Forward view analysis: The power of small changes

The NHS Five Year Forward View is a pithy, intelligent summary of where the NHS needs to go and an estimation of the money needed to do it. Mission well accomplished; there has been strong political consensus on its message after publication.

‘Changing the policy and regulatory “system” cocktail can help nudge progress’

But now the difficult bit - achieving the productivity assumptions set out while improving quality of care. As a report, it’s long on the “what”, but short on the “how”.

Changing the policy and regulatory “system” cocktail can help nudge progress. A first step would be to develop a coherent approach between at least NHS England, Monitor, the NHS Trust Development Authority and the Care Quality Commission on improving care beyond dealing with failure.

Questions include: what are these bodies doing to improve quality; what are the assumptions underpinning their work; and where are the gaps?

Once designed, constant calibration with consistency of purpose over time will help.

But getting the national extrinsic milieu right for commissioners and providers clearly isn’t enough. The action needed is at regional and local level - in particular, leading strategic change across groups of providers in an area, and widespread front line change.

Nudge must be complemented by support to help staff translate their intrinsic motivation into more widespread action. What kind of support? I would suggest there are three major types required.

Learning from success

First, we need to support major transformational change (aimed at manager and clinician leaders) across areas to accelerate new models of care.

We should look hard at practical examples of where in the NHS there has been successful change at scale and examine carefully what it actually took to achieve. The consolidation of stroke and cardiac services in London is an obvious example. Sure strategic leadership will be needed, as will basic management skills and in particular, practical operational excellence.

Second, we need specific collaboratives to boost pace in some key areas including: developing primary care federations; accelerating integrated care on the back of Pioneers and better care fund plans; forward view models of care; and integrated personalised commissioning.

These may not be nationally driven collaboratives, but voluntary regional, area or provider based approaches.

‘Basic practical skills in quality improvement are present in pockets of the NHS but non-existent elsewhere’

Third, and most needed, is therapeutic dosage across the NHS of formal quality improvement skills in frontline staff (managers and clinical staff, particularly physicians). This is very much a Berwickian agenda.

Currently, basic practical skills in quality improvement are present in pockets of the NHS but non-existent elsewhere. Scotland has made a head start, focussing initially on skilling up staff to improve safety. This should be a priority in England, alongside other improvements including flow in emergency care and early and safe discharge of the frail elderly.

The Health Foundation’s funded projects over the last decade show some impressive changes in the use of basic quality improvement techniques in efficiency as well as safety.

Changes are empowering the front line to make and measure the myriad of small changes that add up to something big. A few vanguard centres across the UK have built up capability and now have a sustainable quality improvement infrastructure - fledgling versions of what is seen in centres of excellence in the US we have all heard about.

In the first half of 2015 the Health Foundation will publish a series of UK case studies to encourage good practice.

In our experience, younger physicians in particular need little encouragement - they are hungry for the opportunity. Investing in the above depends on the current “survival of the fittest” approach to improvement (aka do what you can), or on developing a more systematic support. The former results in progress that is not fast enough.

Support at all levels

Finally, where should this type of support come from? It could be provided at different levels, whether nationally or regionally, through commissioners and providers. Academic health science networks, the Advancing Quality Alliance in the North West and local examples at Salford Royal and Sheffield demonstrate how varying forms of support exist across the health service.

But rocket boosters are now needed.

Now is the time to get this right in the NHS more than any other time in the last 20 years. The challenge is also to design an intelligent improvement infrastructure that is stable for the medium term and self-sustaining in the future.

Jennifer Dixon is chief executive of the Health Foundation