Real trust rather than regulated trust should be the foundation on which improvement in the NHS is built

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Last week we launched a report setting out the case for the NHS in England to adopt a quality improvement strategy.

This case received strong endorsement from Don Berwick and Maxine Power, looking from different ends of the quality improvement telescope, and from the leaders who attended the launch event. The sense that now is the time to rediscover the importance of quality improvement was palpable with a feeling of urgency about translating the principles in our report into practice.

In his contribution to the launch, Ed Smith, chair of NHS Improvement, railed against the ‘firing squads’ that sack chief executives and chairs when things go wrong. He was also critical of the focus on short-term targets rather than long- term improvements in care. He urged national leaders and NHS boards to lead work on improvement and to see money and quality as two sides of the same coin. His message that national bodies need to work quite differently could not have been clearer.

In making these comments, Smith referred to a paper he wrote with Richard Reeves in 2006 to remind his audience of the pernicious impact of excessive regulation. In their paper, Smith and Reeves contrast ‘regulated trust’ with ‘real trust’ which is based on a belief that people have a strong intrinsic motivation to perform to the best of their abilities. They argue that real trust is not fostered through reliance on rules but rather through the development of positive organisational cultures that encourage risk taking and avoid blame.

These cultures support people to act in a way that is trustworthy and to do the right thing. They encourage ‘behaviours and instincts’ that enable people to behave with integrity at all times. Positive cultures take time to develop and require sustained effort by leaders and followers at all levels. Rules and regulations designed to increase trust all too often have the opposite effect, resulting in over reliance on compliance rather than the nurturing of commitment. Real trust cannot be mandated and emerges through the actions of leaders who create the conditions in which people are supported to be effective.

Smith’s comments offer the clearest signal yet of the beliefs of the new leadership of NHS Improvement. They echo remarks by its chief executive, Jim Mackey, that more needs to be done to support providers in difficulty, and that NHS organisations need to collaborate in tackling the growing financial and service pressures that they are faced with. But will Smith and Mackey be allowed to follow through on their commitments with anxiety levels in government about NHS performance rising rapidly?

In the short term at least, central grip on the NHS is being tightened and regulation of providers is being strengthened. The freedoms of foundation trusts have been eroded and detailed guidance has been given to the NHS, from organisations including NHS Improvement, on the actions needed to improve financial performance by the end of this financial year. The behaviours of NHS Improvement’s own staff reflect the priority attached to regulation and are often at odds with the values Smith was espousing.

There is also no slowing down in departures of leaders from trusts in difficulty and there is increasing evidence of challenges in finding experienced people to replace them. All the more important therefore that priority is given to leadership development across the NHS, another of the priorities identified by Ed Smith in last week’s speech. It is here that NHS Improvement, working with other national bodies, could make a real difference by putting in place a national leadership development strategy. This means aligning the work of the NHS Leadership Academy with work on quality improvement and supporting every NHS organisation to play its part in talent management and developing a pipeline of leaders for the future.

Our work at the Fund has shown the value of leadership development occurring ‘in place’ through coaching and mentoring as well as providing opportunities for people to attend leadership development programmes. Organisational leaders have a key role in developing cultures that value ‘real trust’ as well as in working with their peers to put in place the system leadership that is needed to develop new care models and sustainability and transformation plans. We will play our part in working with national bodies in addressing these challenges as well as supporting NHS organisations in building the leadership and cultures on which high performance is based, including at our forthcoming leadership summit in May.


Steve Rankin

Managing Director,
Elite Livein Care Limited
Comment date
16 March 2016
As a care provider I made it a priority to read the King's Fund NHS FYFV. However I'm sure the decision makers who make the call on who will provide the care they're commissioning have not. The "Preferred providers list" still seems to be the easiest way to commission care for the decision makers, who should not only be looking at the current standards of care delivery and the financial burden of the "Preferred providers", but also outside of the, what seems to be a gentleman's club.
For example an experience I have had with dealing with a commissioner and a preferred provider. Our company is small and just starting out in the world of care, we have built the company with a vast array of experience all focussed on quality and not making a quick buck, we are in it for the long haul. Our problem is we are not on the preferred providers list. We are cheaper, I stand by us as the highest quality care and service delivery available. I had a call from another care provider who wanted to take a live in care package from the Local Authority, but didn't have a carer available, so wanted to use one of our carers. We do not subcontract our carers out, we recruited them, we trained them and we look after then, so why would we. It was a package of care that we would have charged £895 per week for, but the preferred provider charged £1200 and didn't even use their own carer. I could reel off a number of examples, but I'm sure you get the drift. This one decision has cost the NHS fund £15,860pa If you can justify these decisions, I'm all ears. Not only is the cost high but when a company are using a subcontracted carer, you also have a compliance issue and who will monitor it, thus a reduction in quality. I think the Any qualified Provider (AQP) list is a far more cost effective and fair way for commissioners to do business, but would still agree, the comm9ssioners need to look outside of the AQP for better quality and lower prices.

Dr Mike Tremblay

health policy and strategy advisor,
Cassis Ltd & University of Kent
Comment date
10 March 2016
Chris, your comments worry me if you are really saying it is time to have a quality improvement strategy. What hasn't been happening all these years if not that? For NHS England to need one seems misdirection as it would deskill those responsible for providing care on a daily basis. We've been here before: the Five Year Forward plan morphed into a blueprint for implemenation from a document to instill excitement and motivation to take responsibility for change. NHS England should be more concerned that providers have quality improvment as part of their DNA, including the analytical capacity that it requires. That's also called local leadership.

Is there any wonder the screws are tightening from the centre, but DH logic is understandable: when you are continually let down, you need to act. Quelle surprise!

As for quality improvement itself, you may recall that I led a post-grad degree on quantitative methods for quality improvement at HSMC which focused on formal methods to improve quality. There is a good reason to look at short term data, as it tells you if you're likely to experience performance or system failure so you can take corrective action in time. The inability to manage the various crises in my view illustrates this weakness.

I agree with Don Berwick in other remarks [Era 3 for Medicine and Health Care, JAMA, 3 March] that too much is measured, and more precisely, the wrong things. There is a bias toward administrative data and not enough costed quality data; this ties the hands of clinicians and managers charged with navigating the daily currents of healthcare demand. There is nothing wrong with having long-term objectives, as long as you don't sail over the falls.

The NHS may find that importing talent from outside the NHS may be as useful as growing leaders from within.

Dr Umesh Prabhu

Medical Director,
Wrightington, Wigan and Leigh FT
Comment date
04 March 2016
Very well said Chris. Happy staff - Happy patients. We need a culture of staff happiness and the Board which cares for staff so that staff can care for patients.

NHS Board language has to change from that of targets, blame, humiliation, pace setting, bullying to compassion, caring and staff engagement. We must make sure that throughout the NHS there are values based leaders who promote a culture of patient safety and quality by promoting fair and open culture, supportive and learning culture.

When NHS cares for his staff and puts patients at the heart we can have safer, better NHS.

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