Long Read

Six improvement lessons to apply as winter pressures bite

Six practical lessons for leaders who want to keep the focus on care quality, staff engagement and longer-term improvement this winter.
Penny Pereira , Dr Amar Shah

8 December 2022

The NHS is facing unprecedented pressures. Here, the Health Foundation's Penny Pereira and Dr Amar Shah explore how improvement approaches can help leaders and their teams solve problems at pace, in ways that maintain a focus on quality of care, staff engagement and longer-term goals.

The NHS Confederation and the Health Foundation are currently exploring potential collaboration to understand and support the role of integrated care systems in improvement and bring insight from the Q community to a wider audience.

This long read will be of interest to
 boards and other senior clinical and non-clinical leaders from across the health sector.  Directors with an improvement / transformation brief should find it helpful as a prompt for their own work and to influence the approach to winter in their organisation.

Key points

  • Experience tells us that short-term fixes store up problems down the line, or create unintended consequences. The well-evidenced principles of systems thinking and improvement help address immediate pressures in a way that is sustainable. 
  • Leaders need to ensure ‘top-down clarity and bottom-up agency’ in their organisation to support and empower people to solve problems together.  Taking an improvement approach can identify the practical and creative adjustments needed so systems can run more smoothly, help to keep a solutions focus and also bring much-needed hope to struggling teams.
  • Teams can use improvement methods for rapid priority setting and problem solving. Done well, improvement enables problem-solving that is pragmatic yet rigorous, and more sustainable and innovative than top-down decision-making or traditional performance management.
  • At times of acute pressure, there needs to be a practice of capturing, circulating and acting on emerging learning to keep teams on track. There are a range of efficient methods from the improvement world that can help to build a collaborative and problem-solving culture.
  • An organisation’s response to winter pressures can be built around existing innovations. Leaders can invest in creating the conditions for collaboration during crisis: providing a foundation for longer term service delivery and transformation.
  • Safety science can be used proactively to manage risk. Recent thinking on safety highlights that focusing on resilience and positive responses can help drive organisational engagement and may help keep spirits up.  
  • Leaders need to recognise that staff engagement, morale and wellbeing are critical foundations, especially in times of change and pressure. Taking an improvement approach to managing the current challenges, reinforcing local autonomy and enabling creative thinking, are likely to help prevent burnout.


We are in one of the hardest winters the NHS has ever faced. Our system faces extra pressure with long waits for care, while industrial action and workforce gaps force the suspension of some routine activity. With the NHS workforce already exhausted and many competing pressures on leaders in a fast-changing context, it feels like a perfect storm that is even more challenging than the pandemic peaks.   

The health sector is ramping up focus on certain parts of the system, with intense pressure to solve problems at pace. But experience tells us many short-term fixes we reach for in crisis create unintended consequences, and store up problems further down the line. So how could we apply sound principles of systems thinking and improvement science to solve problems fast, and in a way that leads to sustainable benefits?

We offer six positive and practical lessons for leaders who want to keep the focus on care quality, staff engagement and longer-term improvement through the most testing times. This builds on the range of systematic approaches to improving care that have become increasingly well-established across health care and other sectors in recent decades.  The Health Foundation’s popular guide, Quality improvement made simple, highlights how these approaches give people closest to issues affecting care quality the time, permission, skills and resources they need to solve them. It also provides pragmatic, iterative ways to understand complex issues and achieve measurable changes in performance.

These six lessons are drawn from the pandemic experiences of the 5,000-strong Q community, which collaborates to improve health and care across the UK. They also reflect the ongoing experience from East London NHS Foundation Trust. This has helped to show organisations that embed improvement can adapt to short-term challenges, while staying on track for longer-term goals. 

Lesson 1: Ensure ‘top-down clarity and bottom-up agency’

It is really important to keep a leadership focus on improvement and empowering the frontline. The system is gearing up for command-and-control again: control rooms have been introduced in each integrated care system in England. But a distinctly different leadership style, ‘top-down clarity and bottom-up agency’, enabled innovation during the pandemic. Now is the time, in a fast-changing context, to support and empower people to solve problems as close as possible to when and where they occur.  

All organisations and local systems have people with systems thinking and improvement science skills who can support frontline teams. Do you know where those skills are in your organisation and are you nurturing them? During the pandemic, some organisations saw improvement skills used in ways that were more operationally embedded and inclusive. But those with lower understanding at leadership level lost sight of these skills, with people redeployed to jobs that did not make use of their expertise.

Taking an improvement approach can identify the practical and creative adjustments needed so systems can run more smoothly

Improvement methods can be highly valuable under pressure, but changing services is tough work and needs support. As a leader, you can signal you have confidence in staff to find the best available solutions: ask questions that encourage rapid and robust diagnoses of issues, and testing of solutions. Intense pressures can make it tempting to try to drive performance by pushing people harder. Taking an improvement approach instead can identify the practical and creative adjustments needed so systems can run more smoothly, help to keep a solutions focus and also bring much-needed hope to struggling teams. 

