“Defining the questions and solutions together” – an overview of NHS England’s national quality improvement project

NHS England has published a resource guide for co-production and quality improvement, following a project in which they collaborated with various trusts and organisations across the country to review the quality of care and patient experience in primary, secondary, acute, mental health and community services.

Why do we need quality improvement?

The project emerged from a desire to understand how organisations can better align quality improvement (QI) and improving experiences, two areas generally viewed in separate siloes within NHS organisations.

The project was led by NHS England’s improvement directorate alongside the Initial Advisory Group, people with lived experience, We Coproduce, NHS provider staff, Health Foundation, The King’s Fund and Coproduction Collective (University College London).

The team conducted a deep-dive into the following organisations: East London Foundation Trust, Humber Teaching NHS Foundation Trust, (Belfast) South Eastern Health and Social Care Trust, South London and Maudsley NHS Trust, Tower Hamlets Clinical Commissioning Group and Western Sussex Hospitals Trust.

The study states that their “shared starting point” was recognising that co-production is fundamentally different from previous forms of engagement, in that it acknowledges that people have strengths, assets, resources and networks that extend beyond their title or ‘position’ within a system.

NHSE states that co-production is crucial to ensure change, improvement and transformation emerges from the user’s needs and what matters to them the most. It also allows communities to step up and share in the decision-making processes which shape health and care services.

What happened?

The team began by conducting a literature review to get a feel for how the experience of care and co-production and quality improvement could be better aligned. They asked the following questions:

  • What evidence is there about how co‑production is used to improve the quality of services and people’s experience of care?
  • What makes co‑production successful?
  • What are the challenges and barriers in using co‑production to improve quality of services and people’s experience of care?
  • How does co‑production work in different settings/situations, and for different groups?

Themes and recommendations

The team identified common themes and were able to co-produce some practical recommendations based on their findings.

From a system level, they suggest giving attention to improvements in people’s experience rather than purely focusing on clinical outcomes. Organisational requirements will involve strong senior leadership commitment and necessitates the rapid translating of co-production outputs into strategic decision making.

The other key recommendations suggested were:

  • Identify and build capacity – developing peoples capacity and confidence to engage in co-production
  • Engage the right people at the right time
  • Ensure relevant communities have a say in priorities
  • Communicate openly and formalise participants’ roles
  • Make it easy for people to contribute, be valued and have their input respected
  • Share responsibility for delivery of the changes and outcomes
  • Co-production values different forms of knowledge – ensure narrative approaches as having equal weight to traditional, quantitive evidence
  • Value all perspectives

Key findings

During the project’s deep dive into the aforementioned six organisations, they found that in order to improve together, an intentional shift in culture to align co-production with quality improvement was needed.

“Going beyond one formally responsible director to full board ownership” and “being comfortable with the uncomfortable” were some of the key reflections from the study. They found that strong leaders need to explicitly align co-production and QI priorities together as part of an organisation’s strategy.

They acknowledge that whilst cultural change can be uncomfortable, leaders should model being comfortable with discomfort and embrace it as a natural part of the development process.

Starting from what matters to people

The team discovered that far too often, QI projects are determined by senior management, when true co-production necessitates a joint approach for defining improvements.

The importance of “defining the questions and solutions together” and “using improvement methodologies to focus on what matters to people” were the biggest take aways from this area.

Co-production at the heart of quality improvement

The team concluded that rewarding people with development opportunities and “proper reimbursement” is important during the process of quality improvement. “People with lived experience and staff who are co-producing quality improvement projects should have the opportunity and space” to learn and develop in their roles, the study says.

Power sharing was identified as another key driver for improvement, particularly being reflexive of the process itself and not just the outcomes. The study notes that “taking a curious and reflexive approach allows for a non-defensive exploration of why people may resists sharing power and building new and different types of relationships.”

Nurturing capability, the study found, will involve an assets-based approach and a wide-scale focus on capability building, as well as long term sustainability. The study states that “building networks between organisations and communities can enhance sustainability along with sharing of knowledge and learning.”

Community, system and organisational alignment must involve both the system and community level working together to fully align co-production and QI at the organisational level. The team summarised that promoting and leading capability at a system level and ensuring organisations are connected with communities will facilitate co-production and community-initiated ideas.

Final thoughts

The team are currently awaiting a response from the Quality and Innovation Committee at NHS England, who are working to actualise the cultural shift that is required to improve the way organisations co-produce in the delivery of healthcare.

The “critical ingredients for change” outlined in the project’s summary are co-production as default, leadership for innovation, prioritising reducing inequalities and innovation-friendly environment.

If you would like to learn more about the co-production project, please click the link here.