How to resource improvement and transformation

Penny Pereira

And welcome to the Leading Improvement in Health and Care podcast.

Matthew Taylor

This podcast is coming from our dedicated podcast base here at ConfedExpo. It's the morning of day one. Well, actually it's just past morning and the whole place is absolutely buzzing with energy.

Penny Pereira

Yeah, and in this episode, we're going to be looking at how to resource improvement and transformation. So that's both about how we find the funding, people and other support to deliver change and how we approach improvement so that it generates greater value while delivering other goals. 

Joining us for the first part of the conversation is Paul Corrigan, strategic adviser to the Department of Health and Social Care, closely involved in helping shape the government's ten-year plan. Welcome to the podcast.

Paul Corrigan

Great to be here.

Matthew Taylor

So in this podcast, we explore the big issues and opportunities when it comes to improvement from our vantage point of looking across the sector, connecting policy and practice. And we want to get into what this means for leaders making change happen in local organisations. But we're to start today with some of the ‘macro’ level questions about how we find the resources to deliver the ten-year plan. And then we're going to move into exploring how we deliver service shifts that span multiple organisations.

So we're going to macro, miso, micro in our focus today. Penny is going to explore what it means at the point of delivery in individual teams and organisations. And that will be with our second contributor to this podcast, Amar Shah from East London. 

In terms of the overall context, the spending review is coming out more or less as we speak with welcome investment for the NHS. But think Jim and Penny have kind of got the tone right – the NHS has done better than other public services, but that doesn't mean that we have got all the money that we would have in a perfect world. Resources will feel tight. 

So, Paul, just to start, what's your kind of sense of the level of ambition we should have as we try to achieve recovery, reform in quite challenging financial circumstances?

Paul Corrigan

Well, first of all, I think it's quite interesting that today we're going to hear about the spending review, which is, if the press is right, is going to say an uplift of 2.8 per cent and the point you made is quite correct, that's more than anyone else. And so for several weeks, we've been concentrating on 2.8 per cent. Actually, tomorrow we'll be getting even 100 per cent of the money, which is a lot more than 2.8 per cent.

And the problem we generally have in the NHS is we think the only money we can actually do any change with is 2.8 per cent. And we don't really think about the 100 per cent which at least, if my maths is right, is 30 times greater. 

When the ten-year plan starts, luckily enough it's over ten years, and that means we'll be dealing with £2,000 billion of money. Now, if that's not enough, I don't know what is enough.

If we can actually plan for change and improvement with £2,000 billion of money and we spent three weeks running about 2.8 per cent, we should think about that large number and not about the increment in one year.

Matthew Taylor

So, let's take one particular dimension of this Paul, which is you've done a lot of thinking, a lot of talking over the – for those people who don't know, you've been a kind of source of wisdom and insight for the health service for decades. We've had conversations with you at the Confed about incentives and do some work about payment incentives. But to create incentives, you've got to find that money somewhere else because otherwise it's not an incentive. So how do we realistically create incentives at the same time as kind of keeping things going? That's the hard thing here, isn't it?

Paul Corrigan

Well, I think, I come to this conference with a slogan. And my slogan is, since we're looking at the ten-year plan and we're very worried about what's happening today, exactly as you just said, the only way we're going to solve this is if tomorrow comes to the age of today. And we have got a whole range of possibilities with tomorrow, which we are thinking about in tomorrow, but we're not then thinking, can we do that today?

What's been interesting to me over the last two years or so in working with the NHS is that very clever people are absolutely certain the NHS cannot do two things at once. They cannot both prepare for the future and deal with the present because they think they're separate things and they are not separate things. So how we deal with, for example, waiting times, it seems to be an immediate thing. And it's if we mustn't think about the future in dealing with waiting time because it's an immediate thing. Actually, technology will transform the experience of passive waiting that we've created over last ten years into one of activity. 

So tomorrow can come the age of that. And in terms of money, the way in which we have constructed expenditure in the health service in financial flows which actually do not flow between A and B. It is almost impossible to invest in A and then get that money from B because there is a big brick wall in between. 

