System working thrives in a culture that empowers staff to improve care

System working (which includes health and care) is the only way the NHS can address the interlinked problems of struggling primary care, elective backlog, ambulance and emergency department overload, and delayed discharge.

With staff working at their limits, we cannot improve quality and productivity by running harder. But we can save time, improve outcomes, and improve the experience for patients by thinking and working as a system.

The integrated care systems have a vital role, of course, but they are simply a means to an end. There is no committee membership or governance structure that can deliver integrated care. Meaningful change only comes through changes to patient pathways.

Throughout my career I have made a point of learning from the best, at home and abroad, such as from the Canterbury District Health Board in New Zealand. Time and again I have seen that system working grows from the right culture, clinical leadership and systemwide data.

Empowering clinicians/professionals keeps the focus on delivery and outcomes

System working thrives in a culture of trust, openness, transparency and a sense of shared purpose. Canterbury’s staff try hard to put the patient at the centre of everything they do, thinking about the experience of services from the patient’s perspective rather than through the lens of their own institution or department. They use phrases such as “one system, one budget”, and have brought together a wide range of organisations including public, private, third sector and commercial bodies in an “alliance framework”. Clinicians are encouraged to engage across organisational boundaries and the system invites discussion with its communities, using approaches such as focus groups and lived experience groups to understand people’s needs and experiences of healthcare.

Integration ultimately depends on a culture which empowers clinicians/professionals to take ownership of the multiple challenges they face and find solutions. Organisations, and the system as a whole, should be clinically led and managerially supported. And clinicians means the complete range of disciplines and professions, not just a small group of senior doctors.

Boards, managers, and administrative systems need to help clinicians identify and implement new ways of working which break down barriers between different parts of the patient pathway, and make it easy for clinicians to communicate with senior managers and pitch ideas for improvements. As in Canterbury district, the mantra needs to be “high trust, low bureaucracy”. Too often, the NHS seems to embody the opposite – but our response to covid-19 shows what we can do.

The patient only benefits if we change the way we deliver their services

Empowering clinicians/professionals keeps the focus on delivery and outcomes. When all the power resides with senior managers, there is a danger of ambitious strategy documents which make big promises but fall down on the nuts and bolts of making it happen, which in turn undermines trust, confidence, and the sense of shared purpose. This is neatly summed up in the phrase “nothing changes if nothing changes”. In other words, the patient only benefits if we change the way we deliver their services.

Data is the blood that flows through the veins of an integrated system. Without joined up, real-time data, system leaders do not know what’s going on, and are unable to make informed decisions about everything from resource allocation to breaking down system barriers and improving safety.

Data should be joined up across hospitals, community services, primary care, ambulance services, and social care to understand how local people experience our services. When I worked at Cardiff and Vale University Health Board we used a system called “Signals from Noise” which took data from across our systems and linked it together using the NHS number and other routine identifiers to see how our residents used and interacted with our services.

Information should be gathered and analysed as close to real time as possible and the insights it delivers must be acted upon, otherwise the whole exercise is a waste of time. With comprehensive data and clinical teams, boards and managers can make decisions to drive improvements in productivity, safety, and service experience.

So system working depends on a culture that trusts its staff and empowers them to improve care. Data delivers the insights about where improvements can be made. Clinical teams feel they have the responsibility, power, information, and resources to make the changes that are needed.

None of this is quick or easy, particularly in a system under so much pressure. But system working gives us the chance to bring back some joy to our work, to see past the waiting lists to the opportunities to deliver better care for more patients.