Flow

• The Q Improvement Lab - The Health Foundation 

• LSC Integrated Care Board :: Home (icb.nhs.uk) 

• NHS England » National Improvement Board 

• The challenge and potential of whole system flow - The Health Foundation 

• Home - Flow Coaching Academy 

• Sheffield Microsystem Coaching Academy (sheffieldmca.org.uk) 

• Delivering a national approach to patient flow in Wales - The Health Foundation 

MATTHEW: Hello, and welcome to Leading Improvement in Health and Care. That's the new podcast from the NHS Confederation, the Q Community and the Health Foundation. 

PENNY: In this series, we'll be speaking to people leading the way when it comes to improving health and care in services and systems. 

MATTHEW: Our aim is to shine a spotlight on improvement done well, but we're also going to explore the challenges.

PENNY: We'll be exploring the way improvement can transform health and care and how to make change last. I'm Penny Pereira, I'm the managing director of Q at the Health Foundation. 

MATTHEW: And I'm Matthew Taylor, CEO of the NHS Confederation. So, welcome again to this new podcast series, which is part of a wider partnership between Penny's organisation and mine.

For those of you listening to us for the first time, Penny, can you give us a bit of a refresher on this partnership that we've built? 

PENNY: Yes, it's called Learning and Improving Across Systems. [00:01:00] We're working with health and care systems across the UK, boosting their ability to learn and improve collaboratively.

We're doing that through a peer learning program, insight and innovation projects, and we're sharing what's emerging throughout. So, this podcast series is one way that we're doing that. 

MATTHEW: That's right, Penny. And in our first episode, we focused on the really important issue of staff morale and engagement and we've had some we've had some great feedback on that. But this time Penny, you're going to be guiding us through a different issue and it's one that you, the Health Foundation, the Q community, have done a great deal of work on together.

So, Penny, the floor is yours. What's the focus for today's conversation? 

PENNY: Thanks, Matthew. So this time we're going to be looking at patient flow. And by flow, we mean the way a patient or a service user moves through the different steps and services in the healthcare system to get the diagnosis and the treatment that they need.

For patient care to work well, obviously, we also need supporting information and resources to flow smoothly. So this idea of flow, it's a concept that's also relevant to the bits of healthcare that aren't directly patient facing. I guess for me, for others working in improvement, when you talk about flow, it comes with a set of values and methods that are about helping the system work better for patients and staff.

So, this episode, it's a great opportunity to explore some of those methods that can help our services run more smoothly by design. So by actually making sure we have the right capacity in terms of staff, materials, equipment, to meet the demand, the number of patients coming through at each point.

That's what flow is about. It's not about pushing people and processes harder. Just to give you one example, we've got an improvement lab as part of Q's work that's currently focused on elective flow. It's early days, but the teams are demonstrating really interesting dramatic reduction in delays, like a drop from 240 days to 16 days in one elective surgical service, an average 40 percent reduction in opioid prescribing that speaks to the patient and cost benefits. 

Or another team showing 60 per cent of urology referrals being dealt with in primary care rather than needing hospital based treatment and this is being done within the same financially constrained environment that we're all working in. So with just a bit of seed funding, a bit of protected space and support.

There's so many examples of that kind of work in health and care. It's a long way to go to spread that everywhere, but this is the sort of stuff we're going to be exploring in this episode.

MATTHEW: Yeah, we've got some great case studies now. You've been chatting to folk in various places and our intrepid reporter Gabriella has been out as well. So Penny, tell us about what we're going to be hearing. 

PENNY: So I've travelled up to Lancashire and South Cumbria for this episode, a place that's got a lot going on in terms of flow and also really well connected to wider work in this field.

So I started off by talking to David Fillingham. David's the chair of the National Improvement Board and chair of the Lancashire and South Cumbria NHS Foundation Trust. He's also a pioneer when it comes to flow. So he was the chief exec of the modernisation agency. That showed how these methods could help bring down weight in the early noughties.

That's where we first met. We wrote a report together back in 2016 on the challenge and potential of whole system flow, charting progress in applying these methods, not just in individual teams and departments, but across whole systems. I started by asking him about where he thinks we are now in terms of the use of these ideas.

DAVID: So I think there's a lot of good work being done around the front door of hospitals, around things like same-day emergency care. There's been some good work on the discharge process. I'm not so sure even within hospitals we actually manage the end-to-end process, we still manage our organisations in departmental silos.

