How research can support challenged NHS organisations to improve
With his review of maternity improvement initiatives recently being published in BMJ Quality and Safety, we caught up with Dr James McGowan and asked him about his fellowship project, which aims to help shed light on the particular features of healthcare organisations that may make them more likely to find improving quality and safety of care more difficult.
Why were you drawn to this area of study for your fellowship?
As a public health doctor, I see the issue of struggling NHS organisations primarily as a public health problem. Avoidable harm affects large numbers of patients who use the NHS, disproportionately affects marginalised and vulnerable groups, is open to improving evidence-based approaches, and is best understood through a multi-disciplinary lens. It’s also about values: I believe that everyone is entitled to receive good quality healthcare, no matter what their background is or where in the country they live.
My fellowship is focused on maternity services for several reasons. Maternity has a long history of high-profile organisational failures and patient safety concerns, and public inquiries into these failures have often included accounts from women and families who feel they have been unfairly treated because of their ethnic or socioeconomic background. In England, around two-thirds of maternity units are currently rated as either inadequate or needing improvement by the Care Quality Commission. Partly because of this, maternity services have been subject to a very large number of improvement interventions over the years, making them an important setting in which to investigate the effects of improvement initiatives, including exploring why some organisations and services may be less well placed to improve in response.
What is something you have been surprised to learn over the course of this study?
The first thing that surprised me was how longstanding the issue of organisational failure in the NHS has been. When you look back at NHS history, there have been concerns about performance in healthcare services stretching back to the 1950s – the first modern inquiry in response to organisational failure was the Ely hospital inquiry in the late 1960s. That really stood out for me: this has been going on for a very long time.
The second thing that surprised me is how little is understood about the problem. Despite a number of public inquiries, and the political and media attention that has been paid to them, we don’t appear to be much closer to understanding how we can effectively address these recurring failures. That’s one of the motivations for this project – to try and contribute to the evidence on how we can better understand the underlying causes of vulnerability to failure at organisation and service level. We could then be in a better position to understand how to better design and tailor interventions to these challenged settings in a way that addresses their distinctive needs.
How did working maternity staff and clinicians, policymakers and other stakeholders influence your project?
For this research I aimed to capture the views and perspectives of three different groups looking to understand different components of the problem. For a complex issue like this, it was important to engage clinicians, staff and managers in NHS organisations, to better understand what the local barriers to improvement were, and what constraints staff were subject to locally. It was also important to engage policymakers to understand their perspective, particularly in relation to optimising the large-scale improvement efforts that are so prevalent in maternity. Finally, I engaged researchers with expertise in evaluation of at-scale improvement initiatives to help me better understand gaps in evidence and evaluation.
A key influence on this work with stakeholders was appreciating the complex circumstances of challenged organisations and services, including their distinctive barriers to improvement. Also, my research highlighted the extent to which trusts and services vary in their local conditions, whether that be with regard to digital capabilities, the strength of their clinical governance, their infrastructure or their staffing model. This presents a unique challenge when designing improvement initiatives as they need to cater to a huge amount of variation in how services are set up and delivered.
What is next for you in your fellowship project?
So far, I have focused on understanding what the key sources of variation between clinical services are, how they undermine or support improvement processes, and how they can make responding to interventions more difficult for challenged services. The next step for my fellowship is to develop a framework for optimising the quality and design of improvement interventions, with a particular emphasis on how they can be tailored to best support challenged organisations, and with a view to testing and evaluating its implementation. This could initially focus on maternity services but would have broad relevance for the design and delivery of improvement interventions across the NHS.