The first two decades of the 21st century have posed unique challenges for the UK’s health and care system, alongside remarkable innovation and change. This history describes the role of the Health Foundation and the people it has worked with from its start in 1998 to its position today as an influential voice in improving health and care in the UK.

A fundamental part of how the Health Foundation achieves its mission is through the work of its partners, and the organisations and people it funds. This is therefore a history not only of the Foundation, but of the contribution made by all the people it has funded and worked with to improve the quality of health and care.

Timeline

Initially, the Foundation’s aims focused on applying an evidence-based approach to health research and learning. It immediately became one of the UK’s largest grant-making trusts, supporting areas from service development to research, education and training, across health care and public health.

David Carrington was appointed its first Chief Executive, having previously managed a grant-making trust. The Foundation joined a handful of other organisations in the field including The King’s Fund and the Nuffield Trust. Although there were, and still are, areas of overlap and collaboration, the Health Foundation was predominantly a research grant-making body in its early years.

In January 1999, the Health Foundation launched its inaugural grant-funding programmes. The first of these allocated £5m in grants (worth £15,000–£300,000 each) over a 3-year period. The scheme received thousands of applications and was judged by a global network of peer reviewers. Early grant holders focused on issues ranging from child and adolescent learning disabilities and mental health to reducing the need for long-term care among older people.

The grants established a pattern of maximising impact by investing in talented individuals who would go on to positively influence health care over their careers – a theme throughout the Foundation’s history. First examples included, mid-career awards for health care professionals to carry out research as well as awards to medical students. There was some flexibility in grant making though and a £100,000 donation to an emergency fund for Kosovo was made a month before the war ended. In the years that followed, funding was also dedicated to programmes in Uganda and India supporting maternal and infant health, sanitation and mental health.

In 2001, the board decided to develop leadership and management structures further, building an organisation more like the Health Foundation we know today: combining front-line grant making, and research funding with influencing activities to bring about change.

At the beginning of 2002, the Health Foundation welcomed Stephen Thornton as Chief Executive. A former member of the NHS graduate training scheme and trust chief executive, Stephen would go on to lead the NHS Confederation before joining the Foundation in 2002 (then still known as the PPP Foundation).

In July 2003, Stephen relaunched the organisation as the Health Foundation and developed a new strategy that would continue to evolve over the coming decade. This strategy began the transformation of the Foundation from one primarily focused on grant making to a mixed model combining a variety of methods to achieve impact. The Foundation’s new ambitious aim was to improve the quality of care provided by the health service in the UK. This involved harnessing its endowment to fund, test, learn and spread different ways of improving care, working in partnership with the NHS. The approach, known as the programming approach, was based on Porter and Kramer’s model of how foundations can achieve most value.

During this time the Foundation became increasingly focused on sharing lessons from its research and improvement programmes. One impact of this drive to inform policy and practice was seen in 2009, when the Health Act introduced a requirement for the NHS to report annually on the quality of its services.

As the Foundation’s focus evolved, so too did its approach to funding, which was now aimed at improving the quality of health care at a system level by funding individuals, programmes and research, and sharing this knowledge. The Foundation’s Quality Improvement Fellowship (QIF) programme launched in 2004 and was particularly influential in developing a cohort of clinicians into skilled health care leaders for quality improvement. The programme offered senior NHS professionals intensive quality improvement training as part of a 1-year fully-funded fellowship based at the Institute for Healthcare Improvement in the US. Other leadership programmes with health care quality at their core included GenerationQ, Leaders for Change and Leadership Fellowships.

The Foundation also continued to invest in leaders in clinical and health services research by developing leadership programmes and by providing long-term funding for academics working in these areas. It funded university chairs in learning disabilities and health economics and continued to invest in clinical research through its Clinician Science Fellowships programme, run jointly with the Academy of Medical Sciences.

The Foundation had always commissioned independent evaluations of its front-line programmes to ensure the findings were robust. Now, it began publishing these findings in order to implement and influence evidence-based change.