The money in B could be saved, a lot of money in emergency beds can be saved this year. In fact, if we were to do that, it's very important for the old people that end up in those emergency beds that this winter they don't go there. 

It's not just a money thing, it's a service thing. And if we say, that'll take several years, it mustn't take several years for the sake of those older people and it mustn't take several years for the sake of the money. But that will only work if we construct financial flows which make sure where the saving is can in some way flow back to where the expenditure is.

Matthew Taylor

So before Penny comes in, you spend a lot of time, Paul, out in the service. I know you're really informed by seeing that kind of practice. Give us an example of where you've seen tomorrow coming into today.

Paul Corrigan

So in Surrey they have developed a completely different service for the frail elderly. There's 600 residential care homes in Surrey. So in the sense the nature of frail elderly services there is absolutely core. 

And they've developed over several years a community-based frailty service which does keep people in the homes, reduces the number of people going to emergency beds and they did that in the existing financial flows. 

The hospital has recognised that is now serving them and they give a ‘bung’ back to this. isn't a flow, but it's a recognition that if they can keep that service going, you can now all over the country, there are lots and lots of very small examples of that working where at the moment it's having to work against the financial system and we need to construct a financial system that means it works with the financial system.

Penny Pereira

Another example that we've talked about is Macmillan for example using social investment as a model for end-of-life care. So that's quite a large scale example that Macmillan are able to do. But as you say, there are still examples of individual initiatives, individual projects. Sometimes, for example, I think we'll find lots of things that are happening at the front line. 

I remember working with a diabetes consultant who had developed a completely amazing new model of care, really exactly the sort of thing that we'd be describing in the ten-year plan. And we got to the point of the conversation said, oh, and what are we doing about the commissioning and payment? And they'd literally kept it hidden from their operational managers. They were doing it despite the financial system. 

So I think we'll find quite a lot of those kind of pockets of work that are happening. But to come back to your first point, that's not going to be enough because we need to not be thinking about those few initiatives.

The big shift that I think we need to make in relation to improvement is stopping thinking about it as individual projects focused at particular domains of quality or safety or individual cost improvement projects and much more actually the main thinking very differently systematically about how to better use the resources at the disposable health services and then thinking from an improvement point of view about what methods we could use to make that more likely to be successful.

I think it's helpful to start with the financial incentives. The incentives need to be different, but I think often that's not the primary, certainly not the only block. Often people need to find a kind of different way through those challenges. So to use your elderly care example, there's good methods around understanding systems, improving flow, but they're still pretty underdeveloped in the health service. And until people can understand that there are processes you can go through that will allow you to redesign services properly, that in itself will become a credibility gap and can stop people before they dive into the more radical changes you're talking about and trying to do the transformation alongside delivering today.

Paul Corrigan

I think this is an absolutely central question for the future of the improvement movement. And for me, the problem with the improvement movement is it's become a movement around an abstraction called ‘improve’, rather than a concrete thing of what are we improving. And the way to move the improvement movement to the centre of the NHS is to have it to deal with the central problems of the NHS.

And to give the improvement movement a task. And if the task, if it doesn't succeed in the task, it fails. It fails as well as the NHS then failing. So if it's right and actually there are these immediate problems of money and waiting times, then actually it seems to me organisations need to give the improvement movement those tasks and say, it's not abstract improvement work, we want you to improve one of these two things.

And in doing that, in concentrating on something concrete rather than something abstract, I think my educational philosophy is people learn through the concrete and not through the abstract.

Penny Pereira

I guess I would challenge a little bit on that.

Paul Corrigan

I’d hope so. What’s a Popcast, if you don't have a challenge?

I didn't come along here to agree with you, Penny [laughs]

Penny Pereira

I would expect nothing less [laughs]. 

I guess just to say I think improvement is pretty pragmatic and focused on doing the work of solving particular challenges and helping by clinical and operational teams to do that. If it's not doing that, then it's perhaps not improvement. 

Now, there obviously is a layer that sits on both that that talks in more abstract terms about how we're going to achieve to do it, but that's not the real work of improvement. 

That's not the main reason I wanted to object to what you were saying, though, which is that I think we need to go a little bit further even in thinking about the improvement movement and a set of improvement specialists over here. That in a way cuts against this idea that actually we need transformation as a mainstream business of organisations and systems. 

