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It’s been a busy year at the Health Innovation Network, from publishing new reports on digital health inequalities and diabetes care for mental health inpatients, to starting new workforce development programmes for cardiovascular disease and opioids, through the launch of our new involvement strategy and supporting over £600,000 to pilot new automation solutions.
Medical Director at the Health Innovation Network (HIN), Dr Natasha Curran discusses how positivity, potential and practicality must be balanced when delivering truly innovative new ways of working.
I feel privileged to hold a number of varied health and care positions so read the newly published People Plan with cautious optimism. Whilst undoubtedly a big ask and task to deliver, the People Plan is clearly a positive call to arms.
As Joint Director of Clinical Strategy at King’s Health Partners (KHP) and co-lead of the Implementation and Engagement theme of the Applied Research Collaboration (ARC) South London, I was heartened by how much the Plan has taken account of the system-wide learnings of Covid-19, despite us still being in the throes of the pandemic. As a clinical leader, the call for a greater emphasis on clinical leadership, which during the first wave allowed local self-governing clinical teams to do what was needed, is particularly welcome.
I felt uplifted by the promise of flexibility by default for all clinical and non-clinical posts advertised from January 2021. Having seen over the years how many brilliant colleagues have struggled to balance parenthood, caring responsibilities or simply the emotional workload of full-time hours, when an offer of more flexibility would have supported them to keep going, this feels like a gamechanger. Especially for junior doctor (and other professional) training schemes and primary care. The challenge of course is in making these deliver operationally in the short term.
As an NHS ‘lifer’, I’ve long awaited an NHS plan that gives as strong a focus on health and wellbeing of staff and promises career-long investment, not least because as well as looking after staff, it also translates into better patient care. We know that 50 per cent more staff in the NHS suffer from debilitating levels of work stress compared with the general working population as a whole. Every year in the NHS staff survey, 38 to 40 per cent of staff report being unwell as a result of work stress in the previous year. Research indicating that organisations who prioritise staff wellbeing and leadership provide higher quality patient care see higher levels of patient satisfaction, and are better able to retain the workforce they need, is not new. However, this is the first NHS plan I have read that seems to take it seriously enough to make it integral to how we work.
At the HIN, working in the business of spread and adoption, my main question remains how are we going to make it a reality?
“Bold ideas are not useful unless there is the power, permission and possibility for the inevitable risk that comes with trying something completely new.”
Local innovation versus national control?
My biggest concern is that the onus on large scale organisational or systems change needed to deliver this rests with the same organisations who have said they need help. This, plus the lack of risk appetite centrally to genuinely allow local systems to be very innovative. It’s great that answers such as innovative roles, support to care homes, volunteering and the role of research are mentioned (p10), but what central levers are really in place to connect health and social care, for example? Or to ensure that NIHR (National Institute of Health Research) funding is linked to on the ground need and evaluation of rapid care system change? Or for professional bodies to rapidly collaborate and/or change how they regulate new roles?
That local plans are expected is appropriate, as this will allow systems to think collaboratively. But how much freedom and headspace will they have to create this? For example, would an Integrated Care System (ICS) be supported nationally to test some bold plans, without reams of dragging governance? Would they also ensure evaluations of workforce pilots to include return on investment in longer than two year funding cycles? There are some good early signs with small grant funding from Health Education England (HEE) but these need to be over a longer period and clearly linked to on overall policy.
Bold ideas are not useful unless there is the power, permission and possibility for the inevitable risk that comes with trying something completely new. Will the NHS prove that it actually is committed to learning by giving systems air cover to do interesting things, and with its partners in social care in our ICSs? So that providers can complete properly evaluated pilots of, for example, new roles rather than not even starting because potentially they are considered illegal and/or uninsured? Redeployment was enabled rapidly during Covid-19, especially for intensive care units (p32). Will this scale of reshuffling be so readily facilitated in a more planned way, across all specialities and sector boundaries, and for the longer term? In my own specialty of anaesthesia, which has had a workforce gap for years, I have seen the struggle to embrace new roles, such as physician assistants. Professional bodies such as the General Medical Council and Royal Colleges should, and always will be concerned with standards, but we should also be alert to professional protectionism. If we look back to the difficult detail of the never-final version of HEE’s 2017 draft workforce strategy, we can see that that a truly wicked problem exists. And has been pushed forward to this People Plan.
