Improving quality in the English NHS: A strategy for action - The King's Fund Feb 2016
This is an interesting read and is notable for a number of things. One is that the authors are Chris Ham, Don Berwick and Jennifer Dixon. The other is the inclusion in the introduction of the phrase “joy at work” and how important that is to the theory and practice of quality improvement.
The definition of the latter is the design and redesign of work processes and systems to deliver health care with better outcomes and at lower cost “whenever this can be achieved.” The paper expressly states that it is not about questioning the adequacy of planned funding, “challenging as that is.” Instead the NHS must have “a coherent, comprehensive, unifying and sustained commitment to quality improvement as its principle strategy.” Furthermore improvements “do not occur by chance” but require staff to be equipped with the right skills and to be supported by leaders at all levels. Nor do improvements come for free but need time and resources. The concept of driving up quality by inspecting it into systems a la CQC is condemned by all modern theories of complex adaptive systems all of which also emphasise the “toxic effect of fear in the workplace.” Rather staff need to be trained in the nature of those systems, be able to interpret data over time (to understand variation), to all have an opportunity to be involved and to relentlessly focus on the experience of the “customers.”
The second section is amusingly called “A brief history of policies on quality of care in England” and recounts the efforts of policy makers to respond to well-publicised failures in care such as in Bristol and Mid Staffordshire, voters’ concerns about waiting times and evidence that the NHS has fallen behind other developed nations in, for example, cancer survival rates. Many of these changes “might had placed England at the forefront…had they been pursued with constancy of purpose…[and had not] other priorities and reforms [come] to receive greater attention…” There is a trip down memory lane with the listing of reports such as A First Class Service (1998), An Organisation With A Memory (2000), High Quality Care For All (2008) and Hard Truths: the journey to putting patients first (2014). Along the way we have seen the establishment of NICE, various inspectorates which have reached their apogee in the CQC, the concept of clinical governance and performance management frameworks with financial rewards, the use of targets for access and e.g. healthcare acquired infections, the introduction of the Duty of Candour (April 2015 in primary care), the establishment and later disbandment of the National Patient Safety Agency and the (successive) NHS Modernisation agency, the NHS Institute for Innovation and Improvement and NHS Improving Quality. Strategy Health Authorities with regionalised resource centres for quality improvement also came and went. As far ago as 2008 the Nuffield Trust referred to “a bewildering and overwhelming profusion of Government-imposed policies and programmes.” Since then we have had Darzi, Francis and austerity.
The Nuffield Trust, the same review, identified the conflict between supporters of improving quality by centralised control and devolution. So the Francis Inquiry led to more inspection and Darzi, it should not be forgotten, believed that clinicians knew best how to improve quality in their own localities. Patient choice, market forces and “naming and shaming” have also all been given a role. Berwick, in 2013, took a contrasting view and said that the NHS should be a “learning organisation” with less scrutiny, rewards and punishments. Unfortunately, if anything since then, “the cycle of fear” has grown stronger. Although the latest NHS staff survey has shown that people feel more confident that action will be taken following an incident they also fear they are more likely to be blamed for it. The Kings Fund believes that a more productive approach would be to appeal to the staff’s intrinsic motivation to see quality improvement as something they feel skilled in and knowledgeable about and supported in providing high quality care and continually improving it. The disillusion prevalent amongst so many older GPs “hanging on in there for retirement” and the mood amongst junior doctors embroiled in an unprecedented dispute with the Secretary of State could not be in greater opposition to this ideal. The authors agree and conclude that acting on the evidence of high levels of stress and improving the working lives of health care professionals is necessary. Happy staff provide better quality care and so “Every provider should aspire to create…joy at work and that avoids…staff burnout in the face of rising demands…” One rather fears the NHS version of this might resemble the Emperor Ming’s injunction in Flash Gordon: “All creatures will make merry, under pain of death!”
This document argues that we need a consistent and coherent approach that learns from the successes and the false starts of the past. The mayo Clinic’s mantra is “the needs of the patient come first.” Individuals need to be supported by management at all levels, with boards taking personal responsibility for quality, in using established methods of quality improvement aiming at specific and quantifiable goals. Patients and carers must be listened to and learned from. This must be real experience and evidence, not just those vignettes which provide what your reviewer calls “policy-based evidence.” The NHS will find it difficult to do this under the political spotlight and which works at a scale far bigger than any other health care organisation that has ever brought about whole system improvement. The overwhelming need to “restore financial balance” may well set back quality improvement. Spending “in line with available funding needs to be done in a way that promotes quality improvement rather than making it more difficult.” Another important statement is that inspection has a role in quality assurance but this must not be confused with quality improvement. One result has been an unrealistic expectation of what inspection can achieve.
The next steps will involve “the willingness of politicians to reduce the burden of regulation, inspection and performance management on the NHS to free… [clinicians and leaders to pay]… attention to the work of improvement.” NHS organisations will need to build in-house capacity for quality improvement and some examples from home and abroad are provided. The paper regrets the disbandment of the NHS Modernisation Agency which had a network of some 800 individuals connecting it to virtually every acute and primary care trust in its day. Learning will need to be shared through regional support with reference to the National Primary Care Collaborative which was a result of the NHS Plan in 2000. The Advanced Access model emerged from its work and reference is made to evidence that it improved access without increasing workload, demand on other services or reducing continuity of care. The Advancing Quality Alliance in the north-west of England and UCLPartners, which unites an academic health science centre, network, educational lead provider and two National Institute for Health research groups, has supported improvement s to stroke and cancer care across parts of London. However a “modestly sized” national centre of expertise should also be set up to take forward the good work of the successive previously disbanded organisations. Work on quality improvement should be integrated with work on leadership development by bringing together resources currently residing in HEE, NHSE and NHS Improvement with the latter taking the lead. This understanding of quality improvement should also be built up amongst civil servants and politicians but this would be “admittedly difficult to arrange…” All national bodies, old and new, should provide unified and coordinated support to the NHS as full participants in a single strategy, starting with “challenged organisations.” The need to reduce fear of dismissal amongst the leaders of those providers and to learn from the experiences of challenged organisations would be better than ever closer scrutiny and threats. Frontline clinical leaders and leaders of NHS organisations must be involved in creating the strategy. The latter should have a track record of achievement in quality improvement. Te voice of patients and the public must not just be asked for but also heard and acted upon. The NHS must be open to learning from other organisations at home and abroad whilst recognising that not all of this is directly applicable to the NHS in England. NHS Scotland is held up as an example from which to profit. There is also a plea to work with groups outside the formal structure of the NHS including the Kings Fund! Finally the NHS should be able reflect, measure and learn rapidly about what is and what is not working to make implementation of change more successful. Roy Griffiths is quoted (from 1983) as saying that the NHS “can ill-afford to indulge in any lengthy…soliloquy as a precursor or alternative to the required action.” We need to get on with it and “above all, the NHS needs a much greater degree of stability and constancy of purpose, the lack of which confounds far-sighted investments, co-operation, trust and growth of knowledge, all of which are essential for continual improvement.” A “herculean effort” will be needed to create a coherent quality improvement strategy for an organisation serving 53 million people, employing 1.4 million staff and with an annual budget of £116 billion. Leaders at all levels will have to hold their nerve and resist the pressure towards a “simplistic focus on cost-cutting.”
The document ends elegiacally by saying that “The NHS remains a great source of hope for nations committed to health and health care as human rights. That promise, and that burden, will to be met through over reliance on inspection to stimulate improvement, nor through ever-chnaging rhetoric and ever-migrating goals…” NHS leader must have the will.
Dr Barry Moyse
Deputy Medical Director