Q. or A? – Reflections on the Q Initiative

In May 2015 I was invited to apply to be part of the founding cohort of the Q Initiative. Described as an initiative to ‘connect people skilled in health care quality improvement across the UK’, I was intrigued to learn more.

Like many of my colleagues, I’ve worked in the field of public health long enough to see apparent ‘new’ initiatives repackaged, rebranded and pitched as another example of innovation. Imagine the new must-have toys at Christmas. The once new and exciting Tamagotchi became slightly more sophisticated and later evolved in to a Furby – arguably pretty much the same idea as a Tamagotchi but with a new fluffy outer-layer. Other must-haves then filled the gap for a while (Tracey Island (again!), Bratz Dolls (Barbie with pals), pretty much anything from the latest Disney animation,  before low and behold, the Furby was back – and this time it wasn’t even repackaged or rebranded- it was the same old Furby, only aimed at a new and previously unaware audience.

Clothing, music, toys – you name it and chances are that there’s very few examples of purely original thought in the market place. So it was with a slight caution that I applied to be considered as part of the founding cohort of the Q Initiative.

One of the features of the founding cohort of the Q Initiative that attracted me to apply was the opportunity to shape the future of Q. That candidates would have the opportunity to shape and influence an initiative that has the potential to transform improvement within the NHS. As Professor Don Berwick states;

“If this succeeds, the NHS in the UK will be leading the world in creating, at national scale, system-wide capacities for improvement. This is an appropriate, indeed thrilling, next step for an NHS that already has a heritage of sound investments and a proven track record in quality improvement”.

I completed my application honestly, communicating my anxiety and expressing my hopes and how I felt my experiences in learning and development could contribute to this unique opportunity. I sent it off and waited. In June I received an email confirming my place as a participant in the founding cohort. I braced myself to be inundated with reflective exercises, pre-course reading and plans for the first residential course. I waited. Nothing. I scanned the list of fellow participants: mostly clinical, mostly based in England, mostly statutory, mostly acute, mostly senior management. Uh-oh, the fear started to creep in. Might this be just another well-intentioned, well-resourced talking shop at an enormous cost to the tax-payer? After all, if we’re aiming to connect people skilled in health care quality improvement across the UK, surely one of the first places we should look is to the third sector? And surely, if we’re building a learning community shouldn’t we be reflecting  this from day dot, and adopting a blended learning approach? The course hadn’t even started and already I had donned my ‘black hat’. De Bono proposes that there are six ways of thinking, and those who wear the black hat tend to be critical and focus on the risks. I must admit, black suits me and I find the black hat very comfortable. I’m conscious not to wear it too often though, and took some time to reflect on this initial reaction.

This reflection led me to revalidate my concerns. Often the third sector is indeed third (and last) to be considered: health first, social care second, and us third. That’s one of the reasons that I prefer to talk about the social, or civic sector – but that’s another blog in itself. Some people see the third-sector as a group of people trying their best, but not quite as good as the statutory services. They fail to recognise us as the £4.63 billion industry (in Scotland) that provides over a third of social care services and 5% of Scotland’s workforce. If we don’t look to the third sector though, then we risk not seeing brilliant examples of innovation that are not only delivering care in a person-centred and co-produced way, but can also improve clinical outcomes as a result. Specialist nurses such as MS nurses and Macmillan nurses, links workers, Diabetes UK’s Advocacy service, dementia-friendly cafés, Men’s Sheds, ALISS.org, and countless condition-specific advice lines are just a few examples.

With these concerns live in my mind, and being mindful to pack more than just my black hat, I head south to Birmingham for the first deign event.

Even when queuing for the registration desk there was a buzz of excitement and energy. The welcome pack included a learning journal (woohoo, this might actually be different!) a Twitter hashtag had been provided, (see this Storify for an overview of the Twitter chat during the event), and there was some very intriguing props and visuals around the venue that left me with a mixture of emotions ranging from excitement that this really could be different, to dread – they’re not going to make us role play are they?!

