It may have just as alarming a financial situation as England, but Scotland is superior when it comes to quality improvement, writes Mark Dayan from the Nuffield Trust
The four National Health Services of the UK are a natural experiment in the running of taxpayer-funded universal healthcare.
Like cars being trialled on the same test course, the four different organisations have a similar remit and a similar cultural status in England, Scotland, Wales and Northern Ireland but they work under subtly different conditions and subtly different governance.
The Nuffield Trust plans to study the results in a series of papers which ask what each country can teach the others. We started with Scotland, holding an event in Edinburgh and interviewing senior clinicians, officials and frontline leaders. So what can the NHS in England learn from its northern neighbour?
Scotland’s health service is no idealised model. It faces a financial abyss just as alarming as England’s. With its smaller population meaning even local decisions are raised to the level of a national political debate intensely polarised around independence, tough decisions in shifting care out of hospital can seem even more daunting than in its southern neighbour.
But it has strengths in place of some of the English NHS’s weaknesses. Everybody from civil servants to academics to frontline leaders pointed to its system of improving quality as a prime example – although there are others we explore in our report. They have a point. Scotland seems to be immune to two chronic diseases of the English system of improvement.
The first is constant churn in initiatives. The Health Foundation’s review of quality improvement in England last year described a “priority thicket”. They describe new announcements made every month on average, by many different organisations, focused on many areas and with different methods of delivery.
They argue this encourages organisations to hunker down, lose sight of longer-term and deeper change, and focus on delivering only on what they are most aggressively held to account for.
The second English disease is what my boss Nigel Edwards is fond of calling the lack of a “theory of change”
Scotland’s quality improvement system is marked by continuity and co-ordination. The key themes are safety and clinical outcomes rather than process indicators, engagement with professionals, joint decision making with patients. They have been for a decade, through successive governments and policy documents. The way all this is supposed to be achieved – as I will come to shortly – has also been maintained.
One body, Healthcare Improvement Scotland, is responsible for both inspection and improvement. The OECD has pointed out that this creates the potential problem of a regulator “marking its own homework”, and our interviewees recognised the difficulties it created. But it also means NHS boards do not feel pulled in as many directions, with nobody to resolve any clashes.
The second English disease is what my boss Nigel Edwards is fond of calling the lack of a “theory of change”. Politicians or central leaders decide something must be different; announce it; and then set targets or goals. But the question of what lever actually connects the intention with the change is often not well answered.
The leaders of the English NHS used to believe in the power of the market and financial incentives. But from the quality outcomes framework in general practices to the tariff, the devotional practices are dying out.
At least where quality improvement is concerned, Scotland has a clearer model. This is influenced by its partnership with the Institute of Healthcare Improvement in the US, and is clearly expressed in the projects of the Scottish Patient Safety Programme established in 2008.
It focuses on appealing to the professional values of frontline clinicians and managers, and training them through courses and conferences in quality improvement skills. One of our interviewees described the reasoning as follows: “The key players are clinicians. Nurses, doctors, physios… their loyalties tend to go to the patient; to the GMC and NMC; to their colleagues; and lastly, to their employer. So if you land an organisation-focused plan on them, it won’t work.”
Initiatives are tested at small scale, adapted, and then selected relatively informally for wider rollout by networks of officials and leaders. The changes tend to be highly specific: wound dressings staying intact for 48 hours, access to quiet spaces for mental health patients.
Specific outcomes which matter to clinicians and patients are tracked, and professional pride and informal competition to do better are relied on as motivators. “Scrutiny and assurance are evil. Unshackled altruism is my ideal,” one senior official told us.
This is not to suggest that Scotland uses this method for everything. Waiting times targets are managed with direct oversight which would be very familiar in England. But we heard from several interviewees promising descriptions of a similar way of thinking starting to be applied to the task of shifting care out of hospital.
It would not be easy to simply transplant the Scottish system. Informal roll-out and a co-ordinated approach at the top are easier in a smaller country. Initiative churn is deeply rooted in the way English institutions and politics work.
But if nothing else, looking at Scotland’s NHS shows us that longstanding sources of frustration in the English health system are not immutable natural features. They are merely one way of doing things – and there are alternatives very close at hand.
Mark Dayan is policy and public affairs analyst at the Nuffield Trust.