What does improvement really mean, and what does it take?

When I first trained as a clinician, my mental model was that my best opportunity to support my patients was to be as good as clinician as I could be, and to learn how to be the best team-player alongside other members of the multi-disciplinary team. 15 years ago, I got my first exposure to quality improvement, and I realised that there were ways that we could also influence the design of the complex system in which we worked, that could make a difference for both patients and staff. This realisation about quality improvement changed my outlook on healthcare, and also my career.

Over the last 13 years, I’ve been fortunate to have the chance to support East London NHS Foundation Trust (ELFT) to re-orient its approach to quality – moving away from assurance towards improvement, and then into a balanced management system that incorporates planning, control, improvement and assurance. When we began the journey at ELFT, there were very few examples of healthcare providers in England on this path. The landscape is very different now, and it’s exciting to see the appetite and energy for adopting and embedding improvement across the whole NHS in England, through the NHS IMPACT framework.

Improvement, as a word, brings hope and optimism. It suggests an opportunity to make things better. But improvement is much more than just a word or a slogan. The very best healthcare systems in the world that have adopted improvement see improvement as a more scientific approach to management, and apply real rigour and discipline to the way they go about improving. Just as we wouldn’t expect to gain valuable learning or knowledge from poorly conducted research, we also shouldn’t expect to see results from loosely applied improvement.

At its heart, improvement is very simple – it’s about applying a systematic approach to solving a complex issue, involving the people closest to the issue in discovering new solutions, testing these and learning through the use of data. It is about applying the principles of experimentation, that we learnt in chemistry or physics at school, to making changes in the way we work. Of course, improvement works best when it is truly owned by those closest to where health is created – by patients, service users and family members, and the staff that are delivering care. Our own studies at ELFT on 500 quality improvement projects showed that the projects were 2.8 times more likely to achieve their aim when patients and service users were full and authentic partners in the improvement effort.

So, whilst the essential principles of improvement are simple, shifting the way we operate in healthcare to this way of problem-solving is really hard. It means a new approach to leadership – so that leaders are no longer responsible for solving problems, but for creating the environment in which their teams of staff and patients can continually identify and solve problems themselves, equipping them with the skills to do so, and the close, skilled support they will need. This requires time, regular reflection and often, external support and guidance.

The good news is that there is much flexibility for organisations in England to choose their own path – in fact, it’s probably really important that each organisation owns its destiny, and chooses what will work best. The first step is to choose a method – there are many improvement methods, with the evidence suggesting that the key is to choose one and stick with it. The second is to skill up everyone in the method and tools, relevant to what people will need in their role, and give people an opportunity to apply this to real work – teaching skills without the ability to apply them is unlikely to be effective. The third is to create what John Kotter describes as a secondary operating system – an infrastructure that supports innovation and improvement at team-level; alongside the hierarchical structures that already exist which are perfect for command and control, but highly ineffective for continuous improvement. The fourth is to support and encourage teams to apply the method to solving problems that really matter to them, and the patients they work with, in order to deliver results.

So, go and find out what method your organisation is using. Search for ways to build your own skills and expertise in the method and tools of improvement. Start a conversation in your own team about where the biggest improvement opportunity might lie, and apply your knowledge and skills to working on this, as a team. Just like the delivery of health and care, improvement is a team sport – you will need diverse perspectives, and a range of people involved to truly improve the system you work in. It likely won’t be easy work, but if you persevere and stay focused on the goal, you’ll stand a chance of making a real difference…

Join in the discussion on our FutureNHS workspace or find out more about NHS IMPACT at

Dr Amar Shah, national clinical director for NHS improvement

National Clinical Director for NHS Improvement, NHS England.

Dr Amar Shah is Consultant forensic psychiatrist and Chief Quality Officer at East London NHS Foundation Trust (ELFT). He leads at executive and Board level at ELFT on quality, performance, strategy, planning and business intelligence. Amar has led the approach to quality at ELFT for the past 10 years, and has embedded a large-scale quality improvement infrastructure and quality management system, with demonstrable results across key areas of organisational performance.

Amar is the first National Clinical Director for NHS Improvement at NHS England, leading the application of improvement across England’s health and care system.
He is the national improvement lead for mental health at the Royal College of Psychiatrists, leading a number of large-scale improvement collaboratives on topics such as restrictive practice, workforce wellbeing and equalities.