And the really big gain, I think, would be to join the whole system up to get upstream and downstream into primary care, into social care, into care homes. Make the whole system visible to itself, which Penny is what you and I said in that report that we wrote. And get people working together to redesign the processes so that we keep people healthy and at home for as long as we can, if they are needed hospital admission. 

They can get in, get the treatment they need quickly, and be discharged again in a timely fashion. And we can only do that by the whole system, working together in a joined-up way. It's evolved and grown and developed and improved. So, the great thing about working in improvement is you need to improve your own work, improve the way you do the improvement, and I've definitely seen that over 40-plus years, I would say.

It's quite interesting because I joined the NHS in 1989, having had a decade in manufacturing first, I was pretty shocked to find that we weren't applying improvement consistently, systematically to healthcare and the modernisation agency was perhaps the first time we'd really done that. And yeah, it was an amazing time, an amazing experience.

Obviously, a lot of new resources coming into the industry. The NHS then on the back of the NHS plan, but linking that to really embedding improvement. And we trained in the space of four years, a hundred thousand staff, 10 per cent of the NHS in improvement. 

Some fantastic results through emergency services, collaborative action on orthopaedics, cancer collaborative, and some of that legacy is the stillout in the NHS, it feels like it's time for another go at a really national approach and I think that's what NHS Impact is going to do, and I think it'll be different and better this time. The Modernisation Agency was linked to the NHS Plan in the early 2000s, huge investment coming into the NHS, but alongside that investment was reform, change to the way we were doing things.

And we need to remember that before that. There were very, very few places in the NHS who were really systematically applying an improvement approach to our work and the Modernisation Agency succeeded in engaging 100, 000 staff in improvement, 10 per cent of the NHS over a four-year period and got some fantastic results in emergency care, in electives, in cancer care, in primary care and a lot of that capacity and capability is still out there in the NHS now, which is terrific, but it kind of feels like now's the time for renewing that national approach to improvement once again, which is what we're aiming to do through NHS Impact.

If you look at Chris Hamm's great paper for The King’s Fund on the rise and decline of the NHS, there's a very clear correlation between the amount of resource that's coming in and the results that you can deliver. So we should be under no illusions that we do need to think about the levels of funding that healthcare in the UK receives but we can always do better with the resources that we do have.

And that needs both the small steps of continuous improvements and some of the bigger leaps of more radical redesign. And there is a lot of opportunity to do that. Really exciting that there's a lot of big capital investment into digital and technology now for the NHS.

NHS England now has got the Workforce Remit as well, because it's merged with Health Education England, and bringing together that service redesign, the investment in digital and tech, changes in the way the workforce work. Fantastic opportunity. 

PENNY: What do you think the opportunities for improvement will be over the next decade and beyond?

DAVID: So I think the first thing we need to recognise is that the big national programmes are great, we could go back to some large-scale collaboratives, but actually they have to be then landing in a receptive context. We need local systems and cultures for improvement in every provider organisation, every place, every integrated care system.

So the first big opportunity is to work to build those self-improving systems. We've seen with the five trusts that are part of the Virginia Mason programme, for example, the fantastic results that they're delivering. We need to see that more and more across the NHS, but then linked to that I think we need some big national programmes that are tackling the most pressing issues and anybody who's had somebody admitted to hospital will know it's often great care when you get in but getting in through the urgent care system is really difficult.

So improving flow across the system, emergency flow, elective flow, I think is the most pressing priority and one that we really need to tackle. 

PENNY: Where do you think we're at now in terms of applying flow methods? 

DAVID: So I think there's a lot of good work being done around the front door of hospitals, around things like same-day emergency care.

There's been some good work on the discharge process. I'm not so sure even within hospitals we actually manage the end-to-end process. We still manage our organisations in departmental silos. And the really big gain, I think, would be to join the whole system up to get upstream and downstream into primary care, into social care, into care homes.

Make the whole system visible to itself and get people working together to redesign the processes so that we keep people healthy and at home for as long as we can. But if they are needed, hospital admission. They can get in, get the treatment they need quickly and be discharged again in a timely fashion.

We can only do that by the whole system working together in a joined-up way. Again, there is an issue around resources, we know that the social care sector, primary care, do need more investment, and they are hard pressed. 

But there's also something about the organisations joining up and working really well together, and that's about leadership and about culture, and they're the flip sides of a coin and actually what we need are really good system leaders because the skills you need to lead an institution aren't necessarily the same that you need to lead across a complex multi-agency partnership. So a big priority for me is developing those system leaders for the future.