I guess that's partly why it's exciting the partnership that we've got between Q, Confed, NHS Providers, actually starting to say the mainstream leadership of the NHS is embedding and thinking about their responsibility for improvement. 

And then yes, you'll have some improvement specialists, but the improvement movement needs to be all of us. It's not just this group of people over here.

Matthew Taylor

So let me ask you both a question going off the script. Who needs a script? 

I just want to give you an example, Paul, of something I came across yesterday. And I’m interested in your reflections around the role of improvement in a challenge like this. 

So I, yesterday, visited Specsavers in Sale. Greater Manchester has an autometry contract for the whole area, which is great. But one the things they were saying to me was that there really isn't any reason now why glaucoma should be treated in outpatient clinics in hospitals. It's perfectly possible for opticians to be up-skilled, perfectly possible for them to prescribe the drops, and actually we need to be getting to glaucoma earlier because you get to it earlier you can help. Now, why do we not do that? Well, we can imagine some of the reasons – there'll be a little bit of kind of professional defensiveness from certain quarters; if you're in a hospital and you've got budgetary issues, glaucoma is probably a profitable bit of work for you. You know, it's quite fast hungover, you get paid for it. Quite a lot of people end up going to A &E with eye problems. It was even suggested to me hospitals won't necessarily be opposed to that because they're quite easy problems to solve and it helps you with your four-hour target. 

So my kind of challenge, I know it's completely unfair, is when you think of a problem like that, we could just do this better and cheaper, better for patients, but there's things in the system that are kind of locking it. What's the role, first I'll ask you Penny, and then Paul, what's the role of improvement in unlocking a hard problem like that?

Penny Pereira

Firstly, I guess it gives you a language and a process for getting groups of people together to say, what's the best thing here for the patient? And to really surface some of those things that we know are happening. But until we actually map them out and explicitly show the impact that that's having, it becomes quite difficult to have the resolute commitment and then actually follow through. 

Now, some things like the example you give, those might be set at a national level. I think part of the challenge with improvement is that we've tended to think almost too much can be solved at the frontline. In fact, a frontline perspective is critical but actually a lot of these problems, if they are about national funding models then we need to solve the problem at that level. 

In fact an awful lot of the problems that you face within that particular thing, glaucoma care for example, that will be one of multiple problems that actually need to be addressed in order to shift the kind of practice around the care model.

So, back to what you were saying previously, if you can bring people together you can give them a system analysis so they can understand what the problem is. The most critical thing is that you actually then give them a path to making change happen.

Paul Corrigan

If you take that as an example, is how you mobilize the people that at the moment are doing X that you want to do Y, and in your case, in a totally different location. And for that, I think you need a whole range of change incentives. We were just talking before, some of which are external, which are to do with money. Some of which are external, internal, which is the way in which HR deals with that, and at the moment it deals with it very badly. Some of it are, again, external to itself, a clinical excellence award. 

When SpecSavers gets a clinical excellence award, other people think, ooh! that's the way of getting through the excellence world. And at the moment, we don't think about that because we think that's a different sort of thing. But actually, those are the range of incentives. 

And that then, for me, I always start from my previous experience with the NHS, that nothing works unless you've got a patient-facing narrative. Why are we doing this? And it's not that that means, ah, everyone suddenly do it for that moral reason. But without that moral reason, people stumble around with external incentives and don't really know the belief. 

So in a sense, the number of people with eye problems going into A&E is a moral incentive. Why are we putting up with it?

Other moral incentives, you mentioned Macmillan… fifty-eight per cent of the money spent on the care in the last year of life is unplanned care. That means somehow or another we have a system which is surprised, because it's unplanned, that in the last year of life you need care. That is very odd. Over the age of 90, the numbers of people going into A&E are about 90 per cent, not the whole population, but a very large proportion of people, we're surprised at the age of 90 that people need care.

When you start to talk to people about that, they recognise the scale of change is absolutely imperative.

