Beverley Slater, Director of the Improvement Academy, writes about the changes in healthcare systems that have taken place during COVID-19 and introduces some concepts from Implementation Science that can help us think about what sort of healthcare we want when this is all over.
Two wonderful new blogs published in the past week have captured the challenge and the opportunity of learning from the COVID-19 pandemic to improve how healthcare services are delivered in the future. It has been a revelation to many of us how easy it has been to make radical adaptations to the ways in which care is delivered when there is the urgency and common purpose of a pandemic to address. Many NHS staff have commented that initiatives they have been advocating and trying to get off the ground for years have been implemented overnight.
We all seem to be clear that some good things have happened but there is a sense of collective worry that these good lessons will be lost unless we act quickly to capture the new ways of working. Managing to capitalise on this and prevent sliding back into old ways, as the crisis recedes and the old order begins to assert itself again, is something that is beginning to occupy the minds of health service leaders, policy-makers and academics. There is a sense of urgency about this. This blog draws on implementation science to help clearly articulate this concern and how we might address it.
Understanding what has worked well in health services
We could start by listing multiple individual innovations and adaptations, as indeed NHS England and NHS Improvement have started to do (for example Rastrick, 2020). This will surely be a helpful catalogue, but to focus only on the description of individual innovations might be to miss a possibly more significant point. Some of the innovations that have been implemented so quickly and to great effect, such as telephone follow-ups and video consultations, are actually well-known and not new at all. What has actually changed is the responsiveness of the system to allow rapid uptake of these innovations. Something about the COVID-19 crisis has transformed the conditions for implementation to transform the healthcare system to work in a different way. What has actually happened is a systemic change.
Some of the elements of this new system are captured in the two blogs. Susie Bailey and Michael West in their Kings Fund blog draw to some extent on the findings of a London South Bank University report of interviews with health service staff by Becky Malby and Tony Hufflett (May 2020). They describe frontline clinicians exercising more professional autonomy, freed from hierarchy and bureaucracy. Healthcare staff are described as working with an increased sense of team compassion and belonging, supported by daily huddles, check-ins and other well-being supports. Bailey and West refer to more mutual and more respectful relationships with patients and an embracing of digital technologies.
David Fillingham, Elaine Mead and Stephen Singleton are senior health service leaders and established improvers. Writing in the Health Service Journal (8 June 2020), they highlight that across the system there has been a sudden clarity about what actually adds value to patients, and that anything not adding value to patients (such as travelling, waiting, over-processing) is ‘waste’.
Integral to this new system of working is the practical respect shown to frontline colleagues by their organisations by providing for basic needs including food, water, accommodation and car-parking. Staff are risking their own health through this pandemic and with that comes a new respect and empathy. Bailey and West observe ‘compassionate and collective leadership’ in evidence as managers and clinicians work collaboratively together. Fillingham and colleagues refer to this as managers learning to ‘trust people who run the processes’, having the ‘courage to let go’ and thereby ‘creat[ing] miracles’.
What are the conditions that have enabled this rapid transformation?
Matching the clear focus created by urgency and shared purpose, the healthcare system, at both local and national levels, has responded by reducing bureaucracy (seen as ‘red tape’), and removing routine performance management and inspections (seen as unnecessary distractions). Freed from these constraints, and with increasing respect for everyone’s different roles, the health system has allowed leaders, managers, administrators and clinical staff to align their work and together become high-performing teams.
I asked an implementation specialist what conditions were likely to have enabled this rapid response. He talked about a number of concepts found in implementation science frameworks. Firstly, ‘tension for change‘: government guidance to the whole population meant that patients cannot be assessed in the usual ways. The degree to which stakeholders, both health services and patients, perceived the current situation as needing change intensified overnight – so an external policy has led to a strong tension for change.
Secondly, these changes have been seen pretty universally as important, so relative priority is high. Thirdly, compatibility of the innovations with the existing system is important. For example, telephone consultations can be easily fit into workflows and are not hard to implement. And finally, leadership engagement has been strong, nationally and locally, including tangible commitment evidenced in the availability of resources to undertake these changes. All this means an implementation climate that shows a strong ‘readiness for change’, along with clear purpose, goals, and execution. These concepts will be important if system leaders, managers and clinicians want to maintain and keep the gains that have been evident through this crisis period.
So what are the risks to maintaining this new system of working?
Post COVID, will there really be a commitment to softer hierarchies, increased teamworking, prioritising ‘value to patients’ over attending to the requirements of performance management systems? In addition, is it a realistic ambition for managers to want to give up control by command in favour of collaborative and compassionate cultures? And, if so, do we have the knowledge and expertise to help it to happen?
Revisiting the implementation concepts above, we can see that any call from NHS England for ‘business as usual’ in terms of performance reporting and inspections could create a new tension for change in the system where leadership attention and the relative priority is rebalanced towards externally-defined performance targets, and away from softer hierarchies, teamworking and collaborative management.
Individual innovations to patient pathways which have been demonstrated, through experience, to have advantages to staff and patients may be retained, but managers who wish to keep focus and support at the frontline (such as coaching frontline staff to work in autonomous ways) and patient-focused care will face the traditional challenges of doing so. Managers will have to focus on maintaining a healthy learning climate. To create a learning climate, leaders will need to ensure their team members know that they are essential, valued, and knowledgeable partners in change processes and that they feel psychologically safe to try new methods. They will also need to ensure there is sufficient time and space for reflective thinking and evaluation and express their own fallibility and need for team members support and assistance. Just as before COVID-19, this will be in tension with the system requirements to prioritise, by whatever means, achieving performance targets. It will be through managers daily efforts to balance these that much of this debate will be played out.
At the Improvement Academy we are continuously learning with frontline clinicians, patients and managers about improving healthcare for our communities. As an improvement community we will need to pay particular attention to supporting health services managers to sustain the conditions that have supported innovation, as they critique and re-define their role amidst the very uncertain conditions where the pandemic remains. We have a variety of tried and tested methods to do all these things if organisations and individuals are willing and brave enough to join in the movement!
Fillingham, D., Mead, E. & Singleton, S. (2020) The leadership task is to focus on creating high performing teams who communicate well about the basics and then the task is to just let go. Health Service Journal. 8 June.
Thanks to Claire Marsh and Kristian Hudson for comments on an earlier draft of this blog.
As a post-script to this blog, I would like to highlight the remarks of the Secretary of State for Health, Matt Hancock, on Sunday 5th July (Marr, BBC) relating to the ways of working he would like to keep from the COVID-19 crisis. He was clear that ‘collaborative working culture’ and the ‘freedom and flexibility of frontline staff to use their judgement’ were things he would like to ‘bottle’.
As always, the question is, ‘how?’.
The analysis from implementation science in the blog above suggests that any government really serious about this would actually need to transform the way they themselves engage with the healthcare system. Removing unnecessary bureaucracy is one thing, but it would not be enough. To maintain ‘tension for change’ national bodies would need to be genuinely and firmly focussing on how each healthcare trust is supporting their frontline teams to work collaboratively in delivering healthcare goals. This would provide legitimacy and support for management to focus on the right things.