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.

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#545820 John
Social Entrepreneur & Healthcare Investor

You are entirely correct. A Commonwealth Fund study of the best performing hospitals in US concluded that "if you focus on quality & access, financial results will follow".

And yet, your solution to create a national centre is mildly old-fashioned.

What is it about the users in the UK, that the NHS and its intellectual elites so mistrusts?

Your solution to everything is so bureaucratic. If its not a transformation fund, its a national centre. Your default position is that the NHS needs to do something, or organise something for its poor deserving public.

It doesn't. It needs to set them free.

#545822 Mark Sadler

I'm always warmed when I hear Deming quoted, it shows that thought is moving in the right direction and absolutely right to say that improving quality reduces cost especially in an environment where measurement and continuous improvement (in a kaizen sense) are such alien concepts. For the NHS to become 'innovative & lean' they need to live, eat, breath continuous improvement and it begins with measurement.

#545823 Brian Donnelly

Is this not what NHSIQ was supposed to do? They should have been called NHS Change Agents! There is a blur here between quality improvement and continuous improvement.

#545824 Neil Chadborn
Research fellow
University of Nottingham

Great blog- will read report asap, but first comment, like previous - don't create another 'national centre' - encourage & enable NHS staff to connect with local expertise. Patients are experts by experience as John says above - there's no shortage (but require investment). Also university researchers and educators could be approached. Currently there is a divide between academics & practice; closing this divide will be a win-win.

Patient Partner
University Hospitals of Leicester

The report rightly emphasises the importance of involving patients and the public in improving quality. PPI should be embedded in quality commitments and the processes in which they are developed, and monitored.

#545838 John Frankish
Improvement Lead
Aneurin Bevan University Health Board

Many thanks for this Kings Fund paper and your blog. Perhaps it is not desirable for English NHS to look at the approach to improvement in Wales but you may not need to go to Intermountain and Kaiser Permanente to look at how you can combine QI and leadership development. We are certainly trying to do that here in my organisation. Just a quick note: your report briefly mentions data. Measurement and analysis of systems relies on good data. That is not always available and can stifle QI activity. It is sometimes hard to understand systems if clinically relevant information that links diagnosis to outcome with effective pathway data in between is not available. We do need, I think, a shift in the quality of our data and that requires real investment in 'real time' information generation if we are to understand and intervene effectively.

#545840 Anderson

This is all true. Real-time data is essential and there has to be a balance between accountability and trust. The data will tell you everything you need to know but you need to be proactive at every level. The data is a tool and you have to use it - do something. The real change is cultural. If someone walks by an obvious problem or turns a blind eye then it isn't working. I see that NHS political and workplace culture encourages this behaviour - the messenger (whistleblower) is generally slaughtered. The fact that political and workplace can be used in the same sentence is almost certainly the real problem. Not rocking the boat is encouraged, challengers sidelined at best. There are solutions to this but a national centre isn't one of them IMO.

How have organisations as disparate as Toyota, McDonalds, Kaiser and EasyJet delivered a consistent, valued and safe product? What disciplines and behaviours are encouraged? The NHS has the disadvantage of there being little alternative for their customers to choose. Leadership is first and foremost, behaviours happen bottom up based on the examples set and demonstrated consistently. I saw this described as the art of getting people to give a damn - "you first" - if leaders don't show this consistently why would anyone else?

#545860 Liz Hepplewhite
C.C.G. Board G.P.

When we were first formed we had a brilliant talk about blue sky thinking by Mark Bricknell of K.P.M.G.At every turn the government,NHS England have interfered to ensure that we have a neutered version of what we all aspired to.As they say 'talk is cheap'.Managers and politicians always 'know better' than those of us who have spent our lives working at the coal face of Health Care.Luckily some of us will still fight for the N.H.S. whilst we have breath in our bodies.The folk at the wheel of the boat change but for patients we're the one's keeping the boat off the rocks.

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