Whilst rapid workforce innovation might lead to some individual harm, the greater harm is likely to already be happening at a population level, as a result of not swiftly adapting. The pandemic, for all its hardship and heartbreak has forced action that would have otherwise taken years – perhaps decades – to get through bureaucracy and process. What worked was being explicit about the unknown and trusting and allowing the public to judge us. Will we approach this People Plan with the same gusto for actionable change that Covid-19 forced us into?
Hordes of new workers?
The Plan gives so many positive suggestions, such as the mention of peer-support (p41) – in my view the nation’s greatest untapped resource, alongside unpaid carers – and a call to invest in for example child and adolescent psychotherapy training schemes. But the latter provide expensive services that have been cut by commissioners, as return on investment is often realised way in the future, and/or is counterfactual, and in different parts of the economy such as the criminal justice system. Will commissioners be supported to make potential losses on such services?
“Will we approach this People Plan with the same gusto for actionable change that Covid-19 forced us into?”
There are barriers beyond money too. Data sharing, for example. If staff need to operate across boundaries, then we need to see workforce data (as well as clinical information) in others’ organisations. More significantly, perhaps, are the continued vacancy levels. A focus on people requires people to deliver it. With over 100,000 vacant roles currently in the NHS, who are we expecting to come forward? We are still to see the full effect of Brexit on staffing. We are moving towards this winter with a massive burden of longer wait lists, a huge flu vaccination programme, a potential second Covid-19 wave, plus the hope that we will be delivering a Covid-19 vaccination programme at some point.
The Plan suggests that the positive zeitgeist towards the NHS, which increased during the first wave of the pandemic (perhaps coupled with new unemployment in other areas), will translate into hordes of new workers. Will it be done in time to allow those who have worked during the pandemic to recover? And will the Government make the financial commitment required to back up the Plan’s promise of training and education for a whole career path, not to mention the better pay and conditions that will ultimately also attract and retain staff? The case that we would have been better off investing more before Covid-19 hit, has already been highlighted.
An evidence-based approach to evaluation and spread?
Perhaps the most poignant question of all – if something is a success, how will we know and how will it spread?
While heavy on positive potential, the plan is light on meaningful metrics (promised next month). The Plan cannot be appraised without them. An evidence-based approach must apply to staff wellbeing and retention, healthcare policy and delivery, as well as to clinical care, because as discussed above, these factors unquestionably affect patient outcomes. The pledge that the annual NHS survey will be linked to the NHS People Promise (which has been developed by staff) is a good start. But it would be more effective and efficient to promote successfully proven elements or practices from the People Plan.
This is where us Academic Health Science Networks (AHSNS) could come in, to support the scale and spread of models which work. The Plan doesn’t mention any partnership with, or investment from industry/charity/other sectors, which AHSNs are well-versed in facilitating. Although, hearteningly, I see early signs that others are also thinking this way.
I was interviewed last year about local workforce innovation, and said the following:
“I see an opportunity for the KCL civic university to create an exciting health and care careers offer which goes beyond the Topol review and NHS people plan to attract and retain our greatest talent. I’m interested in working with the KHP partners, Royal Colleges, Health Education England and others to enable KHP to become a world leader in true inter-disciplinary whole career journeys, integrating ‘in time’ learning and structurally enabling individuals to change fields whilst maintaining creditability, and crucially, pay. Examples could include data science, digital, engineering, psychological, and business skills.”
