The Scottish Improvement Journey: a nationwide approach to improvement

5. Spread of Quality Improvement into public services beyond health

As the SPSP was gaining ground, positive outcomes were becoming more and more visible and the SPSP family began branching out into other areas of healthcare, senior Scottish Government leaders started to see the transferability of the methods used in this programme into other areas of government business. Initially, the discussion revolved around improving health of the population and reducing health inequalities in Scotland. There was also growing evidence directing the focus towards the early years of life (Allen, 2011; Anda et al., 2006) moving towards community health and into community planning partnerships. And so it was agreed to take this successful methodology with the aim of reliably applying it across Government change programmes.

Taking the learning from the work on patient safety and aiming to create the correct conditions for improvement that would be common across all Government activities, the 3-step Improvement Framework for Scotland’s Public Services was introduced across Scottish Government. Its purpose was identified as being “to help unlock and channel the collective knowledge and energy of [Scotland’s] people towards a common goal of real and lasting improvement across [Scotland’s] public services” (The Scottish Government, 2013, p.1). With its aim to create a common language and a common way of thinking about how to tackle any issues within the Scottish public services, the framework was introduced to all the public service leaders in November 2011 at the Scottish Leaders Forum Conference with the theme of Public Service Improvement.

The Early Years Collaborative was the first attempt to apply this framework in the broader environment of public services. Subsequently, the Leading Improvement Team was created to promote this framework.

5.1 Early Years Collaborative

The Early Years Collaborative ( EYC) came on the back of a movement highlighting the need to improve health and wellbeing of children in their earliest years in order to improve the overall health of the whole population (Allen, 2011). Evidence shows that the risk of childhood adverse experiences (e.g. abuse, neglect, various stress factors) negatively impact on the likelihood of alcoholism, violence, physical illness or developmental delay in the child’s future life (Anda et al., 2006). If children are to grow into healthy adults, we need to provide them with an environment (housing, wealth, education) that allows them to maximise their contribution. Additionally, economic modelling on the financial impacts of poor outcomes for children suggests that £1 spent on early intervention in the early years can potentially save £9 in the longer term. All this evidence fitted well with the prevention agenda set out by the Christie Commission (2011) report and together the initiative had fantastic support across ministerial and senior leadership levels. The EYC, therefore, takes a life-course approach to the problem focusing on a child’s life from pregnancy through early development to readiness for school.

Just as with many other areas, the early years’ work was struggling with implementation of their policies and their Early Years Framework. At one of the Early Years Taskforce meetings in 2011, Harry Burns, the Chief Medical Officer, made the first suggestion to explore the quality improvement methodology that has seen great success in the patient safety work. Soon after, Mike Foulis, the Director of Children & Families at the time, brought the 3-step Improvement Framework and The Improvement Guide to all his deputy directors. Many discussions followed in order to understand how the methodology could be applied to Early Years work and to start designing it and creating the conditions required to achieve this.

It quickly became understood that if there is to be improvement work done in early years, it must be done jointly and collaboratively across different sectors and agencies and this must be community driven. At this stage, the idea of working with people from agencies with different value bases and different language was quite daunting but the world of children proved to be a place where everyone can subscribe to the common aim. Initially, the leadership hoped to engage 4-6 Community Planning Partnerships ( CPPs) but the ideas were so compelling that all 32 CPPs wanted to participate. Rather than building new structures, the EYC decided to rely on existing governance structures - the CPPs which include social services, health, education, police and third sector professionals.

The overarching ambition for the EYC became to Make Scotland the best place in the world to grow up. The complexity of the issue at hand did not allow for one aim and so it had to be broken down into bite-sized chunks. Long lists of aims were created and ultimately it was decided to divide them by different points in the child’s lifecycle, and group them in terms of reaching developmental milestones. The EYC started with 4 work streams, one to support each of the age-based stretch aims and a leadership work stream. The fourth age-based stretch aim was added at learning session 4 in January 2014 ensuring EYC now fully covered the age range of the Early Years Framework (0-8 years).

Workstream	Age group	Stretch Aim
1	-9 months to 1 year	By end of 2015, ensure that women experience positive pregnancies which result in the birth of more healthy babies as evidenced by a reduction of 15% in the rates of stillbirths and infant mortality.
2	1 year to 30 months	By end of 2016, ensure that 85% of all children in each CPP meet all expected developmental milestones at the time of the child's 27-30 month child health review.
3	30 months to start of school	By end of 2017, ensure that 90% of all children in each CPP have reached all developmental milestones by the time the child starts primary school.
4	Start of school to P4 (5 – 8 years)	By end of 2021, ensure that 90% of all children in each CPP have reached all developmental milestones and learning outcomes by the end of Primary 4.
5	Leadership

* Aims as set out at launch of EYC. Work stream 4 and its aim were added in January 2014.