Penny Pereira

Often we get stuck when we're making the case for investment for improvement efforts. Sometimes we're either a bit too hesitant about making any claims around a financial return or we go the other way and we feel pressure to make such heroic, ambitious claims about what the cash releasing savings might be that they fail to deliver and that then leaves a kind of legacy of scepticism. 

What would be your advice to leaders about how we think differently about incentivising the investment that's needed in improvement work?

Paul Corrigan

Well, to take your point, one of the reasons the claims for what will happen if you invest in me are so enormous is that it's a sort of… I come from a background, there used to be a thing in London called Whitechapel bartering, which is how the docker's got paid.

And so you come in and say, give us 30 quid, and some will say 3p. And you work it out in that particular way. And that is the way in which, by and large, if I will make a return on investment of 50 per cent, then actually, if it comes down… I think the way to get this incentive right is you will only get paid if you make a return on investment.

So that means you have to do it rather than just talk about it. And one of the things this is important about is the NHS over the next ten years will start a whole range of things, many of which will be very good. What it is in danger is not stopping doing things. Unless it stops doing things, it will run out of money.

Penny Pereira

So I completely agree, we need to get much better at learning to stop things and recognise that's partly a technical operational issue, but going back to what we talking about previously, it's also about clinical teams, individuals, letting go and adjusting very cherished care models and like trusting that the future is going to provide a good option for their colleagues as well as for their patients.

Matthew Taylor

I think we need to design improvement and innovation differently. One of my cliches is that if I had a pound for every time someone could show me something that reduced demand, I'd be a millionaire. If I had for anyone in the hospital who could say, we've got a bit of spare capacity now because they've reduced demand, I couldn't buy a pint, even in York. 

We’ve got to start designing these interventions across whole pathways. And you’ve got to say to them it's no good telling us you've reduced demand unless you can show me you've released capacity up here, which can then go back round and we can start to create a feedback loop with - why we're being so bad at that, Paul?

Paul Corrigan

Back to the point where we started off, that the incentives for each bit are entirely different. And there's no incentive for the hospital to have that spare capacity. So what happens if demand is reduced is that they change the acuity level, so more people come in.

Because they're not incentivised to have that - because they're kind people, there's somebody ill at the door they let them in. And if they are not as ill as someone they let in last week they don't notice that and so the acuity level at the door, there needs to be an incentive to keep that…

Penny Pereira

Yes, incentives. I think there's also something about the visibility of the system. The patient in front of the clinician is kind of most visible to them. But I often wonder if some of the amazing tech opportunities and potential that's in this room could be geared towards helping make the system as a whole more visible so that people had a better sense of all of the patient, not just the one in front of them. 

But I guess to come back to what we talking about previously, what we're looking for is kind of radical service shifts and radical changes. And I guess the risk with having to demonstrate a return on investment for a particular change that can drive people to put most of their effort into the short-term things where there's a clearer short-term cause and effect between intervention and response. And that might mitigate against people actually taking some of the bigger changes where the benefit may be more significant, but will be further down the line and perhaps be seen by somebody else in the system. 

The other bit I would add is that we could inadvertently come back to a model where we're thinking about the improvement movement as a kind of separate isolated group of people doing separate projects. Actually, I think the evidence shows that improvement should be considered a kind of essential enabler of a change process that also involves other capabilities - HR, commissioning, finance design, capital and estates.

So, for example, we talk about the huge potential of technology, we should be thinking about improvements as an essential enabler of the benefits realisation and embedding. And that, again, pushes you in a slightly different direction away from run your improvement projects, show that you can give a return to something that's a bit more holistic and I think gets to the 90 per cent not just the...

Matthew Taylor

Last word to you, Paul.

Paul Corrigan

Well, so it seems to me that's another example of what I said. There's a digital maturity index that the department and NHSE constructs, and it generally shows that the money that goes into, say, a EPR will be the money we spent, but the proportion of the EPR that's used is very minimal because no one's put in the work to carry out that change. 

And so we are buying tech and not using it. And that is not a good idea. So if the Treasury says, fine, here's a few billion quid on tech and we spend it, but only it gets used by 5 per cent because no one's actually doing the hard work of implementation. And that is a change issue and not just a tech issue.

Matthew Taylor

Paul, thanks so much for joining us and we'll talk to you again after the ten-year plan is published. 

