“What is the Cardiff and Vale way?”
For systems, such as ours, to flourish amidst the uncertainty and complexity of the problems facing us in the 21st century, we need to learn to adapt in ways that will feel unfamiliar and disorientating. This highlights the limitations of our prevailing mental and operational models and calls us to consider the relationship between innovation, improvement, and leadership.
Systems whose management processes are geared for increases in efficiency and reductions in waste often maintain stability at the cost of agility. The necessary division of labour into ever more specialised units, each with their own culture, requires a robust and top-down governance structure to maintain unity within such a diverse system. In this context, the value of quality improvement is commensurate with the value of the system (silo or pathway) as a whole. That is, improving the quality of an obsolete system (silo or pathway) hardly counts as efficient.
A system which values its members in proportion to their position in the hierarchy is a system in which individual ambition is limited by the scope of their role. This might lead to greater efficiency in a system where a big idea is promulgated from the top and the method of production is highly specified. But in a dynamic workplace, where decision makers are expected to keep abreast of staggering increases in knowledge and care for people who present with an ever-increasing range of problems, the value of individual initiative and compassion cannot be overstated.
The question that emerges concerns how a system cultivates a culture amongst its workforce in which the status, knowledge, skill, or experience of individuals are seen not as boundaries to be reinforced but as currency to be traded in the pursuit of individual innovation and communal flourishing. This is also the question posed at the end of these two papers, written by the Kings Fund: “What is the Cardiff and Vale way?”
The Kings Fund have produced two papers analysing the innovation and improvement work and the approach to leadership in Cardiff and Vale. The author, Ben Collins, draws on interviews with twenty leaders from across the health and care system, including executive and non-executive leaders at the Health Board, senior managers and clinicians, frontline staff delivering services and staff delivering support services. He also spoke to partners from outside the health system, including other public services, the voluntary sector, advisers, contractors and patient representatives.
Both papers chart the dramatic progress that Cardiff and Vale has achieved since the Health Board published its strategy for transforming care, Shaping our future wellbeing, in 2015. They highlights the foundations that have been built over the last six years which have helped other high-performing health systems in developed countries to improve outcomes for their populations. Those investments already appear to be delivering returns. In 2015, Cardiff and Vale had more than 4,000 patients waiting more than 36 weeks for treatment after consultant referral. By the start of the Covid-19 pandemic in early 2020, there were just 300 patients on the waiting list. In addition, in 2015, it was running an annual deficit of £42 million but by 2019, it was in financial balance.
Mindful that we are six years into a ten-year plan, Ben Collins explores what progress we have made and identifies various factors which have enabled our complex system to pursue innovation and improvement. Amongst these is the considerable leadership engagement and investment in systematic approaches to improvement; the attitude and approach of senior leaders; the broader culture of the system; the degree of connectedness within the system and with external partners; and the tangible and intangible resources that the system can deploy to support innovation.
It might seem self-evident that senior health care leaders should play the roles outlined here. However, international research has highlighted that this is not systematically the case and it is a commonplace for boards to spend almost no time discussing patient-centred innovation or improvement, focusing instead on immediate operational challenges, performance targets and financial concerns. Ben Collins describes what appears to have been a revolution in senior leadership thinking in Cardiff and Vale on the importance of innovation as a solution to the operational and financial challenges of the health system, similar to the rethinking that took place in Canterbury, New Zealand and Jönköping, Sweden in the 2000s. It is no coincidence that in 2018, the Health Board completed a diagnostic of leadership styles, climate and culture, which highlighted directive, pace-setting leadership approaches as well as distinct micro-cultures. This has led to work to help leaders adopt a broader set of styles, with a greater focus on coaching, mentoring and other forms of enabling leadership.
One expression of this has been our ‘Amplify 2025’ programme, which aims to build a social movement for the type of whole-system transformation set out in the Shaping our future wellbeing strategy. One of the objectives of the Amplify programme as we know is to broaden and deepen understanding of the Shaping our future wellbeing strategy across the health and care system and build a movement to support transformation. This has had the effect of raising expectations about what the system expects from frontline staff, with a particular focus on encouraging staff across the system to think ambitiously about how they can improve services for patients and spend a proportion of their time on innovation alongside their day jobs.
