Transforming healthcare through marginal changes

At the moment there is lots of talk about transformation, systems thinking and strategy across health and social care.

Recently I was helping a friend who was preparing for a job interview. My friend was anxious because the role was to provide strategic direction to a big transformation programme in social care. Although they had already done a very similar role they doubted their ability to think strategically. The conversation went something like this:

Friend – I’m not sure that I can show that I am strategic

Me – Why do you say that?

Friend- Well, I am good at bringing people together, identifying problems and finding practical solutions but not at having big ideas

Me – So do you have a clear sense of where you want to organisation to get to?

Friend – Yes

Me – Do you have a sense of how to get there?

Friend – Yes, but it is about getting our people to make lots of smaller changes which move us in that direction, not one big change

Me – Do you have a sense of how you can get them to do that?

Friend – Yes, it is change management and using their knowledge and enthusiasm to improve things for their service users

Me – That sounds like a strategy to me.

This is not a unique conversation. I have met many bright and articulate people who feel daunted by either the strategy word or transformation. Sometimes this is because they have seen their organisations parachute in experts who say their strategy of one big change will revolutionise things. Certainly for some services or organisations a big strategic shift, for example from face to face to online services, can be transformative. However, in most organisations there isn’t going to be a single big game changer, or the big project will only deliver part of the strategic shift needed.

At its simplest strategic change is “just” setting clear ambitions, and inviting appropriate actions to move the organisation in that direction. I am great advocate for the Dave Brailsford strategy of making multiple small improvements across a business as or system.

Brailsford is the man credited with transforming the performance of British cycling. Under his direction the GB and now Team SKY have become dominant in the world of cycling. His approach is to look for many marginal improvements which add up to a big improvement overall. A 1% improvement on 100 things can be the equivalent to 100% improvement in one.

It is not surprising that some of our top leaders in the world of health (Simon Stevens and Jim Mackey for example) are talking about system transformation coming through local actions. Enabling change at team, ward or service level is going to be the key to change in the NHS and social care. Who better than frontline staff and their patients to say what can be done better, faster or more cheaply?

However, just as having a big idea does not guarantee change nor does exalting people to make local changes. Marginal gains will only make system level change if they are supported with wider change, which is where they become strategic in my view. So what is needed to achieve change through marginal improvement?

* Cultural change – For marginal improvement to flourish there needs to be a shift in culture. Too often health and care are characterised by professional hierarchies and approvals mechanisms. We need to empower the frontline to self-manage change in their own area.

* Better communication – We need to share new ideas more quickly between and across organisations. It is no good a great but simple idea being used in one team in one trust in one town. Sharing simple ideas needs to be as common as sharing the results of large scale clinical research. The Vanguards are trying to encourage this as are initiatives such as and social media communities such as @Physiotalk.

* Time – In all organisations there can be a tendency to see time spent thinking about change as “not proper work”. This is particularly true in healthcare where patient contact is seen by most clinicians as their main role. Unfortunately this is reinforced by some of the initiatives intended to transform the NHS. Productivity schemes which classify non-patient contact time as non-productive won’t help harness the knowledge of frontline staff to make change. So we need to build time to develop improvements and evaluate new activities into the concept of productive time.

Talking to my friend many of these are issues sound common to social care too. They have a pretty clear vision for how she can engage colleagues to make their own service changes. So I had no qualms in reassuring her she is a strategic thinker. Oh, and they got the job.

What do you think we need to do to harness the power of marginal improvements in health and social care?


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