Lesson 2: Use improvement methods for rapid priority setting and problem solving

Done well, improvement enables problem-solving that is rapid and rigorous, and more sustainable and innovative, than top-down decision-making or traditional performance management. Good application of improvement should also help define a small number of priorities that people and teams can align their work to. This is increasingly important at times of pressure, when well-meaning external and internal interventions can create a confusing set of priorities for teams and leaders to try to navigate. 

Insight into improvement during the pandemic identified five widely established methods that proved particularly helpful during a crisis:

  • Driver diagrams can help diverse groups of people, who may be operating outside their usual roles, to collaborate to achieve a shared goal. These are one page charts that show the factors that need to be addressed to achieve a goal, and the activities that will enable progress against these.
  • Flow charts and process maps can be generated to help when new processes are needed or less time and resource are available. Through rapid testing, processes can be simplified or redesigned by those closest to the work. 
  • Real-time measurement can help support the rapid decision-making that is needed at times of exceptional pressures. 
  • Rapid cycles of testing can help teams adapt quickly with minimal risk and interruption to clinical work.
  • Tools such as system mapping, stakeholder engagement, co-production and more radical redesign approaches can help to build on short-term learning and change made during a crisis. This will engage staff in longer-term ambitions.  

The scale at which you can deploy improvement methods will depend on the investment your organisation has made to date in embedding improvement expertise. But even if your organisation is early on its improvement journey, it is likely there will be individuals and teams where improvement methods are well developed and that you can encourage.   

Pragmatic, iterative changes may be just right when you need to adjust services within hours

There are also likely to be a wider set of people with foundational improvement skills and ideas that can be drawn on. Activate and encourage people to use the improvement principles and skills they have already learnt and practised. And reinforce this through rapid sharing of stories across the organisation.  

Leaders should consider the level of rigour needed for the decisions you are looking to make and the time available. Pragmatic, iterative changes may be just right when you need to adjust services within hours. You will get stronger staff support if this is backed by a commitment to follow up with more careful design and evaluation later. 

Lesson 3: Capture, circulate and act on emerging learning

At times of acute pressure, leaders need to ensure teams act on emerging learning in structured ways, to keep joined up and on track. There are a range of efficient methods from the improvement world that can help to build a collaborative and problem-solving culture. 

For example:

  • Many teams use ‘huddles’ to quickly connect on things that need attention, action or  escalation: short standing meetings that follow a set format. This forms part of a robust quality control system. If you are not using huddles widely or they don’t feel like they are working well, consider whether teams could do with a refresh of the process and principles. 
  • For work on a complex challenge over time, the Flow Coaching Academy has developed guidance for establishing and running ‘Big Room’ processes. This is a structured way to bring together people from all the relevant services and groups on a particular live challenge. A Big Room uses stories and data with facilitation that helps ensure all voices are heard, that actions are identified and change is tracked over time. This may also be a good model for control rooms seeking to bring focus to key complex issues. 
  • Some teams and organisations have developed comprehensive learning processes that describe how insights and solution ideas will be identified, collated, prioritised and how decisions are made. Dedicated support roles can help this run smoothly and make best use of clinical team capacity. This can speed up your organisational learning, but can also give staff a boost when they see issues they’ve raised addressed and taken seriously.  

Lesson 4: Build your response around existing innovations

For all the talk of COVID-19-era innovations, Health Foundation analysis highlights that – with good reason – under pressure we tend to reach for service models that have a pre-existing evidence base and rationale.

As far as possible, focus your winter response on positive service changes you want to see longer term, not on short-term fixes. For example, you could use this as a time to shift to remote care, and expand different models of outpatient follow up and preventative care. This will contain the ‘re-work’ you need to do when you move back to routine services and addressing waits.

Q’s work on embedding video consultations, and work from the Health Foundation on staff attitudes to technology, show that behaviours can shift and organisations can see rapid innovation when circumstances force new patterns of working. Take care when celebrating the pace of change though. Acknowledge the further work needed to assess, adapt and embed changes introduced in crisis circumstances: don’t assume they can simply be extended.

The twists on the path to new models of care are often as much about the relationships, shared ownership and other conditions needed for successful implementation as they are about the innovations. And many of the biggest needs and opportunities are at the interface between services. During the pandemic we saw new levels of collaboration between teams, and across health and care, and with the voluntary and community sectors. Leaders can invest in creating the conditions for collaboration during crisis: it will provide a foundation for longer-term service delivery and transformation.

