For the last two years, the Government has set a target for Urgent & Emergency Care performance in March of 76% and 78%, respectively. Each NHS organisation would have been asked to submit a trajectory of how they were going to achieve this, no matter what their baseline might be, and action plans would have been produced to support them accordingly. 

Inevitably, there will be a variation in how close each organisation was able to get to achieving this target – whether it’s the right target or not is a discussion for another day. The question we should be asking ourselves now is, for those that were able to make significant improvements, what did they do differently, and how is it being sustained?

We can’t speak for every Hospital, but we have been involved with organisations that have seen substantial improvements in recent months and years. Fortunately, there are some common themes to draw on.

The first thing that the NHS organisations we have been involved with did was to allow the improvement initiatives and plans to be designed, developed and therefore owned by the teams on the shop floor. Quite often, we see plans written in a room by one or two people, usually in a senior leadership role within a division or even the Executive team. Whilst it is understandable why leaders may feel their position demands they write the plans, the top-down approach in this context probably doesn’t help yield the most sustainable outcome. Indeed, it can often end up with disillusionment or lack of buy-in from those who actually do the doing.

The above is then complemented by reducing the number of things teams try to change and improve. When developing an improvement plan, it’s easy to want to solve all of the problems, especially when there are so many contributing factors, people involved and pressure to improve. A plan that starts with a few bullet points can soon turn into a behemoth with the smallest tasks and activities recorded in an attempt to cover all the relevant ground.

Improvement plans in UEC: A whole pathway approach

NHS organisations need to ensure that improvement plans for Urgent Care have an emphasis across the whole pathway, as opposed to placing the most (if not all of) the weight on the ‘Front Door’ teams – something my colleague Katie Johnstone addresses in her recent blog; is also critical. Dovetailing this is ensuring the improvement framework, set up to govern any programme of work, is understood by teams and given the time and energy needed to become established. Often we find local/isolated plans with some grip and channels of accountability, sometimes with individuals who have gained some improvement methodology experience, but silo working can quickly emerge in these instances

The key is having something that links the pathway together to not only create a whole hospital responsibility for the solution but also to ensure the interdependencies are clear and managed accordingly. The positive consequence of having such a framework in place, in our experience, is that each element starts to believe that they’re not in it on their own. For example, a great deal of motivation can be garnered from an ED Matron hearing and seeing how the Discharge Coordinators are rolling out an initiative to improve patient flow.

The improvement framework is not something that needs to be overly complicated, but it does need to be set up and facilitated effectively to drive improvement.

Then we come to the who. Who are the right people to lead and deliver the above? Whilst some areas might seem straightforward – the Clinical Lead in ED would likely have a role in the delivery of ED improvements – other elements of the pathway might take a bit more thought.

Five ways to structure a programme

Below are some thoughts on how you might structure a programme to address some of the challenges mentioned above:

1: Build it from the bottom up: The teams will likely know what improvements will support patient flow. Some may need investment and additional support from the leadership, so they need to be considered in terms of priority and timeframe. Giving the teams the opportunity to develop their own initiatives will empower them, motivate them to want to deliver and create a far greater chance of sustainability.

2: Less is more: Staff usually know what their challenges are and what needs solving.  Establishing the top 3-4 priorities can be harder. However, if these can be identified, ideally using data to evidence the need and potential impact, it can start to make a difference. It also helps to structure a programme if each area follows a similar process to identify and prioritise high-impact areas. 

3: Keep a simple structure: Build an improvement framework that is simple by design and has clarity on what each forum is there to achieve.  The terminology will differ depending on where you are, but to highlight a simple format:

• Improvement Board – highest forum of governance. Should receive highlight reports with clear, concise updates on progress against milestones, impact on KPIs and escalations to be mitigated/unblocked. It is also where each element of the pathway can share with the other.
• Workstream – covers an element of the pathway (e.g. Emergency Department Flow). Provides leadership and a point of escalation for each improvement initiative. Houses discussion around what needs to happen to progress and agrees what the asks are of Board.
• Project – where the doing gets done. A project should represent an improvement initiative and be clear on what problem it’s trying to solve, what good looks like as an outcome, who is involved, what the measures of success are and when it expects to see an impact. 

4: Look for effective leaders: leadership doesn’t just exist at the ‘top’ of an organisation. Everyone can be a leader in their own domain, and quite often, it’s the leaders within the workforce that will make the biggest difference when it comes to change and sustainability. Whilst a workstream may require appropriate Medical, Nursing and Operational leaders to steer and unblock barriers, the change champions can come from anywhere within the workforce.  A band 7 Nurse, with the right support, can deliver an immense impact and bring their colleagues with them. As can a Junior Doctor or General Manager.  The ability to find and empower these individuals might make all the difference in the long run.

5: Give it the right support: Quality Improvement teams can be under similar pressure to other staff in terms of capacity. Instigating the above can help streamline how they might support, and it’s critical that they are involved from the outset.  That might seem an obvious statement, but you can also find improvement teams taking on the responsibility of designing and formulating the plans. It’s a balance, but the greatest impact often comes from adding capacity to the project teams, driving the weekly drumbeat and being the conscience of the programme.

Enhancing NHS Urgent & Emergency Care performance has shown numerous key variables that lead to success. Successful organisations have simplified their improvement plans and prioritised a few important areas rather than trying to fix everything at once. Frontline worker ownership and motivation lead to more long-lasting changes when they build these plans.

As the NHS strives for better performance, it must learn from those who have excelled and implement these concepts widely to ensure that improvements are made and sustained.