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Postcards from Scotland

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Carol Craig is the Centre's Chief Executive. She is author of The Scots' Crisis of Confidence, Creating Confidence: A Handbook for Professionals Working with Young People, The Tears that Made the Clyde: Well-being in Glasgow and The Great Takeover: How materialism, the media and markets now dominate our lives. She is Commissioning editor for the Postcards from Scotland series. Carol blogs on confidence, well-being, inequality, every day life and some of the great challenges of our time. The views she expresses are her own unless she specifically states that they reflect the Centre's thinking.

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Posted 26/11/2011

I had the good fortune to be invited to attend Thursday's Public Service Improvement Conference 2011 at the SECC and I really felt that things are beginning to turn in Scotland. I spent fifteen years working as a trainer/consultant in Scotland prior to setting up the Centre. Much of my time was spent in Scottish public sector organisations and I was often taken aback at the fear, inertia and complacency. However, at this event, attended by senior people across the public sector, the commitment, interest and motivation to large-scale improvement was palpable.  And so were real, tangible results …  

The plenary presentation on the 'Scottish Patient Safety Programme' by Derek Feeley and Jason Leitch was simultaneously witty, informative and inspiring. Indeed it was one of the best presentations I have seen for a long time.

Estimates from around the world suggest that ten to twenty five per cent of patients  in hospital are damaged by their care.  This can take the form of the wrong medication, falls, bedsores or hospital acquired infections such as C. Difficile.

Internationally there is now a growing interest in using an evidence-based  approach to tackling such damage and bringing about quality improvement in hospital care.  Scotland's NHS is the first in the world to 'adopt a systematic, nationwide approach to improving patient safety'. The Scottish Patient Safety  Programme, as the initiative is called, is bringing together NHS Scotland, the Scottish Government, various professional bodies and patient representatives in a coalition which is designed to make our hospitals safer for patients.  The project aims to reduce mortality by 15 per cent, and adverse events by 30 per cent.

Results so far have been extremely encouraging. All health board areas have shown improvements – some dramatic.  The initial target to half C. Difficile rates has been exceeded as there has been a 71  per cent reduction.

At the conference we learned that behind this initiative is a particular methodology based on three steps:

Step I  - 'Change the world'. This refers to the need to have a 'compelling vision' and story of change which will engage the workforce.
Step 2  - 'Create the conditions'. This refers to having a precise idea of what you specifically want to change as well as a clear idea of how to get there, how you will know you have been successful and how you will engage staff and deploy resources.
Step 3 – 'Make the improvement'. In other words, make the change happen and use your measurement tools to chart and demonstrate your progress.

Everyone I spoke to at the event was extremely taken by this presentation and inspired by the energy and commitment of those leading it. However, there was some questioning of its applicability  to other settings.

In this instance (reducing hospital harm) no-one can be opposed to the compelling vision. Everyone is going to support wholeheartedly the goal of making hospitals safer for patients. In short, the leadership is guaranteed 100 per cent buy in. What's more, when it comes to delivering the results they are literally in the hands of the hospital staff as it is mainly their actions which are responsible for the harm in the first place.

But this is not true of many of  the problems facing many public sector workers in Scotland. Indeed the problems many of them have to deal with are 'wicked'.

In the 1970s social planners coined the term 'wicked problems' to refer to complex problems which unlike 'tame problems' - such as how to win a chess game or find the answer to a mathematical puzzle -  are very difficult to solve. Many contemporary social problems such as drug-taking, domestic violence, or worklessness are wicked in that they are highly connected, are not likely to be eliminated, and any solution is never right or wrong, simply better or worse. As there are no absolute solutions as such, what might work somewhere at a specific point in time may not be transferable to another area or context. This means that learning from others' good practice may be limited.

All contemporary societies are struggling with how to cope with wicked problems but, given some of our statistics on drink, drugs, teenage pregnancy, inequality and so forth we seem to have more than our fair share. Unlike hospital safety, progress is emphatically not in the hands of the professionals – indeed their actions may often unwittingly make the problem worse, not better.

The Public Service Improvement Conference 2011 was highly successful in inspiring people to be ambitious and embrace large-scale improvement. I found it extremely motivating to hear how our hospitals are being made safer and the methodology that is driving the changes. I sincerely hope there is a 2012 event which gives us more information on initiatives of this type in health care or other areas where improvement  can be brought about through system changes or alterations in practice. But I'd also like to see some room on the plenary agenda for inspiring, insightful speakers on what we need to do to help us tackle the messier, wicked problems in our midst.

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