Our work at The King’s Fund has argued that better value is the most promising way of realising the eye-watering productivity improvements required under the NHS five year forward view. This requires a commitment to building capabilities for quality improvement throughout the NHS. It also requires deep engagement by clinical staff to deliver better outcomes at lower cost by tackling well-known variations in clinical care.
In some cases changes in clinical care are needed in individual organisations, for example to reduce length of stay or improve the efficiency of operating theatres. In other cases, changes are needed in how services are provided across organisational and service boundaries, for example in delivering more co-ordinated care for older people to reduce delayed transfers.
Both kinds of change depend on the use of a tried and tested quality improvement method as observed in high-performing health care organisations. They also require the collection and reporting of data on variations in care to enable leaders in the NHS to understand their performance and identify areas for improvement.
Leadership of improvement work and organisational cultures that focus on better value are the other essential ingredients of successful change programmes. A sustained and systematic investment in leadership development and culture change is therefore a prerequisite in every organisation if the NHS is to bring about the changes in clinical care that are needed.
The NHS has previous experience of trying to deliver better value through improvement collaboratives run by the NHS Modernisation Agency and John Oldham’s work on primary care access and quality. One of the lessons from this experience is the importance of building improvement capabilities in the organisations providing care. Mayo Clinic in the United States does this by training its staff in quality improvement methods and it also employs system engineers (350 in total) on a scale that can only be dreamt of by leaders in the United Kingdom.
To bring about changes in how services are provided across organisational and service boundaries, NHS organisations need to collaborate in place-based systems of care, underpinned by appropriate governance arrangements and system leadership. Building improvement capabilities in these systems will help deliver more co-ordinated care by reducing hand-offs and delays in care transitions. This in turn will improve outcomes for patients and cut waste, contributing to the £22 billion challenge.
NHS organisations need support from NHS England and NHS Improvement if they are to work in place-based systems and deliver operational efficiencies at scale. National bodies need to operate in a much more joined-up way while also offering expertise in how to deliver better value that providers may lack. In so doing they need to learn from the experience of the NHS Modernisation Agency whose good work was undermined when it grew too quickly and took scarce expertise away from the organisations providing care.
One of the difficulties in acting on these ideas is that work on quality improvement does not lend itself to the kind of big bold interventions beloved of politicians. Rather, improvements in care occur through many small changes which over time help to deliver better outcomes and reduce variations and waste. They also occur through the actions of staff throughout the NHS working within a system committed to improvement and learning.
A good starting point would be for the NHS to develop a strategy for improving quality of care and building capabilities for improvement. This would help leaders at a local level to focus on delivering improvements in operational efficiency and breaking down barriers between organisations and services. A strategy for quality improvement needs to be realistic about the time it takes to bring about change as well as the investment in capabilities required. There really is no quick fix.
Our New Year’s resolution at the Fund is to use our resources to help turn these aspirations into practice. We call on national leaders to do the same at a time when the NHS needs to put better value at the heart of its efforts to deliver the £22 billion productivity challenge. Health secretary Jeremy Hunt has seen this at first hand in the transformation in quality that has occurred at the Virginia Mason Medical Centre, and supporting the NHS to do the same could be his most important legacy.