PENNY: What's the priority for systems, do you think, when it comes to improvement and to NHS Impact in particular? 

DAVID: Well, as you know, Penny, that NHS Impact's got five really important domains, which are the DNA of any improvement culture. So building shared purpose and vision, investing in people and in culture, developing the right kind of leadership behaviours, using a robust improvement method.

And then embedding it in our management systems and in our daily work. I think all five of those are just as important at the system level, but we need to apply them differently. And the two things that I would pick out as really critical is that shared purpose and vision across agencies, getting local government, the voluntary sector, acute hospitals, community services and mental health all around a table to say, ‘What is it we need for this place?

What does Blackburn need for its population going forward?’ And then really developing those system leaders, people who can build alliances, who can work to influence and persuade, not just the power of the hierarchy behind them, building the relationships and getting people to work together. And then the improvement methods will come and will follow on, but we've got to get the vision and the leadership and the culture right first.

PENNY: You're currently the chair at a mental health community trust. A lot of the headline conversations about weighting and flow focus on the acute sector. But how are you finding these ideas relevant in these other service areas? 

DAVID: They are. Flow is enormously relevant for mental health, learning disability and for autism.

It doesn't get quite the airtime in the NHS, but it is so critical that we get that right. And you've probably heard of things called out-of-area placements in mental health, where people simply can't be treated locally and end up travelling sometimes very many miles. They might be from Lancashire but end up in a bed in Birmingham and that's completely unacceptable quality for them and their families.

And whilst acute hospitals have people queuing outside in ambulances waiting to get into the A& E department and then waiting to get into a hospital bed for admission, we have people waiting in A& E departments, waiting in care homes, waiting in their own home at a time when they are feeling very, very distressed.

So actually improving the flow into and out of our beds in Lancashire and South Cumbria Foundation Trust is our top priority. It's a safety risk. It's massively important for patient experience. And it's not good use of the taxpayers’ money that we're giving. Those are things that are a real priority for us in LSCFT at the moment.

That we're starting to see some real improvement around, but there's a lot more yet to do. 

PENNY: Flow’s an area of such huge potential. The Health Foundation has been supporting demonstration work in leading places and wider capability building, insight sharing for over ten years so there's lots to build on. Steve Harrison is the deputy director of organisational development at Sheffield Teaching Hospitals, which is one of the places that's been at the centre of that work.

Our roving reporter at the Confed, Gabriella Jones, met with Steve to find out more. She started by asking Steve to explain a bit more about what flow means in practice for patients and for the system. 

STEVE: If you think about healthcare being a system, and that system is there to treat a population of patients, and patients flow into that system, and they require assessment, treatment and eventually discharge.

That process, in some, some levels, can be relatively straightforward, so you could go to your GP and you ring them up and you go and have an appointment and they prescribe some medication or maybe prescribe something you can buy off the shelf. And it's a relatively simple process, but that's actually really rare in healthcare generally.

The majority of time is that when you have some healthcare needs, it requires multiple parts of the system to be coordinated and work together to deliver the value to the patient. So, not only do you need to make sure that the system works well and it's well-designed and it connects together, but also that you've got the appropriate capacity along all of the steps of the pathway, otherwise you create bottlenecks, and those bottlenecks create what, sort of, improvement people would call failure demand, which is demand to do work, to just manage, the bottleneck rather than actually progress the patient's care.

So flow is really important to me. It generates, I guess, a considerable amount of rework and waste and indeed harm in the healthcare system. 

GABRIELA: So could you tell us a bit more about the work that you've been doing and how your approach to flow led to the discharge-to-assess model? 

STEVE: Yeah, definitely. So this goes back a considerable period of time and the flow coaching academy approach came from two pieces of work that we were doing here at Sheffield Teaching Hospitals linked to support from the Health Foundation.

One was microsystems. Microsystems Coaching Academy, which was about the thought that in order to change an organisation, you need to build improvement capability within the organisation. And so in Sheffield, in the early part of the 2010s we set up the Microsystem Coaching Academy which trained coaches who worked with teams to make improvements at the team level.

And we learned a lot about that. But we also started to notice that actually, that was all well and good at the team level, but there were lots of issues that went well beyond the individual team and that were caused by flow, as I've just explained. And then the group, as they started to understand flow, what they realised that there wasn't a method to bring people together in a structured way to solve the problems of the whole process.

