UK: Putting High Quality Care Back At The Top Of The NHS Agenda

Last Updated: 7 March 2016
Article by Karen Taylor

Since the start of 2016, bad news stories about the state of the NHS have proliferated, from a larger than expected deterioration in the state of NHS finances, to the junior doctors strike; alongside evidence of increases in waiting times, cancelled operations and bed occupancy figures. All pointing to an NHS under siege with concerns over quality of care increasing. The publication this week, of the King's Fund report on Improving Quality in the English NHS: A strategy for actioni, provides a timely reminder of the importance of building capability for quality improvement in each and every NHS organisation. This week's blog provides my take on the report and the discussion that accompanied its launch.

The King's Fund report argues that the NHS urgently needs to adopt a quality improvement strategy if it is to rise to the significant financial and workforce challenges it is currently facing. It defines quality improvement as designing and redesigning work processes and systems that deliver healthcare with better outcomes and lower cost wherever this can be achieved.

The report sets out 10 design principles to guide the development of a quality improvement strategy. This includes building in-house capacity for quality improvement, by committing time and resources to acquire the necessary capabilities and learning from the experience of trusts such as "Salford, Sheffield and Wigan where quality improvement is well established". It also recommends that organisations should work together through improvement collaboratives, and the importance of shared learning and mutual support. It highlights the achievements in the north-west of England's Advancing Quality Alliance and in London, UCLPartners academic science partnership.

A more contested suggestion is the proposal to establish a "modestly sized" national centre of expertise, learning from the experience of the NHS Modernisation Agency. While most of the audience at the launch appeared to wholeheartedly support the design principles, like a number of other commentators, I was less convinced about the need for a new central organisation. Believing that quality improvement needs to be owned by and generated by staff on the front line and that previous attempts at creating a central organisation with such a remit have largely failed to deliver the desired impact.

The report recognises the importance of staff buy-in to a coherent and unifying quality improvement strategy and the need to implement this in partnership with clinical leaders and managers who have practical experience of implementing quality improvement. During the discussion that followed the launch, there was a prevailing view that many of these change leaders are already out there in the NHS but that they need to be identified, empowered and supported.

It was acknowledged that those organisations that have been successful in achieving high quality care have focused primarily on identifying and reducing variations in clinical care and, where appropriate, standardising how care is delivered. Improvements have also been achieved by investing heavily in training and development of staff at all levels, and by accumulating many small positive changes over time rather than seeking a big breakthrough in performance.

Finally, the report argues that 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 - "with tone in the middle as important as tone at the top". It suggests that unless the challenge facing the NHS is framed as a challenge to improve quality rather than to cut costs, staff will be demoralised rather than motivated, especially clinicians. Indeed it restates the evidence that Lord Darzi articulated in his 2008 review High quality care for allii, that quality not finance should be the guiding strategy of the NHS, while recognising that the results will take time to show, but that there is no better option for the NHS.

While I agree with the majority of the suggestions in the report, I'm less convinced about the overall conclusion that, despite a succession of well-meaning policy initiatives over the past two decades, the NHS in England has lacked a coherent approach to improving quality of care. Indeed I believe that over the last fifteen years there have been significant in-roads in raising the quality bar in the NHS. Some of the more notable initiatives which are referenced in the King's Fund report include:

  • Sir Liam Donaldson's 2000 report, An Organisation with a Memoryiii, which defined and popularised the field of patient safety
  • Lord Darzi's report High Quality Care for All
  • Hard truths: the journey to putting patients firstiv, the government's response to The Francis' Mid -Staffordshire inquiry.

In addition there have been numerous targeted initiatives on improving quality of services like the National Service Frameworks for Heart Disease and Cancer and the National Strategies for Stroke, Dementia and End of Life Care; all of which demonstrate evidence of improvements in patient outcomes.

However, I also know that governments have to respond to the changing political and financial environment, that people in influential positions move on, meaning that organisations often lack a corporate memory and have a tendency to re-invent wheels rather than building on what works and recognising what doesn't. Consequently, I do believe the time is right for a quality improvement strategy that once again focusses attention on the importance and role of quality to enable the best things about the NHS to be maintained, improved and adopted at scale.

Footnotes

i http://www.kingsfund.org.uk/publications/quality-improvement

ii http://www.gov.uk/government/publications/high-quality-care-for-all-nhs-next-stage-review-final-report

iii http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/publications/

iv https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/270368/34658_Cm_8777_Vol_1_accessible.pdf and https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/270103/35810_Cm_8777_Vol_2_accessible_v0.2.pdf

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