Following this very rapid design phase, the EYC was launched in October 2012 and had its first learning session attended by over 750 people in January 2013. The traditional model of a breakthrough series collaborative had to be amended because the EYC wasn’t going to last only 18 months, it is on-going and growing. This felt like a social movement.

There were fundamental differences between EYC and SPSP from the outset. With SPSP initial work on acute care, the concept and method of improvement had to be “sold” to the teams but the change packages were evidence-based and brought by IHI. With the EYC, teams were generally on-board because there was evidence that the approach worked elsewhere, but the change packages and bundles were not known. Hundreds of projects started running across the country. It was challenging to manage but the energy and enthusiasm were tremendous. By the time the programme was one year old, some of these key change areas were starting to be identified, including early intervention in maternity services, parenting, attachment, income maximisation, continuity of care in transitions between services, 27-30 month Child Health Review, and family engagement to support learning. All these themes have emerged nationally and are to date being adapted into packages. Champion sites for each theme have been identified and given more support to develop the intervention better in order to get it ready for spread. The focus for the future is moving from doing hundreds of things to doing these few high impact changes well and across the system – moving from incremental improvements to breakthrough improvements.

IHI was particularly involved at the beginning. At this time, there was little trained expert improvement capacity within the Children & Young People Directorate, who were leading the collaborative, and so capacity building became a priority. IHI brought a team over in the summer of 2012 to teach QI and then led the first few learning sessions, later gradually passing on the torch to the local leaders and moving into a more strategic role in the background. IHI were able to bring experience from community health and community development which was important in being able to illustrate the method with examples from beyond healthcare.

In terms of results, there are success stories from various areas. As for work stream 1, while more work on infant mortality needs to be done to demonstrate improvement, EYC together with MCQIC reported a 19% reduction in stillbirth rates by the end of 2015, surpassing the aim of 15%. Results for work stream 2 are not available at the time of writing. However, successes are being celebrated in individual local projects. For example, work on income maximisation and healthy start vouchers for mothers-to-be in Edinburgh shows significant uptake of the vouchers and what it meant for nutrition for the mums and for the babies. A number of CPPs did work on bed time stories which are known to have a positive impact on attachment, brain development, literacy, getting comfortable with books, etc. One school reported much higher engagement and level of reading of the children coming from a nursery that improved access to books and encouraged children to choose a book every day. Similarly, powerful results regarding attachment and concentration of an autistic boy alongside the increased self-esteem and parenting skills of his mother were achieved through bed-time stories. These examples may be rather granular but we might be looking at a generation before we see the full scope of the results – we need to wait until the children are adults to see what impact the work has had on them.

5.2 The Leading Improvement Team

While the launch of the 3-step Improvement Framework was successful and played an important role in triggering the Early Years Collaborative, giving people this gift of knowledge appeared insufficient. Therefore, a decision to provide more support for the spread of the approach in the form of a specialised team was made around March 2012. The Leading Improvement Team was established to promote the 3-step Improvement Framework across all of Scotland’s public services, building capacity to do the improvement and helping projects to use improvement methodology. The team officially launched in January 2013.

As a new improvement organisation in a landscape of multiple others, it was crucial to establish what the team would do and how, to build relationships, to ensure the team would communicate a consistent message and that existing improvement organisations would accept the team as a distinct unit that they should not feel threatened by; rather that a collaboration between them would be encouraged.

Some of the team members had already completed the 10-month Scottish Improvement Advisor Programme prior to start, others came with experience of improvement from working on the SPSP. This existing capacity & capability allowed the team to start delivering their own training courses and replace the ‘bought-in’ three-day course from IHI. The first course of Quality Improvement Practitioner Training Programme ran in March 2013 and to date, the team have provided training for 23 cohorts of over 20 participants each from a wide range of sectors and organisations.

As with many improvement projects, LIT started working with the willing. “We can help anybody […]. There will be a way we could help you if you want to – you have to work, you have to do it but we can always help you” - Fiona Montgomery describes their initial approach which relied on people asking for help and support and on word-of-mouth. Thanks to the positive buzz the team created, progressively they got better at actively seeking those that are willing and even entering some priority areas within public services. The team have been supporting projects within education, criminal and social justice, social services, local government, public bodies, the third sector and internally within the Scottish Government.