And so flow cost quality then developed a space which was called the big room, which convened the staff together from across that care pathway and then started to get them to, okay, these are the problems that we've got, how might we work on tests have changed to improvement. So the big room brought in staff from community and the hospital around frail elderly patients.

That was where the sort of engagement and also the problem was. The team came together and brought the stakeholders with patients and they started each meeting with a patient story into a space that met on a weekly basis to look at the data of the system and then try and generate ideas to test and implement to make things better. And one of the issues was around the assessment of frail elderly patients in the organisation on things like kitchen and bathroom assessments and this is where discharge to assess came from.

There was a conversation with a patient in the room about doing these assessments, testing patients where their mobility around kitchens, bathrooms and so on to be safe in their own home. And the patient pretty much said why I'd be much better at doing that in my own home. Why don't you do it in my own home? And of course, there are reasons that it's not their own home.

The staff who would do these assessments are based in the organization. The system is designed around the kind of time of the staff rather than the outcome. So the plan was, after much negotiation, to start to do patients’ assessments in their own home. And it started with one patient on one day that was discharged with the support of the organisation, with a bed held just in case they needed to come back to the organisation.

And the physio who did the assessment went out and came back with a really powerful story about the patient who'd really come to life when they got home and they were very capable in terms of their assessment when they got home. And so that test allowed something that seemed very difficult and also maybe unsafe. It changed the narrative. So there's something about kind of bringing the staff together from across the system to understand that problem with the patient. And then the team also noticed that there was issues at the front door that basically frail elderly patients, as they came to the emergency department, were not being given the optimal value in the optimal time.

So that led to the creation of a frailty unit. And there was lots of tests that happened around that about basically reducing time to senior review at the front door by bringing frail, elderly patients together into a unit that supported their care and make sure they got a comprehensive geriatric assessment at the front door as rapidly as possible.

And that process, which directly treated and discharged many patients and avoided admissions and the discharge-to-assess process had a significant impact on length of stay. I think the number was we reduced length of stay by around a week through, those tests of change, which didn't involve additional resource, they just involved organizing the care in a different way, which was reducing the failure demand that I described earlier. And the Health Foundation were good enough to say, actually, we think this has got more to it than that. We would like you to establish a Flow Coaching Academy, which replicated that model.

So we basically established an academy that trained coaches to understand the system, work as a pair with another coach, and lead the teams who were brought together in these big rooms, which were stakeholders from across the pathway, using improvement, knowledge and science, but also the relational skills to make sure that team worked effectively together and, you know, those skills are just kind of reframing solution-focused coaching and other sort of relational skills were also deployed to kind of flatten the hierarchy and get people on the right space to engage in change and work together and collaborate to make changes.

People came to Sheffield, groups of coaches. They went through an action learning programme where they then established big rooms in their own organisation and learned how to coach improvement and learned how to improve flow. And at the end of the year, we then gave them the curriculum so that then they could establish their own flow coaching academy in their own organisations and train their own coaches and then establish your own coach coaching academy to build your own capability.

Lancashire, who I know that you're kind of focusing in on, were one of those organisations and they really embraced that approach and what they did really effectively was engage their senior leaders in using flow as a strategic intervention to improve care in the organisation. 

PENNY: The flow coaching offer that Steve describes is entering a new stage with a website just launched to help make over 250 practical resources and tools available that can be used flexibly by those working to improve care.

Once you get a taste for these ideas and tools, I've noticed that people tend to jump straight to action, applying the methods to the issues that they're immediately facing in their service. I think one of the lessons from the research is that you can get some quick results that helps to build interest and will, but you're going to get most impact and you're only really going to start to see the difference across whole pathways and systems, which needs to be the ultimate goal, if these ideas are part of a strategic approach that has some proper organisational investment of time and capacity and really pays attention to how you're bringing people together well.

Back in Lancashire, I met with Ailsa Brotherton, who's the director of continuous improvement and transformation at Lancashire Teaching Hospitals. Their journey illustrates for me what's possible. 

AILSA: So here at Lancs Teaching Hospitals and across our ICS, we've been using the Flow Coaching Academy programme to really redesign our pathways of care.

So we were very fortunate to join the Health Foundation funded programme. We trained in Sheffield. The thing that was really helpful for us, Penny, is we trained as a team of ten and actually we came back and made a commitment to set up our local Flow Coaching Academy and really share the learning with partners across our system.

