Adopting QI methods across the Scottish public sector: a Q&A with Jason Leitch

Jason Leitch (@jasonleitch) is a Health Foundation Quality Improvement Fellow who started working on improving health care in Scotland in 2006 as part of the Scottish Patient Safety Programme. Over a decade later, he is now the National Clinical Director of Healthcare Quality and Strategy in Scotland, where he is leading on the roll out of quality improvement methods across government and the broader public sector. We spoke to him about how improvement methods are starting to transform wider health and wellbeing for the people of Scotland. 

What’s involved in your current role as National Clinical Director?

The Scottish NHS isn’t split off from government like it is in England, so about a third of my time is spent trying to lead a piece of the civil service. I also sit on the executive management board for NHS Scotland, so another third is spent on the day-to-day running of the health service, overseeing quality, patient safety and person-centred care, and leading on NHS national planning. The final third I spend looking outside traditional health care, leading a team trying to apply quality improvement (QI) methods to the broader public and third sectors in Scotland. 

How did the work applying QI methods within the public sector develop? 

The Scottish Patient Safety Programme (SPSP) got some really great results – successfully reducing rates of infection and mortality – and that led to other people in the Scottish Government asking for our advice. 

Initially the Director of Children and Families came to us. He’d been trying to improve outcomes during the early years of life, but was struggling with implementation. So, we used the quality improvement we had developed in SPSP, gathered as much evidence as we could about what interventions worked, and ran a massive improvement collaborative, called the Early Years Collaborative. 

Around the same time, another group talked to us about attainment in schools – which led to Raising Attainment for All (RAFA). We were also expanding the Scottish Patient Safety Programme into new areas of health care – looking at improving safety in mental health, primary care, dentistry, and other areas. So, we had large scale collaboratives running across the whole country in multiple sectors. 

After a few years we combined all the work with children and young people. We now have a kind of life course approach to early years and children, called the Children and Young People Improvement Collaborative (CYPIC), which covers everything, from smoking cessation for pregnant women, to positive destinations for young people when they leave high school. 

We’ve adopted a more regional approach, with improvement advisers leading regional collaboratives around different subjects. We also have a team of advisers, called the Leading Improvement Team, working on broader public sector improvement. 

What sorts of projects are these regional collaboratives running? 

I’ll give you a couple of examples. A project in Leith helped more eligible pregnant women access the Healthy Start food and vitamin vouchers available to low income families receiving certain benefits. Midwives started to help women fill in the forms and connect them to welfare officers. It certainly wasn’t a traditional health care intervention, but it resulted in pregnant women accessing thousands of pounds in benefits that they wouldn’t have had otherwise, plus ensuring they got hold of the vouchers, which encourage healthier diets. 

In Borders they’ve used improvement approaches to raise attainment in primary schools. One school started using run charts on the walls to show the numeracy of individual children. They had a system for targeting individual tuition and charting progress. It made a huge difference to attainment levels for the whole school and the head teacher is now working centrally in the local authority to apply that approach to all local schools. 

How different is it implementing improvement methods outside of more traditional health care settings and what challenges have you faced?  

We’ve been working with Cairngorm National Park, teaching improvement methods to staff. Their aims may seem different to the ones we’re used to (they want to encourage tourism, nature diversity, and boost local employment within the park). But there are still evidence-based changes that people are struggling to implement, and providing an improvement methodology really makes a difference. 

Our focus isn’t on improving health when we work in these other sectors, the quality improvement work is just about improving whatever service we are working with. But of course it all joins up. If we improve numeracy in schools, it has a knock on effect on health later down the line because we are improving life chances. Likewise improving the national park means creating jobs and moving people out of poverty, encouraging walking, all things that impact on a healthy population.  

Every new sector we work in says the same thing: ‘we’re different and we haven’t got any money’, but at the end of the day, humans are humans, and systems are systems. Sometimes data and measurement is an issue on some projects, but that’s an issue we often face in health care improvement too. And even if national level data is poor, you can teach local measurement and then teams have what they need to chart change. 

What do you think others can learn from your approach to spreading improvement methods beyond health care?

We get a lot of visits from other countries interested in our work, particularly Canada, Singapore and the Scandinavian countries. When they hear from prison officers or high school teachers who can talk about quality improvement they’re often amazed by how far our approach has been spread. But the methodology we are applying is very similar to what many would recognise in other countries, like what Salford Royal NHS Foundation Trust have done for acute hospital safety. All we’ve done is ignore the boundaries between sectors. 

There’s been some important learning. We’ve found that evidence-based bundles of care are much harder to find and implement the further you move away from acute health care. And that’s because you can control things a lot more closely in a hospital setting, from what a patient eats to when they take their medication and what contact they have with professionals. When we started working with children and young people we realised things are a lot more complex once you’re out in the community. You have to take into account what’s going on in individual families, or a child’s wider environment. There are a lot more variables and there’s less that you can control or easily record and measure. That makes it harder to introduce a consistent intervention and a lot harder to truly track its impact. 

We’ve realised what you have to spread is the method, not the exact approach. Often the most important thing is how you empower frontline staff and positively include service users in the change you are trying to bring about. Those are the main lessons we’ve learned. 

What for you personally has been the biggest success from your work in improvement? 

I feel most proud of the culture change we’ve achieved inside the health care system. We’ve just reached the tenth anniversary of the Scottish Quality Fellowship and some of our fellows are now medical directors, clinical directors and chief nurses of large hospitals and health boards.

We’re starting to see similar capacity and capability developing within the wider public sector, with teams driving improvement themselves and only needing minimal support from us centrally. 

I often wonder if the most important thing we do is build capacity and capability in the workforce. It’s not so much about the improvement, but the fact that we’re building their knowledge and skills and the impact that will have in the future.