But now we're going to layer on a kind of perspective from the front line,

Penny Pereira

So I'm heading off now to catch up with Amar Shah to learn about how East London Foundation Trust has resourced improvement and justified this investment.

So Amar, we've been talking about how to incentivise improvement efforts from a kind of national perspective. So you've worked at all levels in the health system, but for this conversation, I'm particularly keen to learn from you about how ELFT has approached resourcing improvement over the years. 

So let's bring the conversation in this podcast to the point of care where most change is delivered and benefits for patients. What have you learned you need to wrap around frontline team to implement improvements and what can you expect when you get that right?

Amar Shah

Well, improvement is inherently local. So even when you're thinking about national or system or regional level, you still need to think about what you're going to be able to wrap around the people that are actually best placed to do the improvement work. And over the last decade or more, what we've learned is that there are certain ingredients that people need to have around them to give them the best chance of success. And we've worked out that improvement skill needs to be as close as possible to where improvements happening. 

We've originally started with a central team of improvers, but very quickly within the first year back in 2015, we realised that wasn't going to be sufficient, wasn't close enough, not accessible enough. And the relationships were never going to be strong enough from a central team. So we've built a distributed network of improvement coaches, over 200 of them now, so that they are the first line of support. When a team wants to improve, they have someone close at hand who they know who maybe works in a neighbouring team, who has a little bit of time ring-clenched in their job plan to support them. 

But improvement support is not enough. They also need a leader who is responsible and accountable for that part of the system to be playing a much closer role as a sponsor. They also need a way to support patients and service users to get involved because that's not always easy. And they need a place where they can come together and learn. So for me those are the four ingredients. Improvement support, really close leadership sponsorship, a way to help get patients and carers involved in the work, and a learning forum where they can come and problem solve together and share their successes.

Penny Pereira

That's a pretty significant investment as an organisation in that way of working. Have you justified that?

Amar Shah 

It's an investment of leadership energy and organisational change more than it is an investment in money.

So you're right that we had to invest in some capacity from an organisational perspective to have some expertise to guide and advise and coach the organisation and all of our clinical leaders and teams through this. But actually most of the investment is coming from people who are just using their time in a different way. 

So this distributed network of 200 coaches, there's no extra money for that. It's a virtuous cycle of leaders recognising the value of improvement and investing time from their own people to develop into improvement coaches and give a little bit of time, maybe two or three hours a week to this sort of pursuit.

Penny Pereira

And then how do you think about productivity goals within that improvement work?

Amar Shah 

The productivity for me is almost inherent in virtually every type of improvement effort that we are doing.

It may not be the explicit goal and it may not be the word that is used in terms of people's language about how they describe the benefits of improvement, but almost every kind of improvement effort we do has some kind of productivity goal. Whether it's a safety improvement piece where if you avoid incidents occurring, you don't have to put all of the effort and resources into dealing with them when they occur. Whether it's trying to remove waste and inefficiencies from a pathway and finding better ways to meet people's needs earlier. Whether it's even thinking about equity and reducing some of the waste and disengaging from some certain communities. 

Almost every effort has some way in which it is saving people's time and removing waste from the system. But usually it's a by-product and not the goal in itself. The key thing is that we measure it, we sort of predict that this is what we expect to happen and that we find a way to measure it. Because if we can't measure the productivity gains, we're sort of missing some of the benefits of what we're seeing from improvement.

Penny Pereira

How do you think about measuring those gains in terms of the financial benefits, cash savings under the kind of pressures that organisations are under now?

Amar Shah 

Yeah, and you'll know that five years into our improvement journey at ELFT, we published a return on investment framework because we recognised that there was very little written in this field, particularly in the UK or European health economy. And so we've in that framework articulated six levels of return that we have seen from our work, one of which is productivity and efficiency. But actually there are others too, like cost avoidance and cost reduction as well, as well as income generation. 

And so what we encourage people to do when they're starting an improvement effort is to think really carefully about all the wider range of benefits they might see beyond the aim statement. They might be looking to reduce falls or pressure ulcers, but actually there's a wider range of impact that this could have and to think from the outset about how they would measure it, whether it's in terms of time saved, whether it's in terms of equipment not needed or used, whether it's in terms of potentially reducing some costs that they no longer will need in the future. 