So we have a number of FCA big rooms who are focused on internal pathways, but we also have quite a number now that are working right across our ICS. So we use the Flow Coaching Academy roadmap, which is a step-by-step guide to how to do improvement well. And actually what that gives us is an opportunity to create a flattened hierarchy, so our colleagues can come together, we can look at our data, we can set a global aim, and we can really design our tests of change together so we really do focus on improving care for patients.

PENNY: So there's lots of different people involved in delivering care and who therefore need to be involved in redesigning services when it comes to discharge. Can you tell me about how the big room method has helped to support more effective transformation? 

AILSA: Yeah, so the big room method we've been using now for almost four years at Lancs Teaching Hospital and what we've done, the first thing it's allowed us to do is to put the patient at the centre of everything that we design.

So all of our big rooms we invite patients in and we capture patient stories from patients who are both with us on the ward but also out in the community. We use film so we filmed a number of our patients so we can share their messages and what matters to them really widely across our organisation and with our system partners.

The second thing we do in the big room is really work differently to understand our problems. So we use the methodology to really understand where we have delays in our pathways, and we work together to be able to reduce those. So we've got some great examples of where our teams have taken very complex discharge pathways and redesigned them to strip out the waste and the duplication in the system.

PENNY: Give me an example of some of the waste or the issues that you identified when you did that work. 

AILSA: Yeah, so we've got lots of examples of the waste, as many organisations across the NHS would have too. So some of that has just been the delay in between things, so for example, patients who need a referral to a consultant or one of our therapy services, for example, had to wait. So there was a delay. We've introduced some new referral processes to make that easier to refer patients and given the teams visibility so they can see how long patients are waiting. 

We've also done some work with a digital flow system to look at what are our biggest constraints in our discharge pathway and being able to reduce those. So waiting for things like the discharge letter that we need to write to a patient's GP. So we've been able to really quantify the level of waste in the pathway and then be able to do some work to reduce those using the improvement methodology.

PENNY: Can you give us an example of the kind of issues and insights that have come out from using this method to address discharge? 

AILSA: Yes, so if I use the example, we had a big discharge big room set up and they really focused on the biggest constraints. So what were the biggest delays that our patients were experiencing.

So through the big room, we've been able to look at the data, identify those longest delays, and then work to reduce them so that our patients flow through our organisation faster. And we've seen a significant reduction in our length of stay while we've been doing that work. 

PENNY: And have you managed any tensions or competing incentives or perspectives on what's needed between different sectors?

What would be your lessons for leaders in organisations and systems who are trying to enable change that spans sectors? 

AILSA: So, we've seen lots of tension and initially when we start most of our work and especially the discharge work, we've all got different priorities that we need to meet. So how we deal with that is we look at setting a global aim so every partner who's in the room with us to contribute to the aim of the work, and what we find is when we focus on the improvements for patients, and our local citizens, because that's what we all want to deliver, we're able to find a common ground and a global aim with some specific objectives that we can all sign up to, and then we focus our improvement work on those. So we found examples where we've had benefits not just for us in the acute hospital, but for our ambulance colleagues because they provide our patient transport and also for our community partners and social care colleagues.

PENNY: And what's been the impact so far of the work that you've been doing? 

AILSA: The impact's been immense. We've seen an improvement in a significant number of our metrics. So we've seen improvements recently in our ambulance turnaround times. We've seen significant improvements in our length of stay. We've also seen some really important improvements in our safety and quality metrics.

So we're using PSURF at the moment to really look at how we improve our safety and quality metrics. So we've seen clinical benefits in terms of a reduction recently in pressure ulcers, falls, and we've improved our compliance to VTE. 

PENNY: And making changes to pathways of care, it's complex work, it's influenced by a lot of local factors.

How far is it possible to lift ideas or service solutions from other areas when you're doing this work? 

AILSA: So we usually start by doing exactly that and taking the learning from others. So we like to review the evidence, so we make sure that the improvement we deliver is evidence based, but we look up and outwards and see who's performing the best and we often will go and learn from them.

So we've had some great learning from colleagues in Sheffield and Imperial and others for our big rooms. But what we do is we make sure that we bring the learning back and we look to say ‘can we adopt this because it's so similar to our system or do we need to adapt it or actually is our system so different we need to abandon it?’

So what we've learned is going through the process to make sure that we rigorously apply the improvement science methodology as being key to the successes that we've had. 

MATTHEW: Well, Penny, thanks so much for guiding us through that journey. Really fascinating stuff. You know, the way I think about change, and I'm not a technical improvement expert in the way that you are, but I guess I've done a lot of work on organisational leadership and change.

