Blog - To Flow or Not To Flow

Wendy Lewis is the Whole System Flow Programme Lead for the Advancing Quality Alliance (AQuA), and you can follow her on Twitter @ERPwend. Here she shares her thoughts on the current state of play behind Flow, and some things she has discovered throughout AQuA’s journey in understanding this complex issue.

Wendy Lewis, Whole System Flow
Programme Lead

Our Chief Executive David Fillingham recently led a webinar for the UK Improvement Alliance (UKIA) on the subject of Whole System Flow; a subject that we at AQuA have been working quite intensely on with The Health Foundation over the past 12 months.

Having had the opportunity to work on our Flow discovery programme for the past year, I used the webinar to reflect on some of our learning to date. Some of the discussion and questions generated also really helped me to crystallise some key points that the improvement community may want to consider and contribute to.

Our thinking has led me to these main points:

We Still Rarely Talk About Whole Systems

Language is so important when considering flow. By using the title of whole system flow but then describing a patient pathway or service level improvements as the examples, we are pulling the opportunity for learning and line of sight below the system level. This is perfectly understandable, as this is where our energy, effort and money has been spent in trying to ‘fix flow’ through our NHS services.

Throughout our conversations and local discussions about this work, we’ve used the phrase “from a patient’s front door and back again” to loosely describe the system. However, we developed this definition:

The coordination of all resources across a locality to deliver effective, 

efficient, person-centred care, in the right setting, at the right time.

What we have found really important, is that the participants can describe the system they are applying this thinking to and be clear of its boundaries. If the focus for improvement is on an acute hospital pathway or a community based service - describe it as such. Our role as improvement experts is to then support and also challenge that work, and highlight the opportunities for applying whole system thinking.

We Rarely Talk To Whole Systems

Through AQuA’s programme this year, we’ve had the opportunity to work with both a wide variety of our members, as well as partners across health and social care, and asked them to define the current enablers and barriers to flow. The overwhelming response from our first co-design event was “We need the system in the room to talk about it and improve it!” Quite right too! This is a fair challenge and one that we have made efforts to address, but it does remain an issue.

How do NHS soaked improvement organisations engage with system partners from local authority, community groups and charities? When we have new partners in the room but the examples we describe are health-based (and usually centred on acute hospitals); this really doesn’t foster engagement and shared understanding.

We call it Patient Flow!

ARGGGGHHHHHHHHHHH! If only patients did flow as they would want to, and actually as we frequently promise, then they would flow through our pathways!

I’ve become increasingly aware of the language used about the recipients of our services, our patients, our customers within this work on flow. Bed blockers, delayers, usual suspects, frequent flyers… commonplace in our language as well as in the media. How should we lead the change in language that demonstrates respect and outdated, non-paternalistic, approaches to care provision?

Through our work this year we’ve described four elements that have to be understood alongside each other, in order to understand flow through our systems and how we might improve it:

• Patients 
• Workforce 
• Information 
• Finances 

And again, like with not having the system in the room to generate the right level of discussion, by not paying attention to these four elements in parallel throughout flow work, we run the risk of re-shaping a problem, rather than clearly defining and understanding it.

Reality check

The systems and services that we hold dear are under extreme pressure, with improvement priorities coming out of their ears. Where does a new improvement offer add value, not distract from mandated priorities, and support real transformation when capacity to even think about it is occupied? Applying new thinking to a highly reactive and defensive system -a challenge or unhelpful task?

In improvement we teach “go where the energy is”. I think in reality we in the NHS are seeking to fix what’s hurting us the most right now: A&E waits, delayed transfers of care, financial compliance, to name a few. Going where the energy is for improving the system is not the same as following the energy currently being spent on these pernicious problems. How do we support both? How do we create the head space for applying different and new thinking?

We also need to acknowledge how colleagues in our own improvement communities feel about flow. A lot of us have been involved in a whole range of these over recent times; some with support and drive from national structures, and others from local or regional initiatives.

Our differing levels of success and/or sustainability create a new issue; there is frustration, scepticism and even cynicism about creating another offer around improving whole system flow within 'Us Improvers.' However, there are sources of energy and support outside the NHS that could really help us refresh and reframe our thinking.

So – how do we respond to these points? How should we act on them? If we focus for another year on whole system flow - where will we get to?

AQuA Chief Executive David Fillingham CBE, alongside colleagues from The Health Foundation, will shortly be publishing a joint report on Whole System Flow. For more information, please visit the AQuA website or follow @AQuA_NHS on Twitter.