Durka Dougall

Our new report on the Getting It Right First Time (GIRFT) programme describes the efforts that leading orthopaedic surgeons made to improve care in their specialty – with impressive results. It reminds me of an early clinical encounter that shaped my own interest in health and care improvement.

One day 15 years ago when I was working as a junior doctor I noticed that a patient might be showing signs of dehydration. The signs were subtle – it wasn’t clear. Maybe the treatment wasn’t quite right. Should I say something?

I am sure most of us would say we should question the situation. But in practice do we always do this? In the midst of juggling numerous things in a complex health and care system where things don’t always make sense, it is easy to brush off the feeling that something doesn’t quite add up, to tell yourself that you must be wrong or missing an obvious explanation. Those were all things that went through my mind at the time.

Such opportunities to improve practice are all around us. Previous research by The King’s Fund has identified many examples of care that is not bad enough to be deemed ‘unsafe’ but enough to cause waste, variation and reduced quality:

• using higher cost drugs without real reasoning
• a patient’s perspective not being understood
• fragmented pathways, with silo working
• management styles that compromise team morale and productivity
• commissioning approaches that don’t ensure best value.

GIRFT demonstrates the importance of acting proactively in such situations. But evidence tells us that individuals can be reluctant to voice their concerns, and, in some cases (eg, Mid Staffordshire), when they did speak up they were ignored or victimised.

I believe that it is essential not only that individuals do speak up to champion quality but also that their voices are heard – as NHS England’s Sign up to Safety campaign shows is necessary. Our clinical leadership courses demonstrate it is possible to nurture the necessary skills.

In the case of my patient, I made the decision to speak up and question the situation. It didn’t feel easy but it felt right. I used data to highlight the problem, explore the situation and discuss possible explanations. The senior colleague (an eminent surgeon) to whom I spoke could easily have dismissed the issue or turned me away – serving to reinforce my fears and make me feel even less able to speak up next time. But instead he took time to explore the issues carefully with an open mind and a level of humility that demonstrated a dedication to quality and patient care overall. It set a standard by which I have been inspired to behave with my teams ever since.

The importance of clinical engagement and leadership in improvement efforts cannot be underestimated. Both my story and the GIRFT report highlight insights that clinicians have about practical application of theories to the complex health care system and how best to navigate this to benefit patients and communities – in a way that is unique to those with frontline experience. They also highlight the influence that clinicians have on colleagues (peers and junior staff) in strengthening improvement efforts to reach across the NHS and to future generations too.

Although the clinicians in these stories are doctors, it is important to note that ‘clinical engagement’ applies to a wide clinical workforce including allied health professionals and others such as social care workers.

Also paramount is quality patient, carer and community engagement to ensure that the care provided is based on patients’ needs.

GIRFT demonstrates that when improvement efforts are approached correctly much can be achieved. For example, better long-term clinical outcomes can be achieved through the use of cemented hip joints – improving quality of care and reducing waste at the same time.

For my patient… our efforts revealed that the lady was indeed dehydrated. The blood results had been interpreted differently due to complex features of her case. Knowing this, we were able to change her treatment from powerful, costly drugs to intensive fluid therapy – and later realised this action saved her life. She lived for several years more, reaching her 90th birthday, and spent much quality time with her family.

My early experience taught me a valuable lesson that has since been reinforced through my roles as a commissioner, a manager and public health consultant: that improving the quality of care for patients and delivering better value care are often two sides of the same coin.

• Read the Tackling variations in clinical care report