There may be a whole range of benefits, but we've got to think about it from the outset and then capture it in a quantitative way.

Penny Pereira

We may have got into a bit of a challenge in the improvement world where we've almost like for a long time it was you weren't allowed to talk about the money or the financial benefits.

Amar Shah 

That's where we began. When we began this, there was a lot of scepticism about this in 2013, 2014. And so we intentionally avoided talking about costs or efficiencies. But we realised very quickly that, you know, our very first big effort around physical violence suddenly meant that all of our wards were managing within their budgets and they'd never been able to do that.

And we realised that there was an inextricable link between quality and cost. And we become more and more explicit about this. And ultimately, there's no other industry in the world, I think, where you have a management system or an improvement system purely around quality of service or product. That doesn't also deliver on the cost requirements. So we are more and more explicit about using our method for both quality and cost.

Penny Pereira

I mean if we're not upfront about that then we're not having an authentic conversation with staff and in effect you're doing your safety projects or your quality projects and then in a separate activity you're doing cost improvement work it doesn't feel like

Amar Shah 

The true management system should deliver the strategic goals of the organisation. Now you've got to remember though that not all cost reduction is going to be delivered through improvement methods. So there's a percentage of it that I think can be delivered through continuous improvement and the rest will need to be delivered through other mechanisms like structural change, like procurement, those sorts of endeavours that aren't really quality improvement.

Penny Pereira

Matthew and I were talking with Paul about the need for improvement and transformation to become embedded as mainstream business. You were talking about a management system. So you've been on that journey in ELFT. How has that impacted how you're doing things differently now, how you're thinking about resources in a different way from before you were?

Amar Shah 

So a few key learning points for me is one, I'm not sure you can begin this journey by thinking about an integrated management system. It's quite a big ask to think about integrating all of the pieces together from the outset. You have to start somewhere. And all of us have a management system. We have a way to do our work. We have a way to plan. We have a way to assure ourselves. 

The first step is really thinking about where's the balance we're playing across all of those components and how could we better balance? Where do we really get the greatest gain so we maybe need to think about pursuing a bit more effort on one area and then thinking about joining the pieces up. 

Now the key to all of this is leadership behaviours and you know one of the risks of this is that leaders have views and mindset about how to run an organisation and how to deliver. With the transition we have in leaders, one of the really key components to this sustaining is maintaining belief and narrative and real skill and understanding about how to lead in this way. 

Now that I think will mean that this sort of management system is never fully secure because you're always thinking about transition. You're always thinking about when, you the belief might need some strengthening.

I think it's hard to say that this is ever going to be embedded. It's a constant pursuit.

Penny Pereira

And linking that to our earlier conversation, I guess it's part of that leadership discussion, part of that leadership journey, the extent to which you think about having a quality management system or an overall organisational approach to policy alongside other aspects.

Amar Shah 

I think every organisation needs to think about the language that will fit for their own culture. For us, we talk about a management system, because I think if we started to introduce the word quality, our view is that it would disengage people who equally have opportunity to use the management system in pursuit of whatever they're working on that they don't think has a natural fit with quality. 

Obviously, quality for me is the organising principle upon which the whole organisation should work. But the language is important in thinking about how it fits.

Penny Pereira

Thank you. 

Many of the changes that we need to introduce, particularly thinking about the ten-year plan, they're going to span multiple organisations, they're going to involve thinking about value for the whole system rather than just for individual organisations. 

Where do you see the biggest challenges, the biggest opportunities when we start to think about improvement at that scale?

Amar Shah 

Well, I mean, over the last decade, the field has changed considerably from, you know, only a handful of organisations on this journey to now almost every provider organisation, at least somewhere on this journey of adopting improvement. And that means that the potential opportunities perhaps greater now between organisations and across organisations than it is within single organisations. 

But obviously to do that, you need to really think about the key components again about leadership. Are we truly leading in a common way that's going to support this kind of way of working? Are we creating the safety that enables people to learn and try changes differently? Have we got the data coming from different organisations to enable us to see where the opportunities and benefits might be? And are we learning and adopting a single method and language around improvement? So for me there are some ingredients that we need to build in the infrastructure if we're going to truly apply this at systems or across regions or even across the country.

