Health CommitteeWritten evidence from The Health Foundation (ETWP 103)

Summary

Today’s health services require that health professionals learn improvement science, so that the continuous improvement of healthcare is rigorous, systematic, reproducible and based on best evidence, and that their approach is reoriented to share power with patients.

This is a fundamental change which demands a significant shift in both the content of education and training and in the way that it is taught.

HEE has a key role in acting as a champion for change across the education and training system. LETBs need the knowledge and skill to commission education and training for quality improvement.

This submission draws upon learning from our research and programmes.

1. Introduction

1.1 The Health Foundation is an independent charity working to continuously improve the quality of healthcare in the UK.

1.2 We want the UK to have a healthcare system of the highest possible quality—safe, effective, person-centred, timely, efficient and equitable. We believe that in order to achieve this, health services need to continually improve the way they work.

1.3 We are here to inspire and create the space for people to make lasting improvements to health services. Working at every level of the system, we aim to develop the technical skills, leadership, capacity and knowledge, and build the will for change, to secure lasting improvements to healthcare.

1.4 The Health Foundation welcomes the inquiry by the Health Committee. Our submission, based on our research and experience of supporting healthcare professionals to improve healthcare quality in the NHS, focuses on the questions of ensuring:

the training curricula reflects the changing nature of healthcare delivery; and

the existing workforce can be developed and reskilled for the future.

2. Why Improving Quality Matters in Education and Training

2.1 In order to provide patient-centred, safe care and provide value for money, health professionals need more than clinical skills; they also need to be developed so that as well as providing high quality care now, they are also developed in how to continuously improve healthcare quality.1

2.2 Traditionally, professionalism has been seen as a quality of the individual clinician; health services today require a new professionalism with changed relationships between healthcare professionals and patients, other health professionals, and the health system.2 We need to develop a workforce that:

embraces improvement science alongside evidence based medicine;

seeks to constantly improve the quality of their own practice and the practice of the team and the organisation;

takes responsibility for the patient journey, not just the consultation, and does so collectively with colleagues; and

works in partnership with patients, for example making decisions with them rather than for them.

2.3 This demands a significant shift in education and training with:

curricula and training that develop competence in improvement science, systems thinking and motivational training, and a willingness to adapt practice to the needs of the patient and to take responsibility across the system;

a rapid expansion of multi-professional education and training; and

a greater role for patients at every level of the education and training process to help drive an understanding of the patient as a person.

2.4 We should not underestimate the demands this will place on a highly qualified workforce—trained as experts and as carers, who understand their responsibility is to intervene and take responsibility for curing illness—in order for them to shift towards this new way of thinking, feeling and working. The process cannot be taken for granted. It requires strong partnerships between the organisations that determine curricula and exams, service organisations and academic institutions so that learning and training is rooted in best evidence from hard and soft science and evidence from practice. LETBs and HEE must consciously use their leadership roles to develop and model a different mindset; one that values patient autonomy, is open to non-traditional academic learning and methods of teaching, and respects inter-disciplinary and inter-professional working. The measure of success of the new architecture will be the extent to which it delivers these changes.

2.5 The government’s proposals set the ambition to ensure a continuous improvement in the quality of education and training. The skills to continuously improve quality of services must also be a focus of the education and training for health professionals.

3. Skilling and Re-skilling the Workforce for Quality Improvement

3.1 To inform our response to the Committee, we commissioned a rapid review of published information about training in quality improvement. It identified that:

the focus on quality improvement is less explicit in undergraduate training in the UK and there appears less integration of quality improvement concepts into pre-registration courses, than in other countries;

there are diverse conceptualisations of quality improvement, and content of courses and approaches to teaching vary widely;

whilst outcomes such as patient-centred care or outcomes may be talked about, formal techniques for implementing improvement are less pervasive;

most training of students is unidisciplinary; and

education tends to operate within a change management paradigm, focused on making one off improvements, rather than training in how to think critically about improvement and how to continuously improve health services.

3.2 There are some signs that things are beginning to change, with some undergraduate modules addressing critical appraisal, measurement for improvement and quality assurance. There are more signs of development in CPD, through the work of the NHS Institute for Innovation and Improvement, Workforce Deaneries, Leadership Academies and SHAs. HEE must ensure not only that progress is not stalled, but also that momentum is built so that all LETBs, regulators and professional bodies pull together to rapidly extend the opportunities for the workforce to acquire knowledge of improvement science and skills in continuously improving quality.

3.3 Whilst everyone in the NHS needs to have a basic knowledge of improvement science, not everyone needs the same level of skill in applying it. NHS Scotland’s Quality Improvement Curriculum Framework may provide a model for appropriately skilling the workforce according to their role. HEE could provide the leadership and space to develop a similar framework for England which would inform LETBs’ education and training commissioning.

4. Skilling and Re-skilling the Workforce for Working in Partnership with Patients

4.1 To realise a genuine shift in the dynamic between patients and professionals will require supporting clinicians and patients to move towards a new relationship, characterised by collaboration.3 , 4 Training needs to reorient and re-skill professionals to take a supportive, power sharing rather than a caring, power holding approach, developing the skills to increase patient activation and use of information. This is not just about adding a new set of clinical skills to the curricula, but a fundamental change in what it means to be a health professional, requiring leadership from HEE to bring together the professional, educational and service stakeholders.

