The ups and downs on the road to health service improvement

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Parallels between the successful transformation of the Veterans Health Administration (VA) in the United States and the changes needed in the NHS in England have been made for a number of years. But recent troubles at the VA offer some important lessons for the NHS in the future, as we explored in a roundtable discussion held at the Fund this week.

The story of the transformation of the VA is familiar to many. Once a fragmented and hospital-centred public health care system, changes made in the late 1990s helped the VA to become an organisation renowned for providing high-quality, affordable care.

The VA achieved this transformation by doing a number of things differently. Leaders articulated a strong vision for change from the top of the organisation, a new organisational structure was developed based on regionally integrated networks (each accountable for delivering care for a defined population within a capitated budget) and clear performance measures were agreed for networks to deliver (the ‘what’) combined with local flexibility in delivering them (the ‘how’). Power was also devolved to local leaders to manage the delivery of care. You can read more about the VA’s transformation in our report, Reforming the NHS from within.

These changes resulted in improved outcomes for patients and more care delivered out of hospitals. Among other improvements, the system achieved a 50 per cent reduction in hospital bed days through redesigning and integrating local services.

These were the ups, but more recently there have been downs. As demand for VA services has increased – with increasing numbers of both ageing veterans and those returning from wars in Iraq and Afghanistan – and systemic management problems have emerged, the VA has had difficulties with long waiting times and uneven quality of care. It was also revealed that staff had falsified data to cover up these problems.

So what can we learn from these recent troubles at the VA? Three lessons are particularly important for the NHS today.

First is the need to be tight on the 'what' but loose on the 'how'. Combining clear national goals with local flexibility in delivering them was a key part of the VA’s transformation in the 1990s. But over time the VA has become tighter on the 'how', with much more top-down control in the day-to-day delivery of care. Making sure the NHS maintains a balance between tight and loose is crucial to create an environment for local innovation and accountability for system outcomes.

Second is the need for performance management systems that focus on the right things. As the 'how' became tighter at the VA, the 'what' became more complicated. The number of quality measures used at the VA grew too big, and the performance metrics too complex. The result was a burdensome reporting system that people manipulated, and a lack of clarity about the outcomes that really matter. The NHS needs to make sure that performance management is focused and coherent rather than costly and confusing, supporting transformation of care rather than being too transactional.

Last is the need for effective leadership at all levels of the system with the right skills to drive improvements in care. While the VA is currently struggling to strike the right balance between top-down and bottom-up approaches to managing change, much of the VA’s success over the past two decades has been based on equipping local leaders and clinicians with the skills and capabilities to drive service improvements within their own organisations. NHS organisations need to develop similar approaches to improvement from within, rather than relying too heavily on top-down approaches and external stimuli for change. This should include a focus on developing leaders, succession planning and managing talent right across the system – none of which currently receive enough attention in the NHS.

Above all, the experiences of the VA tell us that the road to improvement isn’t smooth. Lessons for the NHS as it navigates this road can be learnt from the recent bumps in the VA's.


Moris Ledaea

Comment date
26 January 2015
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William Cockburn

Comment date
14 September 2014
I believe many, and possibly all, medical professionals in NHS would identify these principles for healtcare improvement as a correct. The NHS is a large service which includes groups of very thoroughly trained and naturally motivated people. Doctors, nurses, pharmacists, OTs, physiotherapists etc are trained to university degree level as a minimum. Broadly speaking these people know how to treat conditions and patients. What the management service, on behalf of the government, needs to do is decide what standards of healthcare outcomes and which healthcare treatments need to be provided in exchange for public funds.
This could reduce Dr Prbahu's ingredients even further:
3.Robust Governance
4.We measure important things which matter to patients and staff
Everything else is the 'how'.
This gives an opportunity to improve services within tight budgetary controls by reducing organisational weight, reducing reporting and hence, non-clinical workload to staff, and where appropriate re-allocating funds identified.

Umesh Prbahu

Medical Director,
Wrightington, Wigan and Leigh FT
Comment date
14 September 2014
To transform any organisation one needs simply 7 ingredients. This is how our Trust has been transformed. Of course we are not perfect but still many challenges but I am confident that we are on the right track to face any challenges. Here are those ingredients.

1. We defined our values with our staff
2. We appointed leaders and managers who uphold those values and promote good culture
3. We have robust governance
4. We measure important things which matter to patients and staff and act on them
5. Effective staff engagement and involvement
6. Effective patient engagement
7. Excellent relation with our CCG, GPs and social services.

Success is never due to one or two individuals. Success is when everyone works towards the common purpose and that is our values. Our values are 1. Patient at the heart of everything we do 2. Happy staff - Happy patients.

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