Lessons from Implementation – after the crisis, what then?
Beverley Slater, Director of the Improvement Academy and co-Implementation Lead for the Yorkshire and Humber ARC, writes about the challenges of sustaining new innovative ways of working after the COVID crisis has subsided. Beverley argues that concepts from implementation science can provide a useful way of thinking about this.
It has been a revelation to many of us how easy it has been to make radical adaptations to the ways in which care is delivered when there is the urgency and common purpose of a pandemic to address. Many NHS staff have commented that initiatives they have been advocating and trying to get off the ground for years have been implemented overnight.
We all seem to be clear that some good things have happened but there is a sense of collective worry that these good lessons will be lost unless we act quickly to capture the new ways of working. Managing to capitalise on this and prevent sliding back into old ways as the crisis recedes and the old order begins to assert itself again, is something that is beginning to occupy the minds of health service leaders, policy-makers and academics. There is a sense of urgency about this. This blog draws on implementation science to help clearly articulate this concern and how we might address it.
Understanding what has worked well in health services
We could start by listing multiple individual innovations and adaptations, as indeed NHS England and NHS Improvement have started to do (for example Rastrick, 2020). This will surely be a helpful catalogue, but to focus only on the description of individual innovations might be to miss a possibly more significant point. Some of the innovations that have been implemented so quickly and to great effect, such as telephone follow-ups and video consultations, are actually well-known and not new at all. What has actually changed is the responsiveness of the system to allow rapid uptake of these innovations. Something about the COVID-19 crisis has transformed the conditions for implementation to transform the healthcare system to work in a different way. What has actually happened is a systemic change.
Some of the elements of this new system are captured in a Kings Fund blog by Susie Bailey and Michael West. They describe frontline clinicians exercising more professional autonomy, freed from hierarchy and bureaucracy. Healthcare staff are described as working with an increased sense of team compassion and belonging, supported by daily huddles, check-ins and other well-being supports. Bailey and West refer to more mutual and more respectful relationships with patients and an embracing of digital technologies.
A second recent article on a similar topic by senior health service leaders David Fillingham, Elaine Mead and Stephen Singleton (Health Service Journal, 8 June 2020) highlights that across the system there has been a sudden clarity about what actually adds value to patients, and that anything not adding value to patients (such as travelling, waiting, over-processing) is 'waste'.
Integral to this new system of working is the practical respect shown to frontline colleagues by their organisations by providing for basic needs including food, water, accommodation and car-parking. Staff are risking their own health through this pandemic and with that comes a new respect and empathy. Bailey and West observe 'compassionate and collective leadership' in evidence as managers and clinicians work collaboratively together. Fillingham and colleagues refer to this as managers learning to 'trust people who run the processes', having the 'courage to let go' and thereby 'creat[ing] miracles'.
What are the conditions that have enabled this rapid transformation?
Matching the clear focus created by urgency and shared purpose, the healthcare system, at both local and national levels, has responded by reducing bureaucracy (seen as 'red tape'), and removing routine performance management and inspections (seen as unnecessary distractions). Freed from these constraints, and with increasing respect for everyone's different roles, the health system has allowed leaders, managers, administrators and clinical staff to align their work and together become high-performing teams.
I asked Kristian Hudson, an implementation specialist within our own ARC implementation theme, what conditions were likely to have enabled this rapid response. He talked about a number of concepts found in implementation science frameworks. Firstly, 'tension for change': government guidance to the whole population meant that patients cannot be assessed in the usual ways. The degree to which stakeholders, both health services and patients, perceived the current situation as needing change intensified overnight – so an external policy has led to a strong tension for change.
Secondly, these changes have been seen pretty universally as important, so relative priority is high. Thirdly, compatibility of the innovations with the existing system is important. For example, telephone consultations can be easily fit into workflows and are not hard to implement. And finally, leadership engagement has been strong, nationally and locally, including tangible commitment evidenced in the availability of resources to undertake these changes.
All this means an implementation climate that shows a strong 'readiness for change', along with clear purpose, goals, and execution. These concepts will be important if system leaders, managers and clinicians want to maintain the gains that have been evident through this crisis period.
So what are the risks to maintaining this new system of working?
Post COVID, what will happen to video consultations, telephone follow-ups, and a hundred little innovations made possible by collaborative working? Will there really be a commitment to softer hierarchies, increased teamworking, prioritising 'value to patients' over attending to the requirements of performance management systems? Is it a realistic ambition for managers to want to give up control by command in favour of collaborative and compassionate cultures? And, if so, do we have the knowledge and expertise to help it to happen?
Revisiting the implementation concepts above, we can see that individual innovations to patient pathways which have been demonstrated, through experience of compatibility and ease of use, to have advantages to staff and patients may be retained. But managers who wish to keep focus and support at the frontline (such as coaching frontline staff to work in autonomous ways) and patient-focused care may find all the traditional challenges of doing so returning. Any call from NHS England for 'business as usual' in terms of performance reporting and inspections could create a new tension for change in the system where leadership attention and the relative priority is rebalanced towards externally-defined performance targets, and away from softer hierarchies, teamworking and collaborative management.
Just as before COVID-19, a more compassionate, collaborative management style will be in tension with the system requirements to prioritise, by whatever means, achieving performance targets. It will be through managers’ daily efforts to balance these that much of this debate will be played out.
As the ARC implementation theme, we are continuously learning with frontline clinicians, patients and managers about how our local research can improve healthcare for our communities. Our local health and care provider organisations have provided environments that are receptive and open to new ways of working during the Covid crisis – and we now want to support them to maintain that responsiveness in the coming years.
Bailey, S. & West, M. (2020). Learning from staff experiences of Covid-19: let the light come streaming in. Kings Fund. 9 June. https://www.kingsfund.org.uk/blog/2020/06/learning-staff-experiences-covid-19 accessed 16 June 2020.
Fillingham, D., Mead, E. & Singleton, S. (2020) The leadership task is to focus on creating high performing teams who communicate well about the basics and then the task is to just let go. Health Service Journal. https://www.hsj.co.uk/leadership/stop-sending-happy-clappy-newsletters-and-go-and-listen-to-staff/7027791.article 8 June.
This is an adapted version of a blog published on the Improvement Academy website in June 2020.