On the front line of quality improvement in Manchester: flashing lights, focused funding and forming habits

‘This is when you learn to breathe through your mouth, not your nose’, the paramedic tells me as I step gingerly over broken glass, into a room where the sole piece of furniture – a torn and battered sofa – barely surfaces above a sea of empty cans, cigarette ends and rotting leftovers.

I’m spending time with the North West Ambulance Service as part of my visit to meet with Health Foundation fellows, grant holders and partners in Manchester. We’re on a callout to a local estate, after a mental health community worker contacted the ambulance service. There’s no answer at the door and some concern at what the numerous flies at the window might signify. It takes the combined effort of the mental health team, ambulance service, and police to establish that there isn’t a dead body in the house. Neighbourhood intelligence suggests the occupant has been seen on the streets in the city centre recently; it’s not unusual for the house to be unoccupied for some time.

The door will be boarded up, information will be recorded and shared, and the next urgent job calls. I’m left with the sense that this won’t be the last ambulance visit needed, as well as unanswered questions about the life of the person who lives here. It’s a small but vivid reminder that health care is often only a very small part of what makes people healthy, of how social (as much as medical) needs absorb clinical time, and of the many sources of knowledge that are required to start to build a picture of, and response to, complex lives.

The aim of my short Manchester trip was to help me understand more about the impact of our funding, to get beyond the London-based circles of daily working life, and to inform thinking about how our improvement work could develop to remain relevant to the challenges that patients and front-line teams are facing.

I’d begun the day talking with the chief executive of a different NHS trust, who had raised a question that resonated all the more strongly after that ambulance callout: what would need to change so that NHS trust leaders could legitimately spend the same organisational energy and resources on tackling worklessness in the city as they do on meeting the A&E target? And what would it take for their counterparts in local government to feel it was a legitimate focus for their executive team to reduce the number of people coming to hospital with exacerbations of respiratory conditions – by providing safe and warm housing, and reducing social isolation, for example?

These questions make me think about research we’re in the early stages of planning, on what it takes for teams we’ve funded to step outside their day-to-day NHS roles to contribute to issues such as homelessness or knife crime – and how this kind of work depends on one-off grant funding, and individual motivation, rather than being incentivised through normal activities. Any research work focusing on front-line teams will also need to address the policy and organisational frameworks that enable (or inhibit) the development of more prevention-led services.

In my morning meeting, we also speak about some of the ideas in our new report on the role of the NHS as an anchor institution and how this represents a start in terms of what the NHS can do to act on social determinants that it can influence, such as local employment and environmental impact.

The next day I start at the Advancing Quality Alliance (AQuA), a leading improvement agency in the region and frequent partner of grant holders on Health Foundation improvement programmes. We talk about work in safety, co-production, improvement capability building, the development of the Q Community, and the changing improvement needs of organisations seeking to focus on integration and place-based care.

Finally, I visit Wythenshawe Hospital, where I attend the Surgery School – part of the ERAS+ Programme that the Health Foundation are funding to scale up in Greater Manchester. This initiative supports patients preparing for surgery to improve their activity levels, muscle strength, chest strength, oral health and nutrition before surgery, aiming to enhance recovery after surgery. A surgical operation can act as a powerful moment in patient’s lives where new habits can be formed, and the partnership with Greater Manchester Cancer allows innovative integration of the clinical programme with GM Active, a network of gyms in the Greater Manchester area. This new innovation, Prehab4Cancer, provides tailored support for people with cancer as they prepare for surgery. Scale up is taking place throughout Greater Manchester, and evaluation is underway.

Other than powerful memories, and relationships new and renewed, what did I take from the visit overall? The themes that struck me were the recognition from improvement practitioners of the case for increased focus on prevention and the wider determinants of health, the importance of better integrated data and information that clinical teams and organisations can use, and the need to develop more programmes that help us learn how to do improvement work effectively across boundaries. Methods such as the Flow Coaching Academy and Q Lab lend themselves well to this ‘meso-level’ improvement work, bringing together multiple different perspectives on a problem.

I travel home with renewed respect for those undertaking the hard work of delivery and change, and a refreshed sense of the importance of providing the conditions and resources which enable front-line teams to make the changes they know can improve people’s health and care.

Will Warburton (@willwarburtonHF) is Director of Improvement at the Health Foundation.