Whilst it seems the sentiment has been mirrored in the new People Plan, the permission to take changes forward will always come with some risk. Will we be allowed to take the chances, forge the partnerships and take the short-term financial hits to really deliver?
Find out more about how the Health Innovation Network supports workforce transformation.
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Laura Semple, Programme Director for Diabetes & Stroke Prevention at Health Innovation Network, reflects on how new prevention techniques might have changed her grandparents’ lives.
I’ve often wished I’d had the chance to meet my grandfathers, Gerry and David. They were both fascinating and spirited people, who led interesting lives. Gerry travelled the world, had a successful career in industry and loved fishing for trout in the Welsh countryside. David worked in finance for London Transport and enjoyed vintage cars.
Sadly, I didn’t get to meet them because, like many people of their generation, they died too soon from cardiovascular disease in the 1970s and early 1980s.
This part of my family history is far from unique. It’s also a big reason why I find it so rewarding to be part of the movement of committed people working to prevent cardiovascular deaths in this country. February is National Heart Month and I’m thoughtful about the real progress that we’re seeing in south London in this area.
One of the main drivers of cardiovascular disease in the UK that Gerry and David grew up in was a lack of understanding around the impact of certain foods and other lifestyle aspects on heart health. It was very common to eat a high fat diet and the true scale of tobacco-related harm was not yet understood. But since the 1970s we have gained a rich understanding of the impacts of diet, exercise, tobacco and medication on heart health.
What’s more, we now have risk models, which enable us to accurately predict how likely it is that someone will have a heart attack or stroke in the next 10 years, simply by knowing their BMI, blood pressure, cholesterol and blood glucose measurements today.
This all makes me wonder just how different it could have been for Gerry and David. Not only are we now able to offer preventative care that extends lives, but crucially these are also improving the quality of those lives.
At its core, most of our work is really about giving Londoners the support they need to live full lives without the burden of diabetes and cardiovascular disease.
The first success to highlight on the prevention front is south London’s contribution to the Academic Health Science Network’s national stroke prevention programme.
Atrial Fibrillation (AF) is one of the most common types of irregular heart rhythm and contributes to one in five strokes. If Gerry and David had been born 20 years later, there’s a good chance that they could have been two of the more than 4,500 additional south Londoners whose AF has been newly detected since 2017.
The latest national stroke audit data shows that in the two years to March 2019 there were approximately 150 fewer AF-related strokes in south London than would have been expected from the previous years’ data. This is 150 Gerrys, Davids, Simones, Ritas, Mohammeds, and many others, who are still thriving as a result. We’ve recently published the results of our innovative work in improving AF detection through mobile ECG devices here and an ongoing pilot of 14-day ECG patches on page 12 of Cardiac Rhythm News January 2020 here.
Then there’s diabetes.
This is a major driver of cardiovascular disease and it’s simply astonishing how much our experience and understanding has transformed since Gerry and David were alive. Back in the 1960s and 1970s, we were not as good at detecting type 2 diabetes, so some people lived with the condition for many years without a diagnosis, which in itself increased their risk of preventable ill health.
In general, there was far less freedom and choice for people with diabetes in how they lived their lives, with many being told to stick to rigid set diets.
But in 2020, we believe in giving people with diabetes as much freedom as possible to live the lives they want, without diabetes getting in the way. South London has a formidable partnership of colleagues committed to minimising the impact of diabetes on citizens’ lives. Together we represent 12 clinical commissioning groups, 12 local authorities, seven acute hospitals, two universities, the King’s Health Partners Institute of Diabetes, Endocrinology and Obesity, the Applied Research Collaborative, several industry partners and community organisations like the Wandsworth Community Empowerment Network The last two years has seen a major focus on type 2 diabetes prevention, with over 30,000 south Londoners referred to the NHS.
