Delivering improved quality in the English NHS


Written by Dr Abeda Mulla

We (the Strategy Unit) read with interest the recent King’s Fund publication1 that sets out the challenge to improve quality in the English NHS. In this blog we offer our support in developing such a strategy to NHS England and the Department of Health and in delivering and evaluating the agreed strategy in partnership with NHS organisations.

Ham et al. define quality improvement quite broadly: “by quality improvement we mean designing and redesigning work processes and systems that deliver health care with better outcomes and lower cost, wherever this can be achieved”. This notion of quality improvement is at the heart of all the service redesign, transformation and analytics work that the Strategy Unit undertakes in collaboration with local NHS organisations, operating as we do as an internal NHS consultancy.

We believe this internal NHS capability for quality improvement is crucial not only to foster the level of engagement required to provide the patient-centred care we all aspire to (and which includes improved clinical outcomes, patient and carer experience, patient involvement in decisions about local services and in their own care) but is also necessitated in the context of the current fiscal constraints: we concur with the call to reduce ‘reliance on expensive and questionably effective management consultants’.

We know only too well that despite the best intentions for quality improvement within both NHS provider or commissioner organisations, building the in-house capability for improvement is always waylaid with the need to comply with external standards, inspection and performance management. NHS organisational leaders must therefore invest in a sustainable quality improvement safe-haven, this will also allow for quality improvement leads to emerge and thrive.

For the NHS, organisational quality improvement can only be the first step; the ultimate goal is for system improvement, as compelled by Vanguards and Sustainability and Transformation Plans. Our experience of these current NHS programmes of work and their predecessors is that without explicit recognition of the need for organisational quality improvement, it will be impossible to embed a culture of quality improvement and as a consequence, attempts to implement a system strategy will be futile.

System or network working in healthcare is now increasingly recognised to fit within complex adaptive systems theory2 as Ham et al. make reference to. This complexity framework acknowledges professionals and patients as ‘agents’ and the behaviours between agents as ‘interactions’. In the complex adaptive system of the NHS, the theory suggests successful quality improvement would be linked to how agents overcome differences in their role, the different clinical pathways they interact in, and the many interdependencies.

In a complex adaptive systems setting, the achievement of ‘joy at work’3 (which the King’s Fund paper also alludes to) through quality improvement initiatives will require a focused approach to ‘relational coordination’4 . Here agents will have to share: aims that transcend specific functional goals; knowledge that enables how individual roles or tasks interrelate with the overarching plan; mutual respect to overcome status or hierarchies that prevent them from valuing the work of others.

There are many examples5 of good quality improvements currently occurring within the complex adaptive system in the NHS and a strategic approach would ensure that these cases are widely shared and learnt from.

In summarising we to offer a parallel delivery implications list to Ham et al list of policy implications for a strategy for action for quality improvement in the NHS:

  • A national quality improvement strategy that facilitates joy at work requires definition of the role and value of the professionals and patients at different system levels and relational coordination of their quality improvement tasks.
  • Leadership in quality improvement should be an attractive development opportunity for clinicians and organisational leaders both in their own organisations and in network models.
  • The resources and expertise to support the NHS into a learning and high-performing organisation is available in-house (for example the Strategy Unit hosted by the Midlands and Lancashire CSU, the Greater Manchester Transformation Team6) and should be considered first.
  • A pragmatic, real-time evaluation of the implementation of a quality improvement strategy is essential and also possible within the NHS setting (the Strategy Unit is the evaluation partner for three local Vanguards and a Test Bed7) or in collaboration with academic partners (AHSNs and CLAHRCs).


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