Sophia Christie on helping the NHS to learn

The government of Ontario is working to identify health systems capable of rapid improvement and delivery. The NHS, specifically Birmingham East and North primary care trust, working with Heart of England foundation trust, has been assessed by 21 international health experts as exemplary.

The NHS has undergone a renaissance in reputation during the past five years, not least as a result of the Modernisation Agency's work in reviewing and adapting best practice (now sustained through Helen Bevan - and yes she should have been in the HSJ50). The clear target-based regime has provided benchmarks for performance and improvement.

This was borne out by the Canadian assessment of our local system, but it also highlighted some of our more counter-cultural activities. These elements will be key to learning in Ontario, but will they be picked up closer to home?

The NHS has learnt a lot from Kaiser Permanente - an organisation viewed as maverick, and indeed 'socialised' in the US. Ironically, the Canadian system, rather than the broader NHS may benefit from our learning about the value of purposeful organisational development, the partnership of managers and clinicians between organisations and a commitment to organising ourselves to meet the needs of local people.

Both the PCT and the foundation trust have invested in a model of formal clinical leadership that holds clinical directors accountable for delivery of core corporate goals and national targets and values a partnership between clinical and management colleagues. The organisations have consistently engaged each other in planning for the local health economy: the foundation trust built its first-wave application on a model of becoming smaller over time; the PCT approach to service redesign has consistently engaged hospital consultants in working with GPs and community staff to design services which make sense clinically and for patients.

The two organisations have nurtured local champions. We have supported them in developing clinical and improvement skills and given them opportunities to see best practice in operation. These are people who will be in the local system for 10-30 years rather than the increasingly truncated life cycle of the NHS manager. Large group approaches, which bring together a diagonal slice of the local whole system, provide an opportunity to spot talent and build capacity.

Although MPs meeting with the NHS Confederation about PCTs seemed convinced that service morale was at an all-time low, the Canadians commented on the 'palpable passion' for change they experienced in talking to front-line staff and the consistency of vision and message at all levels.

This change has been across the boundaries of health and social care, as well as primary and secondary care, with significant cuts in delayed discharges and the use of Health Act flexibilities to create integrated intermediate care services replacing four long-stay hospital wards. The Canadians commented on a 'population focused' approach which saw health improvement and tackling health inequalities as a core challenge for the whole economy, and in their view genuinely sought to design services around specific communities.

The whole-system and consistent organisational development has also meant individual projects can become mainstream practice, moving from the artisan intervention of GPs with a special interest doing well for 20 patients to the industrial scale of 20,000 patients having a faster, more effective experience in orthopaedic triage.

Given the legacy of ill health and limited primary care and community infrastructure in the area, this has been a real challenge.

The visiting team noted that the processes which supported clinical networking also had parallels for performance management and contract discussions, which brought together directors from across the organisations bi-weekly to review progress and discuss tensions on demand management and activity attribution.

These are real worries for local organisations: the size of many hospital clinical coding teams now equals more than half the entire management capacity of their local PCTs. Our collective handling of the arguments on N12s (maternity admissions that end in a cup of tea rather than a baby but are suddenly costing£461 rather than£80 as a ward attender), follow ups rising at the same rate as referrals diminish, and what is included in the tariff for a first outpatient will make the difference to whether PCTs are seen as having delivered on commissioning and, collectively, whether the productivity figures driven by new approaches to activity attribution mean we all get sent to the private sector in disgrace.

The final element has been shameless creative stealing. The organisations have collaborated on sending joint clinical teams to experience best practice elsewhere and have then supported them in adapting and adopting what has been seen locally. But the NHS as a whole is characterised by 'not invented here'. Four years on from Action on Orthopaedics, orthopaedics remains the specialty most at risk of failing the 18-week target, and there remain economies across the country, with one in 10 conversion rates for referrals and no systematic use of extended scope physiotherapy for assessment, immediate intervention and triage despite the evidence of it improving access and efficiency.

A key question, then, is can the NHS now learn to learn from itself? We need the NHS Institute for Innovation and Improvement to support that process.

And perhaps a useful local steal from the Department for Education and Skills would be Teachers TV - best practice goes digital, in your own home, when you can find the time to access it.

And finally, note to the DoH: none of the above would have been delivered if the PCT had been a commissioning-only organisation.

Sophia Christie is chief executive of Birmingham East and North PCT.