I’m curious as to what Gerry, David and their friends might have chosen if they had had access to Diabetes Book & Learn, a radical move to scrap the previous postcode lottery of self-management support for people with diabetes. In this new system, south Londoners are learning how to live well with diabetes at a time and place that works for them in their busy lives, with different languages, digital options, evening and weekend courses and telephone coaching all available.
Would Gerry and David’s employers have supported their access to diabetes education through the learnings of our Think Diabetes report?
People with type 2 diabetes are also increasingly taking charge and setting the agenda for their doctors and nurses in the innovative You & Type 2 programme in primary care.
Would Gerry and David’s employers have supported their access to diabetes education through the learnings of our Think Diabetes report? This was supported by former Labour Party deputy leader Tom Watson. Many forward-thinking employers are using the recommendations in this report to offer support directly in the workplace.
At its core, most of our work is really about giving Londoners the support they need to live full lives without the burden of diabetes and cardiovascular disease. Healthy living is far from easy. People need holistic and non-judgemental support and this is why the offer of psychological support is built into Diabetes Book & Learn and many other new services.
There is a great deal more to do to prevent cardiovascular disease and exciting plans are afoot to do even more to tackle the longstanding health inequalities in our region. For now, I’m asking everyone who has played a role in the great progress so far to take a moment this heart month to remember the strides we have made together and renew our energy to take this to the next level.
If you are keen to join the fantastic team of people saving lives by preventing cardiovascular disease in south London please visit our webpages on diabetes and cardiovascular. Alternatively, get in touch with me on laurasemple@nhs.net. This year we will be focussing on cholesterol and blood pressure as well as continuing to support our members with AF detection and improvements in diabetes care. The more collaborators we have, the more lives we can save.
I know that Gerry and David would be only too happy to see that things are different and getting even better, for the generations who came after them.
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NB: Gerry and David are not the grandfathers’ real names.
Health Innovation Network (HIN) has partnered with The Health Foundation to help grow the Q community across south London.
Q is a diverse and growing community of people with experience and understanding of improvement who are committed to working collaboratively to improve the quality of health and care across the UK. Over time, Q will grow to be a community of thousands, including people at the front line of care, managers, researchers, patients, commissioners and policymakers. Our aim is to connect a critical mass of people in order to expand and accelerate improvement in the quality of care.
Q will make it easier for people with expertise in improvement to share ideas, enhance their skills and make changes that benefit health and care. Q is also the name for the infrastructure we are creating to support individuals with their improvement work and make it possible for the community to connect, share and collaborate.
What is the difference between Q and other initiatives, networks or programmes?
Q is intended to complement and underpin other initiatives, networks and programmes, not compete with them. Q supports people to deliver their existing improvement work rather than being an additional project. Q is aimed at individuals and will provide a long-term infrastructure to support them throughout their career, regardless of where they are employed. Q is not a taught development programme, but a network of support for those already knowledgeable in and undertaking improvement work.
Q supports other initiatives and programmes by:
Where did Q come from? Is patient safety part of Q?
Q began as an initiative to recruit ‘5,000 Safety Fellows’ following a recommendation of the widely respected 2013 Berwick report A promise to learn, a commitment to act.
Recognising those with improvement expertise was part of the report’s recommendations about how best to improve safety in the wake of failings of care at Mid Staffordshire Hospitals NHS Trust. The report made the case for a system devoted to continual learning and improvement.
In 2014 NHS England approached the Health Foundation to lead the design and delivery of the initiative. The Health Foundation’s UK-wide remit and funding means Q brings together those committed to health and care quality across all four countries in the UK.
The decision was also made to expand beyond patient safety to cover all domains of quality in line with the Institute of Medicine’s (IOM) definition: safe, effective, patient centred, timely, efficient and equitable. During the design phase of Q, we also formally extended Q beyond the NHS to all public, third-sector, community and private organisations and individuals with a role to play in supporting health as well as caring for people when they are ill.
In April 2016, sponsorship transferred over to (the then newly established) NHS Improvement.
Who funds Q?
