Stepping good practice up a gear
Health innovation and education clusters have proved invaluable in teaching us about delivering improvement at scale and pace, say Robyn Hudson and colleagues.
The NHS has been criticised for failing to adopt good practice at scale and pace. This failure contributes to variation in the quality of care received by service users, missed opportunities to improve how healthcare is delivered, and poor health outcomes for populations.
Seventeen Health Innovation and Education Clusters were funded by the NHS in early 2010. They sought to address this deficiency through collaborations between primary, secondary and tertiary care, higher education, the third sector and business. The North East London, North Central London and Essex (NECLES) HEIC achieved some success and provided significant learning. This can be applied to the NHS as a whole, to emerging academic health science networks that seek to translate research into practice, and to organisations around the world trying to deliver consistently high-quality health services.
The NECLES cluster was active for two years, covered a population of five million and counted more than 15 trusts and six HEICs as partners. It was organised along three broad clinical themes:
- long-term conditions - chronic obstructive pulmonary disease, and asthma in children and young people;
- acute care - promoting glaucoma pathways and normal birth; and
- prevention - cardiovascular disease and migrant health.
After assessing the numerous projects that took place over the two years, four factors emerged that were clearly linked to success:
- clinical academic leadership;
- collaboration across sectors to make good skill and knowledge gaps;
- data coupled with an educational offering; and
- an entrepreneurial approach.
The most powerful feature of successful projects within the NECLES cluster was clinical-academic leadership from the HIEC facilitator and fellow. The facilitator was usually a respected clinical academic leader in the relevant field. The fellow, while less experienced, also had clinical and managerial credibility, focused on patient benefit at scale. Both acted as advocates for each area of focus. Success in these roles was dependent on a visible passion for improvement, a focus on delivery, and a system-wide approach.
The attributes of these staff allowed the development of networks and communities that transcended organisations, sectors and professional boundaries. For example, the maternity team, led by two midwives, worked with clinicians across 12 maternity units that spanned the full geography of the NECLES cluster. The team developed a community of practice that made it possible to challenge improvement plans and data sharing. This provided an easily accessible network of support across all organisations.
The overall outcome was that there were 900 fewer caesarean sections in 2010/2011 than the year before.
Another community of practice delivered self-management and rescue medication packs to people admitted for acute exacerbations of COPD. This led to fewer readmissions. Overall, the clinical leadership, can-do attitude and patient-centred approach of the NECLES team delivered effective collaborative networks at scale.
The second success factor was to collaborate in a way that addressed skill and knowledge gaps. With partners from all quarters of healthcare, it was possible for the NECLES team to bring like-minded people together for innovative projects.
For example, the cluster developed an android app with the help of an expert app developer, building upon a self-management information folder for young people developed by a leading clinical team. While the content was identical to traditional self-management material, the channel was attuned to children and young people. In the first three months, 200 people downloaded the app, demonstrating more effective penetration than channels dependent on paper and clinician contact.
Other cross-sector collaborations included work by health economists to give rigour to evaluation, and expert knowledge on new ways of working provided by industry.
For example, pharmaceutical company Novartis UK and NECLES sponsored a creativity event. The day brought together clinicians, business leaders in the creative industries, and third sector leaders, and explored ways to identify symptomatic but undiagnosed people with COPD. As a direct result, a trial of respiratory screening in heart failure clinics was undertaken. It was found to be a successful strategy for case finding people with COPD. Twenty nine per cent of eligible patients were referred for respiratory testing, which is more than achieved by standard case finding in primary care. These collaborations beyond the NHS freed and revitalised our approach to innovation and improvement.
Good-quality data was the third crucial factor in project success. At every juncture current and relevant data was made available to teams so that progress and change could be mapped. When coupled with educational support, data collection and analysis was seen as a mechanism for improvement rather than performance management.
For instance, we found that in nine primary care practices, up to 36 per cent of patients had not used spirometry testing as part of their initial diagnosis of COPD. This called into question the validity of the diagnosis. This data, shared with primary care at practice level and coupled with provision of a spirometry course through a local HEIC, was a potent spur to improvement. Participant practices were also offered direct one-to-one nurse-to-nurse mentorship.
Similarly, the glaucoma team linked data with educational opportunities to improve the skills of local optometrists. This reduced inappropriate referrals to expensive ophthalmology glaucoma services. It is clear that giving data to practitioners and providing them with meaningful support to improve can lead to significant patient benefit and a more efficient health service.
An optimistic and entrepreneurial approach was the final success factor. Decision-making was devolved, which saved time, allowed decision-makers to learn from occasional failures, and helped them to keep delivering at pace.
Opportunities were constantly sought to capture and harness resources as they became available, whether money or people. For example, one of the HEICs required a placement for post-graduate nursing students, and we embraced this resource. We trained the nursing students in discovery interview techniques and asked them to interview 90 people with COPD. This has led to a patient-reported experience measure currently subject to validation. The ability to be nimble and to spot opportunities amplified the work possible within the two-year lifespan of the NECLES cluster.
The NECLES experience demonstrates there is significant appetite to deliver improvement to the system through networks and collaborations, strong clinical leadership at all levels and a broad commitment to act for the benefit of the whole population.
Robyn Hudson is director of strategic development at UCL Partners and managing director of NECLES HIEC; Professor Christopher Fowler is director of education at UCL Partners and chair of NECLES HIEC; Dr James Mountford is director of quality at UCL Partners.
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