Always Events: finding out what is important to service users

Helen Lee looks at efforts to define what should happen whenever care is provided

Defining what should happen whenever care is provided

Picture: iStock

Four years ago, NHS England was inspired by the work of Kate Granger and the effects of the #hellomynameis campaign, which highlighted the importance of understanding what really matters to people and how small acts such as introducing yourself can have a huge effect on someone’s experience of care.

NHS England was certain there were other aspects so important to service users that they should happen every time they come into contact with healthcare services, and searched for a methodology to support this. They identified the Always Events methodology, which is trademarked by the Institute for Healthcare Improvement (IHI), in the US.

The IHI defines Always Events as ‘those aspects of the patient and family experience that should always occur when patients interact with healthcare professionals and the healthcare delivery system’.

Criteria events must meet

The programme is not about healthcare providers deciding what matters; it is a genuine partnership between patients, service users, care providers and staff, who work together to seek to understand what matters and to co-design and implement reliable solutions that transform care experiences, with the goal being an ‘always experience'.

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There are four criteria that Always Events must meet:

  1. Important: Patients and family members have identified the event as fundamental to improving their experience of care and think it will have a meaningful impact when successfully implemented.
  2. Evidence based: The event is known to contribute to the optimal care of and respect for patients and family members.
  3. Measurable: The event is specific enough that it is possible to determine whether or not the process or behaviours occur reliably. 
  4. Affordable and sustainable: The event should be achievable and sustainable without substantial renovations, capital expenditures or the purchase of new equipment or technology.

Aspects of care

Always Events often correlate to the relational aspects of care, for example how they are communicated with or how someone is made to feel.

To support implementation, the IHI created the Always Events toolkit (IHI 2016), which integrates the Model for Improvement (Langley et al 2009) into the concept of Always Events and ensures that patients, families and service users are involved throughout the development of services.

The Model for Improvement is a simple tool used to accelerate improvement by focusing on three aspects:

  • What are we trying to achieve?
  • How will we know the change is an improvement?
  • What changes that we think will create the improvement can we make?

These are then tested using plan-do-study-act cycles.

National rollout

In February 2015, NHS England in collaboration with non-profit research institute Picker Institute Europe and the IHI began testing the methodology in three trusts in England. Since then it has been tested, implemented and spread across NHS England to integrate it into front-line services.

More than 100 providers in various care settings in England, including acute hospital inpatient and outpatient settings, primary and mental healthcare settings, learning disability teams, maternity care and children and young people’s services, are now signed up and committed to the programme and way of working.

‘Information I can understand’

North Middlesex University Hospital NHS Trust assistant director of nursing Nichole McIntosh on using and adapting the Always Events methodology:

'In November 2017, we decided to be bold and co-produce a new patient experience strategy rather than tweak the existing one. A working group was established that aimed to start with a blank canvas and fresh eyes and highlight what matters to patients.

'Using Always Events methodology to produce and implement the strategy, the trust signed up for an Always Events cohort launch in March 2018. The co-production journey used a "top-down" approach to secure transformational strategic change and improve patients’ experiences.

Nichole McIntosh

'With patients at the top, the trust worked closely with local Healthwatch groups to co-produce effective and sustainable solutions and initiatives. The result of our engagement was a long list of what mattered to patients in their own words and a platform to identify the top Always Events that would be used to implement our patient experience strategy.

‘I will always receive information that is clear, up to date, accurate and that I can understand.

Listening to patients

'We linked our Always Events workstream with Listening into Action to engage with stakeholders at a crowd-fixing event designed to select which of the top seven Always Events to implement first. It was agreed overwhelmingly to review patient information provision as our first Always Event. The trust radiotherapy team stepped forward to undertake testing change using plan-do-study-act cycles.

'Working collaboratively with our local Healthwatch groups in adopting the Always Events framework to shape an organisational strategic direction was groundbreaking, while listening to patients from the beginning of their journey is fundamental.'


The methodology is also being tested in general practice and care homes.

It does not matter what the care setting is; Always Events are helping to focus quality improvement activity on what really matters to people using the service and so improve their experience of care.

Support package

Organisations that join the programme have access to a comprehensive free support package including:

  • The opportunity to attend a cohort launch event.
  • Monthly coaching calls and one-to-one mentoring support from an Always Events ‘buddy’, who has successfully implemented such events in their organisation. 
  • The opportunity to attend regional events at which organisations engaged in the programme showcase their work and learn from each other.

Providers wanting to learn more about the approach are also invited to hear about the effect of Always Events in local organisations. A series of regional events is planned in the coming months.

There are also resources to support Always Events co-production including a toolkit, short film, case studies and evaluation reports, which can be found on the NHS England website.

Learning so far

As part of the assessment of the Always Events programme, Picker Europe has undertaken two evaluations. The most recent was published in July 2018 (Picker 2018) and highlights some important findings following successful implementation of Always Events in more than 100 organisations. These include:

  • The Always Events methodology is an effective way of engaging with people who use services, their families and carers to understand what matters to them and improve their care experiences.
  • The methodology enables a ‘magic mix’ of people using services, their families and carers and staff at the point of care to generate and test change ideas.
  • Staff engaged in Always Events have evaluated the experience positively. They say they feel reconnected to why they chose to work in healthcare, because they can listen to people using the services and are themselves listened to and supported to make improvements.
  • Always Events are most successful and sustained in organisations in which they are linked to organisational strategies and quality improvement with an executive sponsor to support and maintain momentum.
  • Always Events enable demonstrable, measured improvements in care experiences for people using services, their families and carers and staff.
  • People using services, their families, carers and staff know the challenges and have the best, simplest, most affordable and sustainable improvement ideas.
  • Staff often need to be encouraged to wait and not rush to making assumptions about what matters and developing solutions. By listening, understanding and co-producing quality improvements together, the results will be sustainable and focused on the right things.

