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Using co-design to drive a new improvement culture

Rebecca Palm NHS Leadership Academy 15 December 2016

Rebecca Palm argues that the primary focus for quality improvement should be enabling compassionate care rather than making cost savings.


As part of the NHS Graduate Management Training Scheme I was recently fortunate enough to spend some time working with The Point of Care Foundation. I was exposed to new ways of thinking and new methodologies for Quality Improvement.

A particular focus of the Foundation is engaging patients and improving their experiences. I appreciated the fact that the organisations working with The Foundation are not looking at patient engagement as a tick box exercise. It’s not just about talking to members of the Patient Participation Groups, but also about reaching disengaged patients to obtain a broader picture of what can be improved.

One method I encountered is experience based co-design (EBCD), where staff and service users work together to identify needs and plan services. The experiences of patients, carers and staff are explored through interviews, observations and group discussions. Both positive and negative ‘touch points’ are identified and used to drive quality improvement that’s important to all stakeholders.  EBCD is a cyclical process that promotes continuous engagement and quality improvement, which, by its very nature, makes a long term commitment to this way of working necessary if it is to succeed.

Initially, I was skeptical of how successful EBCD can be given the current financial state of many NHS organisations and the pressures staff already face. However, after attending the training workshop, I was inspired to re-evaluate this way of thinking. My previous role working as a Service Manager was very challenging at times; I felt caught between the needs of my teams and the needs of the organisation. Staff-led ideas for quality improvement were innovative and showed the desire they had for improving patient care. However, many such projects, though sensible and appropriate in every other respect, were not feasible because the resources were not available to support them.

If EBCD becomes a part of NHS culture, I think it could offer a way of driving quality improvement from the bottom up that leads to better use of available resources, through prioritising projects that are of importance to both staff and patients. Quality Improvement work needs to become less about quick fixes and cost improvement plans and more about delivering a high standard of care in a sustainable way. Delivering quality care will ultimately support financial sustainability.

It is important to understand other barriers to quality improvement. Yes it will never succeed if senior management will not support such working, but clinical engagement and leadership is just as vital for this work to be successful. It appeared from stories shared at the EBCD workshop that it was not uncommon for clinical staff to initially not want to engage in such projects. This reluctance may stem from previous experiences where feedback has been perceived as criticism or an attempt to blame the clinical team for a particular issue.

As a manager, I have to appreciate that staff often feel as frustrated as patients by the systemic problems with a service. It’s quite reasonable for a clinician to be apprehensive about sitting down in a room with a group of their patients to discuss their experiences. It is important to share not only negative feedback, complaints and what needs improving, but also what works really well and the praise many patients share during this process.

EBCD creates a platform for staff to better understand their patients’ needs but it also provides an opportunity for patients to better understand the role of their clinician and the environment they work in. My experiences working with clinicians over the last year have changed my perspective as a patient. Whereas before I blamed front line clinical staff when my experience was frustratingly affected by seemingly pointless and ridiculous bureaucracy, I now recognise a lot of this is out of their control and I want to help and work with clinicians and other NHS staff to continue to deliver excellent patient care within a system that helps rather than hinders them.