Ben Collins doesn’t confine his exploration to innovations in service delivery but examines the range of innovation across the system. Such innovations often stem from relatively modest support and also from the infrastructure which helps direct staff attention to innovation and improvement; which creates a receptive environment for change; which gives staff permission and encouragement to innovate and to act as champions for individual innovation projects; providing resources and helping to overcome obstacles. He focuses on the intentional diversity in leadership that has been formed in the organisation and which goes hand in hand with the ‘open tent’ approach to leadership, sharing information, avoiding decision-making bottlenecks and giving frontline teams unambiguous freedom to test and apply changes in how they do their work – an approach that he credits with our robust response to the Covid-19 pandemic.
Ben Collins thinks it is possible to point to an emerging set of principles, gaining currency across the system, on how staff should innovate to improve services. For example, staff delivering mental health services have developed closer joint working with patients to see issues from their perspectives and put patients and their interests at the heart of actions and decision-making. Staff are also building broader partnerships across professional groups and services as a basis for improving care, and focusing on patients’ time as one way of homing in on inefficiency and poor care. These principles appear to be evolving organically, rather than through formal processes.
The creation of a stronger sense of common identity across staff and services in the health and care system is a key enabler of effective partnership working and innovation across complex systems. This open-tent approach, which extends to the local and global partnerships that are being established, is helping us to refocus leadership attention; to reallocate resources; and to put in place new ways of working and supporting infrastructure. Amongst these are the new tools of social innovation, which have the potential to address the most difficult problems that modern public services face, including the complex socio-ecological challenges to health and social care and the question of how to afford people a dignified and enriching old age. Approaches such as these, which harness the resources provided by families and communities, offer new ways of creating value by avoiding a production-line solution to peoples’ problems, which has led in the past to fragmented care, poor coordination, duplication of effort, and avoidable delays.
The investment over the last six years in learning from other systems has helped us to establish open and inclusive teams and to be bold in pursuing iterative rather than planned approaches to some of our most pressing challenges. The pace of these projects and our inclusive approach to problem-solving will not be easy to sustain and not enough on their own to guarantee the future of Cardiff and Vale’ health system. But if we can complete the journey of implanting structured quality improvement, capture and embed its approach to service innovation during the Covid-19 pandemic, and foster an approach to more radical innovation across a broader range of services, we will have a model of improvement and innovation that we can justifiably be proud of and which will serve as an exemplar to other health systems in the UK and around the world.
The importance of sustained relationships, continuity of care, combining health and social support, minimising referrals and responding to what matters to people is clearly crucial to reframing the relationship between public services and individuals. Ben Collins describes this in terms of recasting fragmented health and care services as a coherent, integrated learning system, with the aim of addressing fragmentation and inefficiency in modern health and care services. This will require a reconception of the problems that health and care services seek to fix and an openness to working in broader partnerships to find radically new ways of addressing complex social problems. We are grappling with these questions and our response can be seen in the way we are reshaping primary, community and mental health services and in new partnerships between health, housing and the voluntary sector, which are revealing new ways of supporting the most deprived people in the population.
The leaders of the new Dragon’s Heart Institute, among others, are starting to think about how the health system and other partners could better support the economic and social resilience and sustainability of Cardiff and Vale’s communities. There is no clear path to follow, even if there are bright spots of innovation in Wales, other nations of the UK and other countries to provide inspiration. Among the recommendations in the two papers, Ben Collins points to the importance of sustaining leadership and direction; to systematising new ways of working; to aligning culture with structures; to codifying the emerging philosophy of care; to forging new relationships with communities and developing approaches to social entrepreneurship. This amounts to a charter for continued innovation and improvement. If we have the courage to pursue this with the vigour of recent months, and the support provided through the Dragon’s Heart Institute and its network of partners, then Cardiff and Vale will be at the forefront of innovation and amongst the most ambitious of health systems in the world.
Dr William Beharrell (Assistant Director for Innovation)
Dr Jonathon Gray (Director Improvement and Innovation)