Improving care in the face of pressure, policy and process

The NHS is operating under extraordinarily difficult circumstances. But despite the pressures in acute and ambulance services, staff are improving care, redesigning pathways, solving problems and supporting patients in incredibly difficult circumstances.

Have we become so accustomed to analysing and looking at what is going wrong, that we do not spend enough time noticing and understanding what is going right?

Committing to recognition and learning

The health and care system understandably has robust systems of accountability, regulation, performance management and assurance. They matter, and when something is going wrong, we need to know about it and act. But these approaches need to be balanced by an equally strong commitment to recognition, learning and curiosity about success.

If we continually ask ‘what went wrong? Why haven't we met the target?’ we should create just as much space to ask ‘where is care working exceptionally well? What made that possible?’ This means designing authentic recognition and learning into the way our organisations operate on a daily basis.

Appreciative inquiry offers one way of doing this. It is a strengths-based approach to improvement that focuses on what is working well, why it works and what we can learn from it. It uses those strengths to consider what might be possible, build on success and spread improvement more widely.

Having worked in acute hospitals for nearly two decades, one thing has stayed with me:  better care is being created every day by the people delivering it.

Amplifying success

The ingredients that make change possible are humanistic: relationships, trust, leadership, ingenuity, teamwork and a shared sense of purpose. Change does not happen simply because a new policy, framework or operating model has been published. Those things can create important conditions for change, but ultimately, it is people who translate them into better experiences for patients. Yet the structures and pressures around people do not always give them enough time or permission to reflect on why something worked, share it with others or build upon it.

This is something we need to rethink. What if our systems were designed not only to identify problems, but also to systematically find, understand and amplify success? I believe there are some small factors that can be woven into everyday work across healthcare to develop this:

• Making recognition part of everyday work, rather than something reserved for annual awards or exceptional moments.
• Creating space to learn from success, with the same curiosity and rigour we apply when examining failure.
• Amplifying what works, so good practice can travel across teams, organisations and systems rather than remaining isolated. This means sharing the lessons learned and practical actions taken as well as the end outcome.
• Recognising contributions at every level, including the small, everyday improvements that may never feature in a board paper but make an enormous difference to patients and colleagues.
• Connecting insight to decision-making, so the experiences of people delivering and receiving services help shape organisational and national approaches to improvement.

None of this removes the need to confront difficult realities.

Appreciation without honesty would achieve very little, but equally, challenge without recognition, learning and hope is unlikely to unlock the best of people.

Working in the NHS will always mean moments of urgent action, challenge and accountability, but if we want different outcomes, we also need to create different conditions for change.

Behind every pathway improved, every ambulance arriving when someone desperately needs help, every patient cared for and every service redesigned, are people. Understanding how they do this amid all the challenges facing healthcare is not a distraction from those challenges, it could be an important part of how we solve them.