Justice is one of the areas where LIT became involved early and quite widely. The team supported improvement work with the Scottish Prison Service that focused on a change in process in parole preparation that would improve the quality and completeness of parole dossiers and the timelines of the process. A related project with Parole Scotland looked more holistically at whether the right information was being provided to the Parole Board Members, and also looked at the communication between Parole Board Members and other staff to better their understanding of each other’s processes. Additionally, aligning to the agenda of the Cabinet Secretary for Justice to reduce offending particularly among women, the Penal Policy Improvement Project was launched to reduce the amount of remand and short-term custodial sentences in favour of supervised bail that allows the offenders to live at home under supervision. This is currently being piloted in three different areas with a different focus – supervised bail for women, support for care experienced young people, and mentoring for vulnerable groups. Extending into community justice work, LIT is also providing training for the Building Safer Communities programme aiming at reductions in the numbers of victims of crimes.

LIT has also been working with the Crofting Commission around a new delegated decision-making structure which helped cut the decision-making time by about 2 weeks and simplified the process for their board members and all staff. LIT have also provided support during Historic Scotland’s merger into Historic Environment Scotland and are currently supporting a merger that the Forestry Commission is undergoing. At a community level, LIT supports a project called Building Connections, a programme designed to help people navigate the benefits system, as well as the Local Authority Support Programme forming community hubs for support and resources.

The challenge LIT has been facing is selling the stories of success from their projects, as many teams do not wish to publicise how ‘bad’ they used to be before they improved. However, more projects are coming in and the team is always ready to learn, share what they learned and allow others to learn it too.

5.3 Raising Attainment for All ( RAfA) Programme

With the work on Early Years advancing successfully, there was a long-standing interest to extend the approach into the education sector. To test out if the improvement method could work in an educational setting, a project called The Self Improving Schools Pathfinder was launched in October 2013 in 6 schools for a short period of 6 months. It was a collaboration between the Learning Directorate and LIT. The Pathfinder provided very helpful information and experience that gave the team enough confidence to start exploring the potential of a bigger programme.

Following learning from the Pathfinder, the Raising Attainment for All ( RAfA) Programme was officially launched in June 2014. Taking learning from the SPSP and EYC, the design stage for RAfA placed greater focus on structure during planning, building improvement capability and on selecting priority areas. Demonstrating the maturity of Scottish improvement teams, RAfA was launched with minimal support from IHI. As with previous national improvement programmes, whilst many stakeholders were supportive, RAfA experienced tensions in some stakeholders between the new methodology and previous improvement and inspection efforts.

The vision of the RAfA programme was for Scotland to be the best place to learn, to have each child enjoy an education that encourages them to be the best they can and provides them with a full passport to future opportunity. This is to be achieved by supporting consistent improvement in attainment and achievement – raising attainment for all learners and closing the attainment gap for the more disadvantaged.

Strongly linked to the work on Early Years, several teachers attended the EYC learning sessions prior to the launch of RAfA. However, some resistance was felt entering the education sector and attempting to align the new programme with existing streams of work. The challenge was collaborating with existing organisations such as the Association of Directors of Education, or Education Scotland, the national improvement body for education that combines inspection and improvement with a focus on best practice. Despite this initial friction, these bodies are now becoming more engaged.

The way RAfA was designed was around the different levels of achievement set out by the Curriculum for Excellence ( CfE), and existing framework allowing the team to use the language of the educational sector. Evidence for interventions largely comes from the Education Endowment Fund Toolkit. The first work stream was essentially the same as work stream 4 in EYC, nicely demonstrating how the programmes complement and dovetail each other.

Aims for Raising Attainment for All Programme
1	To ensure that 85% of children within each school cluster have successfully experienced and achieved CfE Second Level Literacy, Numeracy and Health and Wellbeing outcomes in preparation for Secondary School by 2016.
2	To ensure that 85% of children within each school cluster have successfully experienced and achieved CfE Third Level Literacy, Numeracy and Health and Wellbeing outcomes in preparation for Senior Phase by 2019.
3	To ensure that 95% of young people within each school cluster go on positive participation destinations on leaving school by 2018.
4	To provide the leadership for improvement, both nationally and locally, across the Raising Attainment for All Programme.