Penny Pereira

Yes, we need both highly effective individual organisations that are feeling confident about their role in improving quality and then for those organisations to be thinking in system terms and as you say to have the additional components that...

Amar Shah 

And that's not easy, partly because coming back to the resources question, how do we find the resource and skill to do that level of work? Because it's harder than doing it in a single organisation. And I don't think the approach of just simply drawing on the capacity that exists in providers is going to be enough, because that's the capacity needed to work within the organisation. There's probably not a lot of spare improvement capacity that can be deployed. And you need a certain greater level of skill, I think, and expertise to do this across organisations.

Penny Pereira

Yes. Within Q we provide some mechanisms to help people think about pooling and sharing resource and skills between and across organisations. But I agree it's going to need something that's more substantive at greater scale and better resourced to enable the kind of change that's needed. Obviously there's a risk with the structural changes within ICSs in supporting that level of change.

Amar Shah 

But the challenges are similar. 

If you just take one example of mental health where we currently have a large program involving every single mental health provider in the country, 200 wards all working together and learning together around improving culture of care on inpatient units, that's for me a real prototype of what it could be like if we adopted improvement at scale, bringing people together and learning communities. But it's required some time to build the infrastructure to able to do that level and scale of work.

Penny Pereira

So this podcast is particularly thinking about the resourcing of improvement and the kind of investment case that needs to be made. I guess when you're talking about larger system changes, the benefits are often seen over the longer term, they may be seen elsewhere in the system from the place where people put in the work. 

Do you have any reflections about what might be most helpful, both at local level and nationally, to help us make the investment case for improvement work at system level?

Amar Shah 

I think the case is strong and it's growing all the time and I think belief in improvement is also growing. 

Two examples of how that's playing out is the really large-scale operational improvement training which is aiming to reach almost all band 6 to 8 A's and clinical equivalents of that across the whole country in the next year. That's improvement training of a scale that we've never really done in this country. 

Another really good example of people believing that this is the right approach is the board and executive development that we're just about to commission and then roll out over the next three years, recognising how important leadership behaviours really are. 

So I think people are believing that this is a way to solve some of our most complex challenges in the health and care environment. The real opportunities to think about stability and constancy of purpose, as Deming would have said. We've got to maintain constancy of this for a decade or more to give it any chance of embedding and becoming the go-to way for people to solve problems. And that's what we've had to do at ELFT. It's not by accident that it's taken us this many years to really feel like it's our way of working and our way of solving problems.

Penny Pereira

People will start with some belief but say with that exposure to the tools and methods and examples that will come through the training that you talked about and then the opportunity to put it into practice that's when that kind of belief and confidence will grow to the scale that we've talked about.

Amar Shah 

Yeah, and I think as an improvement community we need to get better at measuring the benefits and demonstrating the return on the investment. It's not enough to just work on projects that show isolated impact. You've got to then be able to demonstrate improvement at scale. And that takes a level of skill again in thinking about design and the infrastructure you need. But unless we can demonstrate we can do this at scale across an organisation and that is hard, it's really difficult to then make the case that we can do it across a whole system or a whole region.

Penny Pereira

Can I ask you one final question? What do you think would be most hopeful in the tenure plan when it comes out to give this work a boost?

Amar Shah 

Goodness, I hope that the ten-year plan reinforces the mindset that problems are best solved through people who have true lived and learned experience of what doesn't work and what might work better. I think if we adopt that mindset, then improvement is a natural vehicle for us to tap into that wisdom and help us solve some of the really big challenges we've got today. 

Penny Pereira

Thank very much, Amar. 

Matthew Taylor

We're back here now in the Confed podcast studio to wrap up this episode. Thank you to Paul Corrigan and to Amar Shah, our contributors to this episode, to our audience who've been listening, wrapped to the conversation as we record this at ConfedExpo.

Penny Pereira

You can find links in the show notes to discover more about the issues that we've discussed. And if you liked what you heard, please share it with others. See you next time.