Commitment to change the NHS must come from within

It is time to bring about a fundamental shift in how the NHS is reformed. This is the clear message of a new report from the King’s Fund, Reforming the NHS from Within.

‘Much greater priority should be given to reforming the NHS from within’

Much less emphasis should be placed on the use of external pressures, such as targets and inspection, and much greater priority should be given to reforming the NHS from within.

Sustainable improvement in the NHS needs to be based on commitment rather than compliance, learning from high performing organisations in England and elsewhere.

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Watch out for negatives too

This means appealing to the intrinsic motivation of staff to provide the best possible care and providing them with the skills needed to improve care.

Leadership at all levels needs to be strengthened to enable NHS organisations to make the changes now needed to transform services.

The argument for a fundamental shift in how the NHS is reformed is based on a comprehensive review of experience in England over the last 20 years, coupled with evidence from other systems.

‘Leadership at all levels needs to be strengthened to enable NHS organisations to make the changes’

This shows that targets, regulation and competition have had some positive impact on performance, but they have had negative consequences too.

These consequences include managers misreporting data to avoid being penalised for failing to achieve targets, and regulators failing to prevent serious failures of care, such as those that occurred at Mid Staffordshire Foundation Trust.

Likewise, the benefits of competition claimed by some researchers must be weighed against the substantial transaction costs involved in organising a market in healthcare.

Look abroad

The alternative to relying on external pressures is to learn from high performing healthcare organisations here and around the world.

These organisations have achieved high performance by developing a clear and compelling vision, linked to specific goals for improvement and making use of explicit improvement methodologies. Measurement towards goals is reported transparently to support implementation.

‘Resistance was tackled by developing an explicit compact between doctors and organisational leaders’

A well known example is the Virginia Mason Medical Center in Seattle, visited recently by health secretary Jeremy Hunt because of its outstanding achievements in improving patient safety.

The centre’s achievements are due largely because of the way it adapted the Toyota production system to reduce waste and minimise errors.

It started its journey in 2001, with its top leaders deeply and visibly committed to implementing its vision throughout this period. 

Many challenges have been encountered along the way, including resistance from some doctors to more standardised ways of working. This resistance was tackled by developing an explicit compact between doctors and organisational leaders, setting out mutual expectations about what it means to work at Virginia Mason.

Good practice at home

Closer to home, Salford Royal Foundation Trust has delivered outstanding results following its adoption of a vision to become the safest organisation within the NHS in 2008.

Key goals included reducing mortality, improving patient experience and improving reliability, as well as reducing harm to patients. These goals have been pursued by developing a culture to promote safe care throughout the organisation.

Salford’s culture embraces a number of core values, with staff supported to put these values into practice through training and development. The content of training includes improvement skills, understanding “lean” methods and statistical measurements. These skills are applied in a rolling programme of quality improvement projects.

‘The focus must shift to supporting organisations to transform care themselves, instead of putting even external pressure on them to do so’

Drawing on the experience of these organisations and others, the focus must now shift to supporting NHS organisations to transform care themselves, instead of putting even more external pressure on them to do so.

Priority should be given to investing in staff, developing leaders – including clinical leaders – and recognising the time it takes to bring about sustainable improvements in quality and safety.

For this to happen, it is essential that the role of politicians is clearly demarcated to avoid short term political initiatives getting in the way of the long term commitments needed to deliver change.

A new settlement is needed that clarifies the strategic role of ministers and provides local leaders with the space to develop new models of care.

Devolution and transparency

Accountability for operational performance should rest with the leaders of NHS organisations and the regulators that oversee their performance.

This should be accompanied by a stronger emphasis on devolution within the NHS, learning from the experience of foundation trusts based on the principles of presumed autonomy and proportionate regulation.

‘Devolution and transparency are the essential ingredients in the next stage of NHS reform’

Challenging NHS organisations to improve by comparing their results with peers through open reporting of performance data also needs more attention.

Devolution and transparency, linked to developing leaders and staff to improve care, are the essential ingredients in the next stage of NHS reform.

This must be underpinned by a commitment to put patients first and enhance their role in the design and delivery of care. The experience of high performing healthcare organisations is that this commitment has to come from within organisations. It cannot be mandated from outside.

Professor Chris Ham is chief executive of the King’s Fund