Why the NHS needs a quality improvement strategy: Chris Ham in conversation with Don Berwick

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Don Berwick

Don Berwick is an International Visiting Fellow at The King’s Fund. He led a review into patient safety for David Cameron in 2013, and is recognised as an authority on health care improvement.

Chris Ham asks him why he thinks that now is the right time for a quality improvement strategy.

Why does the NHS need a quality improvement strategy?

Think of the alternative: either acceding to current levels of quality or assuming that improvement will somehow come automatically, with no conscious intention or shared approach.

I find the first choice irresponsible. As good as the NHS is, it suffers from serious deficiencies and, even where it is excellent, it can always be better. Patients, communities, and the NHS workforce deserve more. The second option is illogical. It is unscientific. Even simple improvements take intention and method. In complex systems such as health care, with high levels of interdependency, risk, and hard-to-see dynamics, without stewardship and active nurturance, things will decay.

A shared approach to improvement is essential. Exactly what that approach should be is open to debate, but, without a strategy, what would we expect to happen?

With all the strain on NHS finances, is this really the right time for this approach?

The easiest, fastest way to reduce costs is to cut the NHS budget. But, in my view, that is the wrong way. To protect patients, carers, and the mission of the NHS requires a more subtle approach asking: ‘Where is the waste in our current use of resources?’ And, ‘What new forms of care – new designs – can lower cost and provide better outcomes for the people we serve?’

The good news is that both questions have many answers. But these can only be discovered through systematic approaches to learning, design, and redesign, and only with the authentic engagement of a buoyant, supported workforce. Forty years’ experience convince me that almost any organisation can – with proper leadership, a learning culture, and sufficient investment – identify and reduce waste, and identify and implement new, better models of work.

The bad news is that this approach is a lot harder and takes longer than just cutting the budget. Improvement takes patience, scientific discipline, and – yes – some slack in the system to give people the space and time to innovate.

So, ‘Is this the right time?’ No, if you are willing to just cut the budget and walk away, and unwilling to take a longer term view. But, absolutely yes, if you want to create not just a leaner NHS, but a better one.

What great examples of quality improvement and/or innovation have you seen recently?

I find gems everywhere I look. I actually believe that individuals have a native drive to improve through learning. And so, when I visit health care organisations, it is common for a member of staff to grab my sleeve and, smiling, say, ‘Look at what I have invented!’ At the organisation level, that sort of conversation is a bit rarer, and dependent on how leaders are behaving. Do they promote invention? Or are they after mere compliance?

I have seen brilliant re-designs across England, some, though not all, in the vanguard sites. Here are just a few examples.

At Alder Hey Children’s Hospital near Liverpool, I saw the use of patient-centred care as a design principle. For example, each medical–surgical unit has a professional chef on constant duty. Meals are prepared when and how each child wishes. The results: cost savings through a massive reduction in food wastage, much better nourishment, continuing education of children and family about their food choices, and delighted staff.

At the Walton Centre for Neurology and Neurosurgery, I met physicians and nurses who want to reduce the overuse of ineffective interventions around spinal injections and surgery. They are starting with co-design and new relationships with patients and community physicians, and they are laying the groundwork for a nationwide effort that will reduce costs and improve outcomes.

There are leaders from the Isle of Wight, who are trying to take community-based care design to a new level, using the theme ‘My Life a Full Life’ and knitting together all relevant community resources to help people truly take responsibility for their care and health.

Clinicians and others at Tower Hamlets CCG are engaging in extraordinary levels of dialogue with the communities they serve to help design and redesign care processes.

If, as a learning organisation, NHS England can support, encourage, and harvest these examples, it will have the pieces to sew a ‘quilt’ of innovative care that can advance the Triple Aim: better care, better health, and lower cost.

What do you see as key to spreading innovation in the NHS?

Great innovation has bi-directional kinetic energy: ‘top-down’ and ‘bottom-up’ at the same time. From the ‘top’ can come resources, clarified aims, permission, and assets for collective learning. From the ‘bottom’ can come great ideas, tested, de-bugged and exciting. And local innovators can become teachers for others. Key to spreading innovation is a combination of (a) strong respect for and support of local improvement and (b) consistent, positive and generous leadership from executive and clinical leaders who believe that shared learning almost always beats central control.

The enemy of the spread of innovation is fear. I counsel every leader I know to become fully self-aware about how and why fear develops in organisations, and how to restore confidence and the willingness to try new ideas. One of my beliefs, with which many smart people disagree, is that management and policy initiatives that rely primarily on extrinsic incentives – pay for performance, naming and shaming, or even reward – erode the cultural attributes that foster good learning and fast spread. They may appear to help in the short term, but, in the longer term, their cost is inestimably large.

Overcoming the ‘not invented here’ syndrome is also essential, although in England this barrier is low: people seem to be curious as to how others address common problems. The next step is to ‘globalize’ that curiosity. England can, and should, learn from any country, anywhere, where health care inventions are under way. (Lord Nigel Crisp has written about how much there is to gain by extending that curiosity to low income countries, where agility, pragmatism, and open-mindedness continually yield new ideas full of implications for nations with greater wealth.)

Why do you think a national centre for quality improvement is part of the answer?

Although a great deal of learning and improvement are, and must be, local, economies of scale and the opportunities for leveraging expertise also make some centralisation of support logical and effective. In my view, the overall success of the Modernisation Agency in the first few years of the 21st century testifies to this. The Agency created and supported some of the most successful large-scale improvements ever seen in health care anywhere.

There are risks, of course, to centralisation, and it is important to make sure that the local organisations retain both respect and resources. Nonetheless, as NHS England develops its improvement capability, a modestly-sized national centre can be a home for people to learn improvement methods, engage in virtual and face-to-face improvement collaboratives, and share data and information.

Much of my thinking about such a resource centre comes from the highly successful Qulturum agency in Jönköping County, Sweden. I think an English analogue could be brilliant.

One more point: no such centre, no matter how well-designed and supported, can substitute for alignment of aims, management philosophy, and priorities among the several organisations – including NHS England, NHS Improvement, and the Care Quality Commission – that constitute the ‘family’ of oversight, management, and resourcing for the NHS. These organisations and others compose a single system of leadership. Fragmentation is toxic, and co-ordination is tonic.

This article was originally published in The King's Fund Insight magazine, summer 2016.