What steps can be taken towards quality improvement in the NHS?

The NHS in England faces the immense challenge of bringing about improvements in patient care at a time of growing financial and workload pressures.

In a report published today, we argue that the NHS urgently needs to adopt a quality improvement strategy if it is to rise to this challenge. All NHS organisations need to build in-house capacity for quality improvement and to commit time and resources to acquiring the necessary capabilities. They should do so by learning from the experience in trusts such as Salford, Sheffield and Wigan where quality improvement is well established.

Organisations need to work together through improvement collaboratives and other means to share learning and provide mutual support. This is happening already in the north west of England through the Advancing Quality Alliance and in London and the south east through UCLPartners. The newly established UK Improvement Alliance is also beginning to play a part.

By learning from these examples the NHS could reduce reliance on expensive management consultants and make better use of its in-house talent. A modestly sized national centre of expertise, learning from the experience of the NHS Modernisation Agency, could also contribute. This centre should comprise leaders with a track record of achievement in quality improvement, and a small number of focused teams such as the Emergency Care Intensive Support Team.

Quality improvement is not new to the NHS in England, but it has been pursued in fits and starts since the foundations were laid by Liam Donaldson in the late 1990s. We argue that national bodies need to adopt a coherent and unifying quality improvement strategy and implement this with a constancy of purpose that has been sadly lacking over the past 20 years. The strategy should be developed in partnership with clinical leaders and managers who have experience of implementing quality improvement in practice.

Quality improvement is quite different from quality assurance, which is undertaken by the Care Quality Commission (CQC) in its capacity as regulator and inspector. One of the major missed opportunities in response to the Francis Report has been the failure to understand this distinction and to place far too much emphasis on inspection as the route to improvement. There needs to be much greater realism about what CQC can achieve and much greater recognition of the role of quality improvement.

All providers, wherever they are on the performance spectrum, should be working to improve quality of care. They should draw on the intrinsic motivation of staff to deliver the best possible care rather than requiring them to respond to external pressures and sanctions. As argued by W Edwards Deming, one of the founding fathers of quality improvement, quality has to be built in from the outset, by focusing on the system of production and designing this to reduce waste and error.

Many health care organisations in the NHS and other countries have found that quality improvement can deliver better outcomes at lower cost. These organisations focus primarily on identifying and reducing variations in clinical care and, where appropriate, standardising how care is delivered. They do so by investing heavily in training and development of staff at all levels, and they improve value by accumulating many small positive changes over time rather than seeking a big breakthrough in performance.

Recent guidance from national NHS bodies urges providers to use all means at their disposal to reduce deficits, including reviewing headcount. There is little recognition that improved financial performance can be a consequence of improvements in quality, nor that changes in clinical care should be a key focus. There is too much reliance on leaders in the NHS tightening their grip on performance and too little on the need to engage and support staff at all levels to play their part in delivering better value.

Unless the challenge facing the NHS is framed as a challenge to improve quality rather than to cut costs then there is no hope of motivating staff, especially clinicians, in the vital work that needs to be done. That is why quality, not finance, should be the guiding strategy of the NHS in England. The results will take time to show, but there is no better option under the circumstances in which the NHS finds itself today.