4.2 Involvement of patients and carers in education is patchy, particularly in medical education and in postgraduate and continuing professional development. It tends to be low on the agenda of influential leaders in health education. Whilst there is little evaluation on the long-term impact, there is strong evidence that patient/user involvement has short-term benefits for learners, educators, institutions and the patient/users themselves across knowledge, skills, attitudes and behaviours.5

4.3 The Health Foundation’s MAGIC programme is demonstrating how to embed shared decision making in practice. Education and training is a key component of the approach, developing both knowledge and practical skills. The programme links together academic expertise, front-line services and educational institutions.

4.4 The Health Foundation’s work in Co-Creating Health has demonstrated how patients can be involved in multi-professional training, co-facilitating training. The Practitioner Development Programme supports clinicians to acquire and strengthen the skills that best support self-management by people with long-term conditions.

4.5 Local provider-led models are emerging. For example, two London teams are exploring how to mainstream the skills and approaches taught in the Practitioner Development Programme with the deans of their local medical school, their Health Innovation and Education Cluster and the Academic Health Sciences Centre; Addenbrookes Hospital has integrated the approach into the GP Vocational Training Scheme; and NHS East of England has rolled out training to whole GP practices, community teams and clinical specialist teams. These examples are both a model of how LETBs can work together locally to develop and deliver training in new skills and a test bed of joint working. The challenge is mainstreaming such evidence-based training, particularly with the potential disruption as structures are transformed. HEE can play a key role in ensuring that best practice is shared across the LETBs.

Skilling and re-skilling clinicians in multi-professional working

4.6 A recent summit on clinical commissioning6 demonstrated commitment to multi-professional working, for example producing standards of care along patient pathways. Best care is delivered to a patient by a multi-disciplinary and multi-professional team. However, currently siloed education and training does not develop professionals with the skills to work effectively with other professions.7 Creating a stronger system of inter-professional development will not be easy. Status expectations will need to be challenged through HEE leadership and LETB commissioning of robust pedagogic methodologies.

4.7 Evaluation of the Health Foundation’s leadership programmes highlights the importance of developing leadership skills which focus on the needs of patients and which promote system improvement, multi-disciplinary approaches to leadership development, and the fundamental importance of enhancing the emotional intelligence of leaders.8 The Foundation is putting this into practice through a masters level programme to develop the quality improvement leaders of tomorrow.

5. The Importance of Re-skilling the Current Generation of Healthcare Professionals

5.1 As the main deliverers of care, the existing workforce will have a greater impact on the quality of health services over the next 10 years than new staff. They have been trained to hold certain values, certain expectations and certain behaviours.9 They also educate, train, mentor and manage the next generation. It is therefore doubly important we invest in the development of the existing workforce to ensure that they have the aptitude and attitude to meet the needs of tomorrow’s health service.

5.2 One way to support this will be through revalidation. Revalidation aims to ensure that doctors can practice safely and deliver modern health services. Revalidation standards can promote competence anchored in continuous improvement, shared decision making, support for self-management, system responsibility, improvement science and multi-professional working. The GMC and HEE will have an important role to guide LETBs in commissioning CPD that meets these ends.10

6. Teaching the New Skills

6.1 Learning about quality improvement requires a different approach to the traditional “fact based” learning of many clinical disciplines and a new set of knowledge and skills to put this approach into practice. Development needs to instil a desire within clinicians to constantly improve what they do, accepting change as an asset rather than a threat.11

6.2 Co-Creating Health and MAGIC have demonstrated it is not simply the content of courses that needs to change, it is also the means by which skills are acquired. There is strong evidence that blended approaches that include active learning strategies where participants put quality improvement into practice are more effective than didactic classroom styles alone, and that roll play and simulation can help in the learning process.12

6.3 Including patients and carers in the co-design and delivery of training has a positive effect on trainees understanding of the psycho-sociological aspects of illness. This is particularly valuable in relation to long term conditions. A fundamental change is needed in medical education to shift the patient role from that of “exhibit” to teacher at the earliest stages of clinical education.13

6.4 The Foundation funded Learning to Make a Difference project, led by the Royal College of Physicians of London and the Joint Royal Colleges of Physicians Training Board, introduces quality improvement into core medical training and models a way of aligning professionally relevant development that delivers service improvements in line with provider priorities.

6.5 This project reinforced the importance of trainers understanding the changing needs for tomorrow’s workforce and having the competence to supervise them as they learn new skills. Ensuring there is a sufficient faculty of teachers and supervisors skilled in improvement science and shared decision making will be an essential task for the new architecture to deliver.

6.6 Good care is delivered by teams. Training needs to prepare clinicians for the practice of working together. We think the best way to do this is by training teams as a whole, enabling each team member to support the new behaviours. If individuals are trained in isolation the norms of their team’s behaviour may lead them to revert to conventional behaviour.14

6.7 The new architecture provides an opportunity to strengthen the links between training and service needs. Integrating services across hospital and community settings demands integrated working, which in turn demands professionals learning together across traditional boundaries.