The day started with an overview of the theory of Q and an exploration of what success might look like. The first audience poll (check out Sli.do) indicated that the vast majority of participants felt excited and I counted myself amongst them. After lunch the participants were introduced to the design process and were then invited to participate in a number of activities that explored three main themes: Understanding us and our world, Exploring how we will work together to design Q, and Exploring our hopes, aspirations and fears for Q. Almost 30 activities using various creative methods to explore these themes had been set up at stations throughout the venue and I started to feel the black hat creeping back on to my head. Given that we had been tasked with exploring fears for Q and wanting to remain open-minded, I comforted myself that perhaps a wee black fascinator could be appropriate millinery for the afternoon…

The venue became reminiscent of the Next Boxing Day sale, such hustle and bustle and a mixture of anxiety and excitement in the air. The passionate participants were eager to pin their speech bubbles on to the cardboard man, pin their knickers to the washing line, or scribble on the graffiti wall… I considered if this could be considered ‘accelerated learning’ but with a scheduled 17:30 finish and the evening drinks reception began at 19:00 I was concerned that I wouldn’t have time to reflect on and digest day one before the start of day two.

The plenary session identified day one as an ‘information dump’ and a second poll indicated that again I was not alone. The majority of participants identified as feeling overwhelmed or tired. I chose to trust the course leaders, embrace the unknown and hoped that day two would bring more focus and maybe even some outputs.

Day two came and despite the 15:30 finish, I was even more exhausted and overwhelmed than day one. The day consisted mainly of break-out sessions that explored different topics e.g. “What do you hate about networking (THIS!)”, and “What are the barriers to Q? Choose 12 barriers and explore how to overcome them in eight minutes”. NO! ENOUGH! Eight minutes to address 12 barriers to Q?! NOPE! Surely by participating in this activity we would be colluding with the idea that we (the health and social care workforce) can achieve what needs to be done in the limited time available to us if we just work harder. Our table agreed to choose one challenge and explore ways to overcome it properly. We did and we came up with some great innovative ideas in the limited time allowed. It was at this point that I began to question the role of anarchy in Q. I went to the graffiti board and drew on the Q logo overlaid with the Anarchy A as this was my over-riding thought for the two-days.

We could (and probably will) develop the best learning network and improvement materials for the workforce, but what is our role as Q fellows in challenging the increasing pressures that we face as a workforce to enable this network and tools to be effective?

Let’s go back to the Tamagotchi and Furby. Should we tweak the system and facilitate its evolution, or should we use the shared voice of 5000 Q fellows to radically change the way in which services are delivered?

I look to the private sector for inspiration.

The private sector is filled with innovation, and latterly innovation only made possible by technological advances. Skyscanner is a leading global travel search site and yet it does not own any travel agents or airlines. Air BnB does not own any B&Bs and Uber does not own any taxis or employ any drivers yet all are leaders in their field. What these companies did was think differently, they looked to transform and not to tweak, and they transformed with the experience of the end user in mind.

Improvement science is great for helping the Tamagotchi to evolve in to a Furby, but I question whether these incremental gains will be enough. What good is an established learning network and brilliant learning tools if the workforce doesn’t have time to use them? “Revalidation will sort that” answered a fellow participant. Will it? As a manager looking to release staff from the ward, what do I need to know about Q to support this decision – how will becoming a Q fellow be worth time away from the ward when you could also meet revalidation requirements with an online learning module? How much resource should we spend developing the network and how much in challenging the system? What existing infrastructures can facilitate this conversation to continue and what will the workforce require in order to utilise these?

It was these questions and others that kept me busy in my journey back to Glasgow and for the following days. The Q conversation continued amongst dwindling numbers of travellers as we shared our journey home. Some participants shared my concerns and others shared my enthusiasm. Whatever feelings we left Birmingham with, whatever opinions and judgements we shared, one fact remains. It is with us, the founding cohort of the Q initiative, that the power lies to make sure that this is not ‘just another improvement initiative’, that the Q initiative achieves its full potential. I draw parallels to the Links Worker Programme, The ALLIANCE’s Randomised Control study that seeks to transform Primary Care, and not just to tweak it.

The Q Initiative is not a ‘programme’, it’s a community. Like all communities it consists of a complex matrix of relationships and will face many challenges, but we will face them together. Successful communities thrive when they have a shared sense of purpose, a culture of sharing, a mixture of skills, commitment, and communication. I witnessed all of these in the first design event and it’s with a renewed energy that I don my black hat, and look forward to continuing the conversation…

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