Making things better is less about the nitty gritty than values, leadership, will and skill

Both of us have spent much of the last 20 years talking to organisations about the improvement journey. Our experience is that while improvement requires some important technical issues, the day-to-day business of it is not really about technicalities. Rather, the drive for improvement over any length of time is about values, leadership, will and skill.

It is axiomatic to say the NHS is a values-rich organisation but the use of those values can be disappointing. They can be used as something to keep people warm on cold and difficult mornings rather than as shouted directions for action.

The improvement journey needs values as guides for difficult action and values which need to be mobilised as the common ground for action. If the improvement journey is to continue over time, it will need explicit explanation of purpose again and again and as a bedrock of values. It is this clear definition that then guides all activity and is at the heart of any successful organisation.

We have seen this in some of the recent achievements in the NHS. The Primary Care Collaborative, constructed by Sir John Oldham, worked with around 5,000 general practices to achieve change. This, initially, was viewed highly sceptically by clinicians. Yet asking crucial questions (are your patients happy with the status quo, are your staff happy, do you want to do a better job, is there a different way?) enabled the framing of actions that connected with hearts and minds and struck a chord with the underpinning values binding all those practices.

As the critical mass grew, so did the skills, knowledge and advocacy of the participants, the crucial activity being the translation of values and aspiration into plans for action in their workplaces. People heard from others how they had benefited from the change and wanted it for their patients and themselves.

The same effect was seen in the Australian Primary Care Collaborative and with those who helped deprived communities to improve their health, reduce the number of falls and improve nutrition in their areas.

Whatever their background or organisational boundary, what united them was wanting a better community. Professionals from housing and voluntary agencies shared this value with their communities and became peers and equal team members, creating improvement.

The shared purpose in the NHS, whether patient, manager, nurse or doctor, is to do the best for patients. But as a system and as organisations we still fall short and there is something very painful about that. We need to find ways of helping people confront that pain.

Courage to act

We suggest that if you want NHS organisations to improve, start by talking with patients and staff about the improvement of their care - and keep talking. Find out about their experiences, good things as well as failures, and do it not just once but all the time. Only then will you develop an understanding of how to change.

But this won't happen without leaders who grasp this first principle of a service organisation. There are many examples in the NHS of people and organisations that are full of values but fewer examples of those that live them. Having values means little for patients unless leaders have the courage to act on them and lead their organisations to act on them.

It was very obvious in the work Sir John did with schools on raising the achievement of underperforming pupils that schools where the headteacher and senior management team were completely engaged in the improvement process went further and faster than schools where they were not.

There remain leaders in the NHS who are immune to concepts of improvement or are even ignorant of what their patients think. It cannot be acceptable for discharge summaries to be four months late, or patients to be told that a consultant routinely starts his outpatients' clinic an hour late because he cycles in and then has a shower before starting.

Yet the leadership in some of these organisations seemingly does nothing - or does not know. As in every other activity in life there is variation in the quality of leaders, and we are naive if this surprises us.

In London at the moment, many primary care trusts are just recovering from acute financial problems, with their chief executives having been fully focused on the financial balance sheets. But at the same time, to provide something positive for their organisations and local people, there has been a continued focus on reducing health inequalities. Some PCTs in deprived areas are on track to increase life expectancy as they begin to catch up with England's average life expectancy. We need more of this.

People believe that improving organisations to deliver better services is easy because it is something that everyone wants to do. But this is not the case. People who make this happen need to keep driving forward and not worry about popularity.

This is the lesson we see from other industries. Toyota will tell you it continues to learn about and drive lean techniques 30 or so years after their introduction.

But improvement is a process, not an event. The next phase therefore needs to build on the significant foundation of improvement that has been laid during the hard work of the last decade. Capacity and capability in improvement techniques per se have dramatically risen to the point that flows, process mapping, redesign, and root cause analysis are common parlance and embraced by influential opinion leaders throughout the country.

To err is human

We have perhaps focused on the technical element to the detriment of the human element. Yet we know from work on creating reliable and safe organisations that it is an assiduous systematic approach to the behaviours in an organisation that make the difference. Behaviour affects patients; improved organisational behaviour improves patients' lives and leaders need to set the pace in both tone and style.

Improving behaviours now needs to be high on the agenda of the leaders of every provider of NHS services. This covers not only customer service training for frontline staff but a complete understanding of how our behaviours affect reliability and safety and the systems that can ensure it. This education should extend into induction, appraisal and ongoing training. Stories of incidents should be used to distil learning and make the process real. They should feature at every board meeting of every trust.

The real-time experience of patients should be factored into commissioning decisions for services. If there are consistent adverse experiences, commissioners must take this into account when considering the decommissioning of services. That really would be payment by results - as determined by the users of the service.

Most crucially we need to ensure that the personal development of leaders in the NHS includes systematic, formal understanding of how to create a service oriented, quality driven, reliable organisation. This should be required to achieve senior positions.

Over the last decade people, organisations and the NHS have come a long way in improving services and we need to understand that part of the journey in terms of the next phase of increased improvement.

Early on we learned that the possession of evidence-based knowledge of care was insufficient on its own, without the mechanisms to ensure implementation through improvement methodology. Facts alone changed little, even when they were very good facts, without a methodology of improvement like the collaborative.

In the same way, technical aspects of reform and improvement are also insufficient unless rooted in clearly expressed and meaningful values and purpose; meaningful both to staff and to the users of the service. Values and the behaviours that support them need to be acted out and championed by the leadership of an organisation for them to make a difference. Addressing the human factors of improvement are a crucial part of the equation. This is now where the task lies in the NHS; in values, in leadership and in behaviours.

Improvement in our behaviours needs to quicken until eventually there is an automatic culture of responsiveness to patients' needs and experience. We can then be safe in the knowledge that in each interaction every effort is made to maximise both clinical outcomes and beneficial experience for the patient while minimising the waste of human and financial resources of the NHS. And safe in the knowledge that if errors do occur (for to err is human), the organisation learns and gains for the future. It starts with the leaders.