The RAfA Programme started with about 80 schools across 12 local authorities, within 6 months grew to 120 schools and after 2 years has reached 180 schools across 24 local authorities. With support from John Swinney, the Deputy First Minister of Scotland and the Cabinet Secretary for Education Skills, the remaining 9 local authorities are to hopefully join soon.

Front-line staff were given the choice of intervention they wanted to do, similarly to EYC, but broadly these do fit into three key areas – literacy, numeracy, and health and wellbeing. The first priority is now to start reaching results at scale by spreading those improvement projects that work well. The second priority is to create conditions for local improvement teams to become independent in their ability to create and drive forward improvement – a goal that is going to be achieved by capacity building with teams and within systems with the help from IHI over the next years or so.

The next phase for both EYC and RAfA work has begun recently with combining of the two programmes in order to create The Children and Young People’s Improvement Collaborative ( CYPIC). Whilst work had been underway to deliver this integration for about a year, the first learning sessions as a joint programme took place in November 2016. The idea for this integration came both from the leadership, who had envisioned this long ago but acknowledged it could not have started as a joint programme, and from the front-line staff asking why these programmes are not one when they work with the same children. The new CYPIC team also works closely with the affiliated maternity and paediatrics collaborative from SPSP and the Permanence and Care Excellence programme which focuses on looked after children.

5.4 Permanence And Care Excellence ( PACE) Programme

Around 15,000 children in Scotland are looked after away from their home. Evidence published by the Scottish Children’s Reporter Administration ( SCRA) (Henderson et al., 2011) showed that the waiting time for children to go through the system until securing permanence, i.e. a legally secured alternative home to living within family, varies from 12.5 months to 10 years and 10 months. Delays in reaching decisions, obtaining a permanent placement or going through multiple placements has a negative impact on outcomes for the children.

The PACE Programme is unique in that it applies improvement methodologies to identifying and addressing a social policy issue in a very focused way and in a multiagency setting. It was launched in January 2014 with the aim to reduce drift and delay for looked after children in achieving permanence using a whole system approach. With children and young people at the heart of the programme, PACE provides support to local authorities and their partners in healthcare, Children’s Hearings, SCRA and the Courts, to develop improvement projects that look across the whole of a child’s journey to permanence and to identify delays, blockages and difficulties and test changes to address these.

It was agreed to start very small. Aberdeen City was the entry site, followed by Renfrewshire 3 months later. The momentum was building quickly once the programme started seeing success in the first two localities leading to a natural desire to scale up. Now PACE is delivered in 10 local authorities, with further 4 in various stages of joining and others doing preparatory work. In December 2015, the ministers announced that PACE would be made available to all 32 local authority areas in Scotland making the spread and scaling up the current focus of the programme.

While the early successes may not have been every time for every child, rather for some of the children some of the time, they are resulting in significant reductions in drift and delay in the child’s journey to permanence and are being spread across the local area as well as nationally. Adaptation is essential as it is a multi-layered system influenced by multiple legislations and a variety of decision-makers at every step of the journey ranging from social work teams, through the children’s hearing system, to the Sheriff. Additionally, every region has different processes in place, not allowing for the same prescription for the whole national system. What is very particular about PACE is not only engagement across the multiagency spectrum, it is the direct engagement with the judiciary, something achieved against all expectations.

The PACE Programme is delivered in a joint partnership between the Scottish Government and the Permanence and Care Team at the Centre for Excellence for Looked After Children in Scotland ( CELSIS), an academic centre for resource and delivery based at the University of Strathclyde in Glasgow – bringing together expertise in permanence and in improvement programme delivery. The core improvement advisory support initially came from LIT but there has been a lot of on-going capacity building within CELSIS as well as within the local authorities. There is a high level of engagement with the Government working alongside the people who are delivering their policy, starting with a 2-day training on arrival to a new area, through help with relationship building across the multiple agencies, to coaching support on a fortnightly basis. And it is extremely valued in the local areas.

This programme is an example of how Scotland adapted the Breakthrough Series Collaborative method to suit their needs and projects by taking into account that solid research evidence is not always readily available and waiting for implementation. The PACE programme took a democratic approach in collecting the evidence and opinions from all the involved partners in order to create and test their improvement interventions. Bringing in some strategic help from IHI in June 2016, PACE was tested for readiness for scale up.

Given the planned growth into all 32 local authorities, a new delivery model is currently being sought. Similarly to CYPIC, the PACE programme is aiming to build core teams leading on the improvement work within each of the new areas in order to respond to the increased demand for improvement support and coaching within a tight timeframe for delivery.