England lacks an effective strategy for quality improvement in the NHS, but a new King’s Fund paper offers thoughts on the way forward, write Chris Ham, Don Berwick and Jennifer Dixon
The NHS in England is facing a major crisis. Deficits are large and growing; performance on key waiting time targets is deteriorating; and staff are experiencing high levels of stress. Hardly surprising therefore that national bodies are tightening their grip over the NHS to restore financial balance and ensure delivery of key targets.
Now more than ever the focus must be on improving quality of care and engaging clinicians at all levels in so doing. The prize is to improve efficiency alongside other domains of quality through clinically led improvement rather than setting up an unnecessary opposition between financial performance and quality.
In a new paper, we argue that England lacks a coherent and integrated strategy for quality improvement despite multiple well-meaning initiatives over the last 18 years. Many of the foundations of such a strategy were laid by Liam Donaldson in the 1990s when he was chief medical officer but these have not been followed through by the many changes of leaders at a national level. It is difficult to chart a course when both the destination and the captaincy are changing.
We also argue that in response to the Mid Staffordshire Inquiry report, far more emphasis has been placed on using inspection to provide quality assurance than on continuous quality improvement. In some quarters there have been unrealistic expectations of what inspection can achieve and a failure to invest time and resources in supporting staff to improve care from within the NHS.
A small number of NHS organisations have demonstrated what can be achieved when their leaders do make a commitment to quality improvement as a core strategy. Examples include East London Foundation Trust, Salford Royal Foundation Trust, and Sheffield Teaching Hospitals Foundation Trust. Each has trained staff in quality improvement methods and has supported them to deliver better outcomes and improved patient experiences.
Other NHS organisations need to learn from their work if they are to play their part in ensuring sustainability and transforming care. This means building in-house capacity for quality improvement and adopting a scientifically grounded method for improvement. It also means investing in the education and training of all leaders and staff in this method and in acquiring skills to support its use ‘from the board to the ward’.
Shared learning through improvement collaboratives can help organisations work and learn together. The basis for shared learning already exists in the form of AQUA in the north west of England, UCLPartners in London and the South East, and the emerging UK Improvement Alliance. The capacity and reach of these alliances needs to be extended without detracting from the primary responsibility of every NHS organisation to give priority to improvement work.
A modestly sized national centre of expertise should be established to support NHS organisations and alliances. This should learn from the experience of the NHS Modernisation Agency which from small beginnings grew rapidly and in so doing took scarce expertise away from the organisations providing care. A new national centre should be a repository of intelligence about quality improvement with responsibility for a small number of focused programmes that are best led nationally.
The centre should take responsibility for leadership development as well as quality improvement as they are two sides of the same coin. Resources currently spread between NHS England, NHS Improvement and Health Education England should be brought together to make best use of the scarce expertise that exists.
The design of this system of support should be undertaken by national leaders alongside NHS leaders with a track record of achievement in quality improvement. Those involved should include managers and clinicians with experience of using quality improvement methods and skills in real world settings. The voices and views of patients and the public should also be sought and heeded.
In the face of growing pressures in the NHS, now is not the time for the ’Hamlet-like soliloquy’ that Roy Griffiths famously warned against
The NHS can shorten the time needed to develop a QI strategy by being open to learning from elsewhere. An early priority should be to study work going on in Scotland as well as capturing lessons from high performing healthcare systems in Europe, Australasia and North America. There is also much learning in England from the many leaders who have received training in quality improvement through our own organisations and others.
In the face of growing pressures in the NHS, now is not the time for the ’Hamlet-like soliloquy’ that Roy Griffiths famously warned against in his report on general management in 1983. The key is to get started and having done so, to reflect and learn along the way.
Chris Ham is chief executive of The King’s Fund. Don Berwick is international visiting fellow at the King’s Fund, and president emeritus and senior fellow at the Institute for Healthcare Improvement. Dr Jennifer Dixon is chief executive of The Health Foundation.
Improving quality in the English NHS is published by The King’s Fund on 23 February