6.8 It will be important for HEE to support LETBs in promoting multi-professional team training both within and between service settings.

6.9 The nature of the environment within which the learning takes place has a big impact on the effectiveness of learning. By bringing together commissioners and providers of learning, LETBs offer the opportunity to become learning communities, creating an environment conducive to effective and service-oriented learning. The Health Foundation is exploring the key characteristics, drivers and ways of working of learning communities.15

7. System Leadership

7.1 HEE has a key role in acting as a champion for change across the education and training system. We highlight the following areas where we believe the HEE could make a significant difference by acting as champion for:

patient/user involvement in education and training;

multi-professional training and development; and

continuous improvement/improvement science.

7.2 HEE also has a role to:

ensure that England learns from international best practice, including systematised methods of teaching; peer review and structured feedback; and work-based learning;16 and

build the knowledge base on the impact of training on health outcomes, so that the training budget is used most effectively.

7.3 The HEE needs to take a strong and authoritative national lead to ensure that education and training is preparing the workforce for tomorrow’s demands as well as delivering for today’s service needs. The CfWI needs to have the competence to deliver a strong foresight function for HEE, understanding social and cultural changes; technological and demographic change; and biomedical advances. This will underpin the role of HEE as system leader: a foresight function 20 years ago might have reshaped education and training to meet today’s health needs.

7.4 As the single leader across the system, HEE will have the opportunity to create the space where the regulators and professional bodies can discuss and agree how to introduce standards for training providers that provide a proper training environment for quality improvement. These standards should be met in order for a provider to be a training establishment.

December 2011

1 This is in line with the description by W Edwards Deming, one of the founding fathers of the quality improvement movement, that in order to improve outcomes, people need not only the specialist knowledge of their profession, but also an understanding of how to create a conducive environment in which to both deliver and to continuously improve their work.

2 Christmas S, Millward L, New medical professionalism. London: The Health Foundation, October 2011. http://www.health.org.uk/public/cms/75/76/313/2733/New%20medical%20professionalism.pdf?realName=JOGEKF.pdfhttp://www.health.org.uk/public/cms/75/76/313/2733/New%20medical%20professionalism.pdf?realName=JOGEKF.pdf

3 The Health Foundation (2011): The Health Foundation’s response to Liberating the NHS: Greater choice and control—A consultation on proposals http://www.health.org.uk/areas-of-work/influencing-policy/consultation-responses/the-health- foundation-s-response-to-liberating-the-nhs-greater-choice-and-control/

4 Huw Davies (2007): Healthcare Professionals views on clinical engagement in Quality Improvement—Health Foundation publication http://www.health.org.uk/publications/engaging-clinicians-report/

5 Can patients be teachers? Involving patients and users in healthcare professionals’ education. London: The Health Foundation, October 2011. http://www.health.org.uk/public/cms/75/76/313/2809/Can%20patients%20be%20teachers.pdf?realName=br0eQj.pdf

6 The Health Foundation, Academy of Medical Royal Colleges and RCGP Clinical Commissioning Group hosted a summit on clinical commissioning which was attended by representatives of a comprehensive range of professional bodies.

7 Training in Quality Improvement. Rapid review for the Health Foundation’s submission to the Health Committee.

8 What’s Leadership got to do with it? London: The Health Foundation, January 2011. http://www.health.org.uk/public/cms/75/76/313/2119/What%E2%80%99s%20leadership%20got%20to%20do%20with%20it.pdf?realName=JTGpo2.pdf

9 Max Planck observed that ‘A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it. (Planck, Max (1943), Scientific Autobiography and Other Papers, 1943, quoted in Kumar (2009), Manjit, Quantum). The NHS does not have time to wait for a new generation to arise.

10 The Foundation will be publishing a report on revalidation in Spring 2012 highlighting that quality assurance and quality improvement approaches are both necessary to ensure that doctors are both competent to deliver the job of the day and capable of adapting to deliver the job of tomorrow.

11 Lemer C; Stanton E (2010): Engaging with Clinical Communities—Strategic Aim Review. Internal Health Foundation report

12 Training in Quality Improvement. Rapid review for the Health Foundation’s submission to the Health Committee.

13 Can patients be teachers? Involving patients and users in healthcare professionals’ education. London: The Health Foundation, October 2011. http://www.health.org.uk/public/cms/75/76/313/2809/Can%20patients%20be%20teachers.pdf?realName=br0eQj.pdf

14 NHS Scotland is supporting Practice Based Small Group Learning. Individuals pay an annual subscription which gives them access to a range of training materials that are designed to be worked on in a group setting. Individuals form their own group, either colleagues in practice or other affinity groups, meet in their own time and use the materials to work through various topics and development.

15 The Health Foundation is funding a two year study of learning communities in Sheffield and Tayside in the areas of dementia, chronic obstructive airways disease (COPD) and medicine for elderly people, with the aim to getting a better understanding of the key characteristics of learning communities, their drivers and ways of working

16 For brief notes on the differences between countries see de Silva, ibid

Prepared 22nd May 2012