Ed Smith: How should quality improvement be taken forward?

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  • Posted:Tuesday 23 February 2016

Speaking at our breakfast event on 23 February 2016, Ed Smith, Chair of NHS Improvement, gives his response to The King's Fund's report, Improving quality in the NHS, and discusses how quality improvement should be taken forward.


So one of the things I did at the NHS providers’ conference a couple of weeks ago, is something which I'm going to do every time I stand up and speak, and I'm probably therefore going to do it for the rest of my days which is to ask everybody in the room to stand and applaud the million people that work in the NHS day in day out. And I do that because actually what Don said, it’s about the people, it’s about the motivation, it’s about getting up because we actually can do this and this report talks about a herculean effort, well those of you who don’t have anything better to do on a Saturday evening might have watched Jason. Hercules is some sort of late, middle aged, fat guy whose cup is half full and he moans and groans about getting stuff done, but there is no resemblance whatsoever apart from physical to my approach to improvement in the NHS.

I absolutely welcome this report. In fact a lot of it was referred to in the report I did on leadership and IQ over a year ago but this absolutely codifies it into ten things which are really really important.

There were two recommendations in that report which were not unfortunately accepted and I’m still in pursuit of them because I think they’re important and one of them Don didn’t refer to. The first one of the whole role of leadership, the positioning of leadership in the NHS. My personal view is that until we get leader led development in the workplace then having a leadership academy where you inject people and they return to what I call the slurry pit of organisations you’re not going to get the type of enlightened leadership, consistent leadership, leader led, coaching led leadership that you need in the system.

So I want to work really hard in supporting the leadership academy, reposition itself as a piece of the answer around leadership development rather than the answer, which is sometimes portrayed.

The second one is the role of AHSNs particularly in the space of innovation. I think they have the potential to be great. We said in the report they had the potential to be great, but the rights and obligations of the way HSN’s were set up and their role as a convener was not done in the way in which I think it needs to be done. So I think we need to re-visit AHSNs with regard to the role of innovation, the role of connector and particularly when you look at the life sciences agenda in this country, the role of fast paced innovation, the role of bringing new products, new services at speed into the system, when you look at it, the transition from innovation to implementation is extraordinarily slow and quite frankly it is holding us up. Part of that’s the tariff, part of it’s the process, and part of it’s our approach to new ideas.

So I do welcome the report. I think it’s partly about tone. If you live in a country where the firing squad is the basis of encouraging people to step up and take risk you’re not going to get people appearing to innovate, wanting to improve because they know what’s coming. And we’ve have too much for too long of let’s fire the next chief exec, let’s fire the next chair, let’s suspend the whole board, let’s throw everybody out that doesn’t meet a particular short term target.

Doing improvement in this country in a complex system is not like running a corner shop SME, it’s a complex system and it needs long term dedication and skilled resource working as a team. It needs an improvement resource absolutely at the right hand of every chief exec in his or her trust. It needs an improvement resource locally supporting each board, it needs the board to move away from, and I said this last week, boards and leaders in this sort of environment become managers. Managers become administrators and administrators give up. We’ve got to reverse the flow of that process so that we create space at the top table of organisations to join hands with other organisations to get the job of improvement done over the long term, not to chase short term targets, short term measures which quite frankly will not lead to long term improvement. That doesn’t mean to say money isn’t important, money is critical, but both money and quality are two sides of the same coin and Aaron said that in our report that was published a couple of weeks ago.

So I embrace the ten recommendations. One of the things that we’re doing at NHS improvement is absolutely note building a central large resource, in fact we’re going the other way, we’re regionalising the existing capability within Monitor and TDA, we are building a very small improvement capability and not yet formally announced but we are appointing and introducing a clinical improvement faculty and I can say, I think Chris, that you, Don and Jennifer are going to join with Aaron and a number of other people not named as of yet, I know them but I want Jim to announce it all, to create this clinical improvement faculty which is essentially a steering group around which we will support and facilitate local improvement and it will not be done centrally.

That said what we do want to do is drive a leadership development strategy centrally because we don’t have leadership development as a strategy in this system, we don’t have talent development, we have talent elimination often because they fall at a hurdle like a poor horse at Beachers they get shot and that’s not the way to run this system.

The other thing we will do is focus very hard on technology. I was in the States last week and I had an absolutely tremendous time seeing what some organisations were doing with digital technology, with analytics, we have data but we have so much data nobody can actually see it, and we’ve got to change our approach to data. I have an NHS providers’ survey which said 96% of providers say there’s been an increase in data requests. Where do they come from? They come from a fragmented system of CCGs and of regulators and we need to de-duplicate the massive, massive data industry that has been created. That can be done through harnessing digital, through asking for the data once and using it many many times. I was delighted when I chatted to David Prior and Ben Gummer a couple of weeks ago, they are onto this with the confed and with us on looking at a big data de-duplication and deregulation agenda.

I wrote something ten years ago which I showed Don last week. Cultures which oxygenate organisations come from the right balance of rules, instincts and behaviours and what we have in our system is excessive rules, in the same way that in society we have excessive regulation and what that does is stifle the innovation and creative behaviours of people working day in day out. We have to reverse that flow and I think quite frankly Don that’s in here. Local led, day in day out improvement. People at the frontline know how to do this stuff.

So with that I'm going to leave it, I’m not allowed to be terribly provocative, one day I will go off on one but I hope there’s some food for thought there. Thanks very much.


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