Lesson 5: Use safety science to manage risk positively

Times of particular operational pressure will surface many risks. This may call for different safety approaches to those used routinely, especially if your standard processes are mainly geared to responding to regulatory requirements.

It is important to remember that the biggest risk and harm may be in places that are less visible to you when the system as a whole is under extreme pressure. Sadly, we learned this lesson through the experience of care homes during the early COVID-19 peaks.

There are people with expertise in safety science in all parts of the health sector. Encourage them to think about where attention should be focused and the ideas and approaches particularly needed in a crisis context. Consider whether this attention should take priority over routine work, but maintain data collection if you can. 

Think about your structures for surfacing and sensing issues that span department and organisational boundaries. Take a big picture view when assessing risks and ask questions that might open up new possibilities. For example, you may need to ask if out-of-hospital care leads to people being held in hospital longer than needed. 

Getting the leadership tone right when things do go wrong will be important for all those watching

Human factors is a strand of safety science that explains when and how people are likely to make mistakes. Especially during a period of sustained stress and additional hours, this can provide an objective framework to help minimise the circumstances for harm to occur, focusing on systems rather than blaming individuals. This can also signal support to staff who may experience distress from providing care below the standards they aspire to.  

While you may feel under pressure to project confidence, particularly in crisis conditions, you will do better to model what’s been described as ‘problem sensing’ rather than ‘comfort seeking’. Getting the leadership tone right when things do go wrong will be important for all those watching. While you should engage openly in the current reality, you may also want to celebrate when individuals and services have adapted and averted or minimised harm. Recent thinking on safety highlights that focusing on resilience and positive responses can help drive organisational engagement and may help keep spirits up. 

Lesson 6: Recognise that staff engagement, morale and wellbeing are critical

Last, but perhaps most important, recognise that supporting our people is probably the greatest lever we have. If we look after our people, they will be able to support our patients, service users and local communities. The evidence is stark: those organisations that have the highest staff engagement also have better operational and financial performance. Organisations in the top quartile for staff engagement have 40 per cent fewer safety incidents than those in the lowest quartile. [ 1 ]

The relentless pressure over the last few years, staff recruitment problems, combined with the cost-of-living crisis and industrial action, have created an extremely challenging environment. Leading authentically, bringing hope, and demonstrating values that encourage autonomy, creativity and compassion are the key to supporting our teams.

Leadership for improvement includes finding ways for teams to take a step back and adopt a systems-view and problem-solving approach. As demands increase, the need for space and time to think critically, appraise the situation from different perspectives and consider change ideas is even more important. Many local and national organisations are using improvement approaches to address known drivers of staff health, wellbeing and engagement. For example, in East London NHS Foundation Trust, there is a clear focus on the ‘essentials’ such as recruiting, removing the ‘pebbles in my shoe’ (such as unnecessary meetings and work), and the opportunity to help make things better (with psychological safety key to this).

Using effective improvement, collaboration and learning approaches when introducing changes can support staff engagement and morale. Improvement gives people tools to understand and address problems that are frustrating them daily, and also supports stronger team connection.

An unrelenting focus on delivering to meet immediate pressures can inevitably wear people down over time. Many organisations reported that improvement methods were being used more during COVID-19 than pre-pandemic to solve immediate problems and engage staff, but the most advanced were able to combine that with a sustained focus on the longer term.

So, what next?

Leaders can create the space and support to enable improvement skills to be used and thrive at any time, including during crisis conditions. This calls for the modelling of authentic and collaborative leadership that may be hard to maintain under pressure, but is needed now more than ever.

Help is available: we’ve pulled together resources to support your teams put these six lessons into practice. And there are people with improvement expertise in your local area who understand these ideas: the Q community directory can be a good place to start.

About the authors

Penny Pereira is Q managing director at the Health Foundation. She joined the independent charity in 2011, leading work on improvement capability building, patient safety and improving flow, among other things. She has led Q since its inception. Before joining the Health Foundation, Penny was the director of strategy and service improvement at a trust in East London. Penny has spent her career leading improvement work at local and national level in the NHS, with particular expertise in process and system redesign, leading strategic change across organisations, developing networks to support improvement and collaborative design.

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. He is the national improvement lead for mental health at the Royal College of Psychiatrists, leading large-scale improvement collaboratives on topics such as restrictive practice, workforce wellbeing and equity. Amar is a Q member and has experience of working with health systems across the globe, helping them apply improvement science to better meet the needs of their local communities.


  1. 1. Thorp, Jonathon, et al. “Workplace Engagement and Workers’ Compensation Claims as Predictors for Patient Safety Culture.” Journal of Patient Safety, vol. 8, no. 4, 2012, pp. 194–201. JSTOR, https://www.jstor.org/stable/26632860. Accessed 6 Dec. 2022.