Q is co-funded by the Health Foundation and NHS Improvement. Previously Q was co-funded by NHS England. On 1 April 2016, the Patient Safety team transferred to NHS Improvement, along with co-funding commitments to Q.
Are there other sponsors?
In line with the Health Foundation’s UK-wide remit, Q has benefited from advice and support from leaders and founding members in all four countries since its inception in 2014.
Early conversations are underway with Healthcare Improvement Scotland, Department of Health Northern Ireland and NHS Wales with the intention of them becoming ‘system-level partners’. By becoming formal partners alongside the Health Foundation and NHS Improvement, Scotland, Wales and Northern Ireland will reinforce their support for improvement and for sharing across organisational and professional boundaries. It will make it easier to maximise synergy between Q and other initiatives within each country. The aim is to formalise partnership arrangements in spring 2017.
Who designed Q?
To ensure the design of Q meets the needs of those of the community, in 2015 we collaboratively designed the initiative together with 231 founding cohort members.
In addition, throughout the design process we have involved eminent leaders of improvement and wider stakeholders. To date, we have engaged more than 500 people in the design of Q.
More about this process can be found in Building Q – learning from designing a large-scale improvement community.
Q will continue to evolve, being shaped and grown by members of the community and partners.
What is the Q Improvement Lab?
The Q Improvement Lab’s mission is to explore ways to build a more sustainable health and care system in the UK for now and the future. In a stressed and pressured sector, the Lab will provide time, space and opportunity to tackle complex problems.
Emerging from Q, the Lab will bring people together to explore, develop, test and spread ideas that can significantly improve health and care for people in the UK. The Lab will provide space – physical space, virtual space and headspace – for people to work together on high priority challenges that many stakeholders want to solve. A small team will support the process and invest time in curating and sharing the findings, as well as seeking to influence at a wider system level, building capacity for change across the sector. Through our planning and research phase for the Lab it became clear that having a dedicated, physical space for the Lab is crucial. As part of the pilot Lab, we have dedicated space at King’s Cross in London.
After the community voted, the first theme the Lab will explore is empowering people to manage their own health and care needs. They will be exploring the following topic -‘What would it take for peer support to be available to everyone who wants it to help manage their long-term health and well-being needs?’
Over the coming months we will identify a particular topic within this theme to explore over a nine-month period, starting in spring 2017.
We envisage that over the next few years we will establish a small number of Labs across the UK where members of the Q community come together, facilitated by a small team with specialist skills, to make progress on complex challenges facing the health and care system.
For more information, please visit q.health.org.uk/q-improvement-lab/.
What is the difference between Q and Generation Q?
Generation Q is the Health Foundation’s fully funded 18-month taught leadership and quality improvement programme. It provides senior leaders working in and with the health service (including charity organisations and policymakers) with a postgraduate certificate in Leadership (Quality Improvement) from Ashridge Business School (with the option of completing an MSc).
Q is not a taught programme, nor does it come with funded time. It is a long-term community of those with improvement expertise. There are fellows from Generation Q who have also joined Q – you can be both a Q member and a Generation Q fellow.
What are the benefits of joining the community?
People who join Q will join a diverse community of other improvers – a ‘home’ to turn to for inspiration and support. Q provides ways for members to learn, share and get advice from a wider network of peers, offering flexible development in a way that taught courses aren’t easily able to provide.
Members are added to Q’s online directory, hosted and promoted by the Health Foundation. We will offer access to online learning resources in exchange for your commitment to share what you learn.
There will be opportunities for sharing ideas, enhancing skills and collaborating on improvement projects, based on what the founding members identified as most useful. This will include Do-It-Yourself online resources, networking events nationally and locally, masterclasses and exchange activities (including site visits). Some of these are designed and organised through the central team, while others are managed through regional improvement organisations or self-organised by members.
