Chinese philosopher Lao Tzu said, “Give a man a fish and you feed him for a day. Teach him how to fish and you feed him for a lifetime.” We can rephrase that slightly: “Give NHS staff an improvement and you solve today’s problem. Teach them how to improve and you solve every future problem.”
If we are going to build an NHS workforce that is able to improve – and will sustain those improvements – we need a different approach.
And this is why I am excited about Improving Quality Together. The bronze level ensures all staff in NHS Wales are introduced to the world of service improvement. They begin to learn the language. They are encouraged to apply their learning to problems they need to solve. And they can move on, learn more through the silver and gold levels.
So, we won’t have just 20 or 30 superheroes, we’ll have 85,000.
Mike Davidge is the Senior Improvement Advisor for 1000 Lives Plus