Published: 08/04/2004, Volume II4, No.5900 Page 31
The NHS is conducting a phenomenal volume of service improvement work. The Modernisation Agency recently commissioned research in a number of health and social care communities and found 250-300 improvement projects were being undertaken in each.Yet we could still develop better, faster, more sustainable outcomes for patients.
Making better, more explicit use of theory would help. Another research study concluded that, even in NHS organisations with a strong track record of improvement, there is little reflection, hypothesising or consideration of alternative actions before embarking on change processes. Rather, teams decide on a specific course of action and jump straight in to make changes.
When we mention theory, most of us think of academic theory, yet each of us uses our own 'theories of action' to guide what we do every day. They dictate the design and implementation of all our improvement activities. If we are explicit about our underpinning theory, we create more opportunity for examination, understanding, learning and effectiveness.
A prevalent theory of action which drives NHS improvement is 'scalability'.
This means starting with a small number of projects and groups of patients, and spreading or scaling changes to multiple settings and many patients.
The evidence suggests that scalability does happen. It works best in situations of low complexity through a process of peer-to-peer spread.
However, there is variance in the extent to which people buy into the scalability model and undertake the change process. A plethora of small projects do not typically scale up to whole-organisation change.
In general, NHS improvement work is under-conceptualised. The next stage of the NHS modernisation journey is about making improvement mainstream: transforming patient care by building improvement into everyday work at every level of the system. The theories of action we are using are insufficient to get us there.
We need to strengthen the theoretical base which underpins our improvement work, particularly focusing on theories for wholesystem change.We should explore existing theoretical models and develop and test new ones. Social movement theory provides insight into ways in which we can mobilise and liberate NHS staff around the goal of better patient care. Some promising new directions are emerging. Complexity theory helps us understand the structures, processes and patterns in change. Theories related to queuing and flow, traditionally used in manufacturing sectors, can help smooth the patient journey around the health and social care system.
Let's be explicit about theory but understand that theory alone will not make a difference. So, the next time you devise your chronicdisease management strategy or orthopaedic inpatient plan, understand that you are basing your approach on a set of theories about interventions and consequences. Are your theories adequate?
What else is needed? How will you test them? This process of understanding and learning does make a difference.
Helen Bevan is director of knowledge and innovation, Modernisation Agency
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