So thinking about organisations as a whole or systems as a whole. And, and what fascinated me, you know, listening to the examples is that they've got that combination, haven't they Penny? They, they use a toolkit of techniques and they use data. 

They are strongly motivated by a commitment to make things better for patients. So this is not in the end, I mean, it might, it will save money, it will make things work better, but the most important thing is it will make things better for patients. But also this is a methodology with a lot of creativity in it. It's not just about following things by numbers. It's allowing people to experiment and to learn and it sounds to me hearing these examples that everyone involved must feel that they're growing and developing and actually must enjoy the experience as well.

So all those kind of ingredients come together don't they Penny? 

PENNY: Exactly. I mean, I think people have an inherent will to make things better while also seeing their own role and that of their colleagues feel reasonable. I think the experience of working in the health sector is often that, in practice, trying to do that change is often pretty painful and often not very successful and takes a long time.

So there is something about these processes that have quite a pace for them. So the big room, for example, you'll meet weekly, you'll have a really inclusive dynamic process. You know, you'll have the visual and the data around there. 

You'll use a lot of visual management and methods that help people see the progress they're making along the way, because these are long journeys and helps them see the difference that it's making to multiple different perspectives within a particular system or service. And when you're doing positive work together, when you're spending time together, actually solving problems for patients, that creates the kind of relationships that are both critical to morale, critical to then actually implementing change that will benefit patients.

And that's also the essential building blocks of effective system working, right? Like one of the things that I think is really important about flow, when you think about the formal development of systems in the health sector, is that these methods can really ground the work of systems in the kind of practical work that will make a difference for patients.

And that can be quite refreshing sometimes if it's done in the right kind of creative dynamic way that isn't all about the technical process. It's also about the relationships between people that can be really energising and can help energise something which can otherwise feel sometimes a bit bureaucratic and process driven.

The methods used to see the process in this way can also help provide fresh perspectives on the nature of the demand on a service. Steve mentioned the concept of failure demand. This is a really important idea, I think, especially when thinking about whole-system flow. There's huge pressure on services, but when we actually analyse why people are coming through the door, the level of demand is often not straightforwardly linked to changes in population need, or that's only part of the explanation.

It's because we're not meeting people's needs at the right point or in a way that works for people. That's, in itself, creating work for the health system. And that's the idea of failure demand. So understanding, unpacking that demand supports then the case for not just adding capacity, but being able to reorientate care around the needs of populations.

There's also additional failure demand, additional work created in how we organise care. For example, when patients need to double check what's happening with their appointments because our systems aren't reliable or clear. The demands on the service are still challenging to meet, of course, but understanding what's causing the demand can help change the conversation about what's needed.

MATTHEW: And Penny, we're drawing to a close, so I'm going to ask you the most basic question: What does it really take to do this properly? And I think you've got some evidence in relation to what goes wrong if you don't do it properly. 

PENNY: There's an example from Wales that we can learn from. The Health Foundation funded an evaluation of a flow programme in Wales some years ago that supported health boards through a process that had been really successful elsewhere.

But, as we often find in the health sector, they reduce the dosage of capability building, they change, they squeezed aspects of the programme design. And that led to overall the programme under delivering. We're all trying to get more from the limited resources we have so it's completely understandable that we try and apply improvement ideas with the minimum time and resource.

But there is evidence that you only get a return in terms of reliable performance benefit if you dose the support for this work properly. We didn't have time to explore the innovative work that Lancashire are doing in collaboration with the Royal College of Engineering. You can find out more in the show notes.

The work involves the level of rigour and proper investment in system diagnosis and really understanding user needs that engineers would routinely bring to a problem, but that is rare in healthcare. When the systems we're leading in healthcare are so complex and the implications are life and death, I think this should really make us think about the investment needed to redesign services properly.

MATTHEW: That's all we've got time for on this episode. 

PENNY: And we'll be back over the coming months with more insights from across the improvement world. So please do make sure to subscribe wherever you get your podcasts. And if you like what you heard this week, go ahead and share this episode or get in touch with us to let us know your thoughts.

You can find us on X @NHSConfed and @HealthFDN and @TheQCommunity. And if you'd like more information about our Learning and Improving Across Systems partnership. Please email improvement@nhsconfed.org You can also find transcripts and our show notes on our website. You'll find the link in podcast description.

MATTHEW: Thank you Penny, and thank you all for listening. We look forward to talking to you again about improvement very soon. Goodbye.