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MSC for the NHS by Sarah Chalmers-Page

The NHS employs more than a million people, and millions more people work in social care. And millions more than that are patients, or are people who need care, every year. The NHS and care touch almost all of us. And all these people have their own stories, their own wisdom, insights and needs. But historically, very few of these stories get told. Quantitative proxy measures like hospital readmission rates, narrowly focused feedback surveys and traditional consultations can struggle to get to the “why” of whether a service reaped its expected benefits, or the “so what?” that would explain why a change made a difference to patients or staff. Most significant change offers a more collaborative, open approach to service design and evaluation which can provide far more insight into the benefits, issues and barriers to change, and has real potential to drive learning so we can change for the better.

What really matters?

Traditional evaluation feedback like friends and family scores can measure whether a patient felt they would recommend care to others, but not why. And many patient and staff surveys ask for responses about pain, or confidence with a new skill, from a list of drop down menus. This imposes preconceptions about what matters; for example a patient may be asked about post-operative pain, but the person designing the survey may not understand the impact of fatigue, or the impact of scarring on self image, and may not think to include them as a prompt. Most Significant Change allows staff and patients to discuss what about their treatment made the biggest change to their lives, or whether there was any aspect that meant the benefit was not as big a change as they had hoped.

Early seeds of change

Evaluation windows necessarily follow funding cycles, which can be too short to show change. In particular, it can be extremely hard on a one year evaluation to track whether something did NOT happen – whether helping people to exercise more led to fewer hospital admissions when someone has a long term condition. Most Significant Change allows patients and staff to talk about what has changed for them, in an open, storytelling format. Whilst that cannot establish long-term gains for certain, it is less likely to mask long-term gains than small percentage changes in hospital episode statistics.

The human face of change

We know that the impact of individual members of a team on change is both key, and very hard to measure and appreciate. Many health professionals would be happy to acknowledge the role of the receptionist who went above and beyond to support a new process, the porter who touches the lives of every patient they encounter, the cleaner who noticed a patient rapidly becoming ill in a waiting room and got help. Traditional evaluations leave little space for this to be discussed and acknowledged, but understanding the personal influences of individuals on change can increase the chances of future change embedding, and also allows people to be properly thanked.

New perspectives

The perspectives that inform existing evaluation questions and structures are influenced by the existing evidence base, which in turn, is influenced by traditional power structures in medicine. Despite good intentions and continued efforts, the evidence base is influenced by the greater emphasis on publishing medical articles in peer reviewed journals, with a strong emphasis on quantitative measures. Staff groups like administration teams with insight into how processes work, porters who understand the hospital logistics, and domiciliary workers with huge insight into the day to day lives of people with long term conditions and frailty, have neither the skills to write a peer reviewed article nor the time. But they do know how to tell their stories, and Most Significant Change methodologies allow their perspectives and wisdom to be included in evaluations and learned from.

Most Significant Change

Change is what all service improvement seeks to achieve. NHS and care workers chose their careers in order to change their patients’ lives for the etter. Most Significant Change methods allow a rich, sensitive way of acknowledging that the changes that matter most to patients are not always the ones most obvious on a spreadsheet or survey form. We believe that Most Significant Change methods will offer a more detailed, bottom up, broad perspective on what will make the biggest impact on patients and staff, and how well this has translated into action.


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