Next steps

The programme has built a social movement of more than 100 provider organisations committed to co-producing quality improvements. Regional events inform other organisations about providers in their geographical areas.

NHS England is supporting the testing of the approach at regional level, with providers of acute, community and mental healthcare services committed to improving people’s experience of discharge through co-production. The method is also being tested in different care settings, including general practice and care homes. Our experience over the past four years demonstrates that, whatever the care environment, the programme results in better service user experiences.

The government (Department of Health and Social Care 2018) requires an increase in the percentage of staff who refer to feedback from service users to improve care.

Good experience of care

This is because people using services, their families and carers, with the staff at the point of care, can identify what is important to ensure a good experience of care and because they have great ideas about improvements. Always Events is a methodology that has been successfully tested in the NHS with some fantastic results, helping to bring co-production to life.

In February 2019, we will celebrate four years of using the Always Events methodology in the NHS in England.

If you are interested in finding out more and signing up to the next cohort, go to the NHS England web page or email england.alwaysevents@nhs.net

To help bring the theory of Always Events to life, four providers share their journeys of co-producing improvements in care experiences and describe the effects in case studies.

Young people's transition to adult services

East Suffolk and North Essex NHS Foundation Trust head of patient experience Sarah Higson on supporting young people through the transition to adult services at Ipswich Hospital

'Ipswich Hospital set up a vibrant young people’s involvement group, Voice4Change, in 2015 and quickly identified transition as a central issue for our young patients. The following year we discovered Always Events, which seemed an excellent vehicle for driving forward this issue as its focus is on co-design and working with patients to identify and make improvements.

'Sarah Smith, then matron for children’s services and now head of nursing for women and children, and I worked with Voice4Change to run a workshop for young patients to draw out what matters to them at this crucial point in their care, and to start working on an Always Events vision statement that would form the basis of their next steps.

Working in partnership

'The next steps are working in partnership with young people, with a specific point-of-care team, to drill down further and test ideas to ensure we are co-designing a model of transition that works for them.

'Some of the elements that worked well were: having a senior nurse leader with passion and commitment to really listen to and work with young people; the Voice4Change group getting involved and supporting peer-to-peer conversations; and support from the patient experience team to keep up the momentum.

'The challenges included identifying the right point-of-care team to work with on next steps. The temptation was to "go large" straight away, and we had to rein ourselves in to do this in a manageable way.'

‘My voice always matters’

Lancashire Care NHS Foundation Trust head of hearing feedback Sarah Harrison on improving feedback from people at a medium-secure mental health unit

'Our Always Events project started from a point of curiosity. As head of hearing feedback for Lancashire Care, I had noticed that we were not getting feedback from people using our secure health services.

'I asked for an invitation to their champions’ meeting to seek their insights. They were happy to share why no one at Guild Lodge, a medium-secure mental healthcare hospital for men and women, shared their stories and concerns. People believed that giving feedback was pointless as nothing changed and they did not feel the process was robust enough.

'Using the Always Events methodology seemed the best way to ensure that we co-designed a new approach that service users and those working with them could contribute to and own. We needed to provide a person-centred approach that allowed for flexibility and supported people to share their experiences.'

Poster to encourage feedback

Simple and effective

'The ideas generated were simple and effective:

  • They wanted the process to be confidential. It was suggested that a post box emptied by administrative staff, or someone not involved in their care, could be used. Before this, people had to hand letters of concern to someone who provided their care.
  • People wanted independent reviewers who were not from their ward. This is now in place.
  • They wanted it to be easier to give feedback. We have provided freephone numbers on ward phones, improved our relationship with advocacy services and co-designed promotional material to encourage feedback.
  • They wanted to know the effect of their feedback. We now support the staff who review clients’ feedback to provide more information about what happens as a result of feedback.

'Our collective work increased feedback substantially and staff and service users feel that the approaches created by the co-design team mean that everyone is more satisfied with the experience. People feel supported and empowered to use feedback to inform improvement and believe there is greater honesty in the responses.'

‘Listening, talking and listening again’

Humber Teaching NHS Foundation Trust clinical nurse lead Joanne Bone on co-producing an Always Event in a learning disability unit

'At Townend Court Learning Disability Assessment and Treatment Unit, everything that matters to our patients matters to us. Using Always Events is a new way of working with our patients to improve their experiences of care. Implementing our first Always Event supported people with even the most complex of needs to connect with people important to them using telephones, smartphones, social media, Skype or letter writing.

'Using co-design and co-production, patients and carers worked in partnership with staff to develop accessible materials to promote participation, implementation and spread of the event from the pilot site across a whole inpatient service.

'Inviting senior trust management and other staff to come into the service to meet with patients and hear their stories and share their feelings was a huge influence in ensuring the success of the event, by securing equipment and resources to make the vision a reality.

Driving the initiative forward

'Identifying someone in the team with a transformational outlook committed to the methodology is integral to driving the initiative forward, while listening, talking and listening again is fundamental to working alongside our patients.

'Working in partnership, we have changed our behaviour from "doing to" and "doing for" to "doing with", supporting each other to motivate, influence and shape new visions, and to listen to what is important to our patients rather than believing we know what is best.

'People, including those with complex needs, have an intrinsic understanding of what is important to them but often lack opportunities, time or ways to share these with others. Being patient centred in our interactions, co-producing information to enable participation, creating time for participation in groups or as individuals, going at a pace that was right for our point-of-care team and resisting calls for time-defined outcomes were important elements that ensured our vision statement happens every time, every day for everyone.'

Helen Lee is experience of care professional lead, Patient Experience Team, NHS England



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