Q is still relatively new, with some of the activities and opportunities still being designed as the community grows from hundreds to thousands. We are piloting activities together with members to ensure they genuinely add value. Individual activities and the portfolio as a whole will continue to evolve in line with feedback from the community.
What is expected of people who join Q?
The success of Q is largely dependent on the community. There is no minimum time commitment, but generally speaking the more you’re able to contribute, the greater the benefit. Some members will take a more active role in the community, while others less so and we expect individual involvement will vary over time.
We worked in collaboration with the community to develop a ‘compact’ that describes the expectations of those in the community and encourages a creative and safe environment for learning and improvement. The compact can be found on the Q website.
How long will I have Q membership?
People join Q as an individual, not a team or organisation. This means members remain part of the community when they change role, circumstance or organisation. Members of the community can share and collaborate with other members throughout their improvement career, even if they move abroad.
How much does it cost to join Q?
There is no membership fee to join the Q community. Travel and expenses are not covered by Q.
There will be times when we will cover travel and out-of-pocket expenses in relation to Q activities for those who are not in paid employment. This will need to be pre-approved and in line with the Health Foundation expenses policy.
What time commitment is required?
There is no minimum time commitment for members of Q. It has been designed to help support busy people with their current improvement work and ongoing development and to promote their visibility as a leader of improvement. Q should support members to tackle the challenges they are working on, rather than feel like an extra project.
Who is currently in Q?
We have 799 members in the community at the moment with numbers expected to reach the thousands during 2017. This number includes the 231 who helped to co-design Q, along with 216 who joined as part of a targeted pilot to test how we will grow the community in 2016.
352 members have joined as part of a phased approach to growing the community which is being rolled out across the UK. They joined from the North East and North Cumbria, West of England and South West.
We have recently closed the application window in the following areas – Scotland, Yorkshire and Humber, UCLP, North West Coast and the West Midlands and look forward to welcoming new members from these areas in June 2017.
We have partnered with a number of organisations that are helping us to grow the community. These are Healthcare Improvement Scotland, Public Health Wales, Health and Social Care Northern Ireland and the Academic Health Science Network in England. Our partners are helping to promote Q, and will also be delivering activities and opportunities for members at a local level.
When will opportunities to apply open up?
There will be phased opportunities to join Q during 2017. Anyone who feels they meet the criteria and is based in the area can apply and there will be no cap on numbers.
During May-June 2017, applications were open in the following locations:
In August we will be opening applications in Northern Ireland, East Midlands, Oxford, and the Imperial College Partners and Health Innovation Network AHSN areas in London.
We anticipate opening up opportunities more widely at the end of 2017/early 2018.
What is involved in applying to join Q?
To join the community you will need to complete an application via an online portal – AIMS. As part of the process, you will be asked to reflect on your knowledge and experience of improvement and how you can benefit and contribute to the community. The application process should take one to two hours and you can pause and return to the process at any time.
Why are there selection criteria?
We worked together with the founding cohort and others to develop selection criteria for joining Q. The decision to have selection criteria was made after much debate. It is there to ensure those who join share an understanding of improvement and are able to contribute equally and as trusted advisers.
We are looking for people who have experience, knowledge and commitment to the collaborative improvement of health and care. We hope to attract people with many different sorts of experience and people whose knowledge has been gained in a number of ways (taught courses or on-the-job learning). Those applying should be able to articulate and reflect on the approaches used personally and by others involved in improving quality. They should also have experience of playing a role in efforts to improve quality across team boundaries.
Who assesses applications?
Applications will be assessed by a small panel of people who understand improvement led by our partner organisations and supported by the team at the Health Foundation and NHS Improvement. The partner organisations will assess applications from their area of the UK. For example, if someone based in the West Midlands submits an application then our partner organisation West Midlands AHSN will be lead assessing it, together with the core project team.
For more information about Q process, click on the button below to download The Health Foundation’s ‘Decision Tree’.
DownloadIf you have any questions or would like more information on Q community, please contact us.
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