Quality improvement

In 2004, the Foundation launched the Engaging with Quality Initiative (2004–08), followed in 2007 by Engaging with Quality in Primary Care (2007–11) – both £5m improvement programmes aimed at supporting clinical teams to test new ways of improving patient care. Meanwhile, Closing the Gap through Clinical Communities (2009–12) aimed to build the knowledge and skills of clinical teams. This programme inspired similar work elsewhere in the UK and internationally. In 2010, the Foundation also launched Shine – a programme providing grants to test small-scale innovations in the way health care was delivered. These programmes, alongside the Foundation’s investments in patient safety and person-centred care, helped to bring quality and quality improvement methods into mainstream UK health service reform.

Alongside its UK focus, the Foundation also funded and developed, with a consortium of international experts, a major £6m quality improvement programme in Malawi in response to the UN’s Millennium Development Goal to improve maternal health. MaiKhanda (2006–10), which means ‘mother and baby’ in Chichewa, aimed to improve women’s birth outcomes and reduce neonatal mortality. The independent evaluation found that at least 1,000 newborn babies’ lives were saved during the programme.

Improvement science

An important part of the Foundation’s quality improvement work was the development of the evidence base for improving health care quality. During the 2010s the Foundation led efforts to develop and strengthen the field of improvement science – multidisciplinary research that aims to understand, develop and evaluate improvements to health care practice. This work included convening experts, funding a range of fellowships in improvement science, and partnering with the BMJ to develop the journal BMJ Quality & Safety – now internationally recognised in its field, and still co-owned by the Foundation to this day. This focus on developing and strengthening the field of improvement research culminated in the Foundation’s biggest investment to date: the establishment of THIS Institute (see section 5), dedicated to strengthening the evidence base for improving the quality of care.

Person-centred care

From 2005, the Health Foundation was at the forefront of building the evidence and practice of person-centred care. Person-centred care involves health and social care professionals working collaboratively with people who use these services – supporting people to develop the knowledge, skills and confidence to manage and make decisions about their own health and care. For over 10 years, the Foundation invested more than £20m in improvement programmes and research, raising the profile of person-centred care in national policy and health care delivery.

This work was in two main areas. First, it developed thinking on self-management support for people living with long-term conditions through Co-creating Health (2007–12) and Spreading Self-management Support (2013–15). Second, it focused on shared decision making, with its MAGIC (2010–13) programme helping clinical teams share decision making with patients in their everyday practice.

The Foundation also supported projects in other areas of person-centred care. Between 2011 and 2013, Closing the Gap through Changing Relationships helped teams to change the dynamic between clinical teams, patients and communities. One example – shared haemodialysis – was later scaled up to another 19 NHS organisations.

Alongside National Voices, the Foundation successfully campaigned for the Health and Social Care Bill 2012 to include duties for NHS commissioners to promote patient involvement. This included helping to draft the statutory guidance for commissioners to meet these duties.

In 2015, this work culminated in the Foundation and partner NESTA being chosen to deliver Realising the Value – NHS England’s flagship programme to build the evidence for embedding person and community-centred care. The programme’s findings and resources would go on to substantially influence the development of both the NHS Long Term Plan (2019) and the Comprehensive Model for Personalised Care.

Patient safety

Drawing on its expertise in safety and quality, the Foundation began promoting patient safety as something that should be at the forefront of policy and practice. Beginning in 2004, the Foundation invested almost £25m in safety-related programmes and initiatives over the next 12 years.

Early programmes – most notably, the £10.5m Safer Patients Initiative (2004–08) and the Scottish Patient Safety Programme (2010–17) – focused on reducing or eliminating known areas of harm, such as health care acquired infections, falls and surgical or medication errors. As well as reducing harm at participating hospitals, the programme also inspired regional and national initiatives (such as the Patient Safety First Campaign). Between 2008 and 2013, the Foundation built on this work by sponsoring the Patient Safety Congress to engage leaders in patient safety, supporting the Patient Safety First Campaign and launching a dedicated resource centre. The Foundation also explored approaches to proactively reduce hazards through the £4.4m Safer Clinical Systems Programme, and later the £4.5m Closing the Gap in Patient Safety Programme (2014–17).

The Foundation’s work encouraged a shift from ‘counting harms’ to measuring and monitoring safety. The measurement and monitoring framework, developed with the Foundation’s support, became the basis for Care Quality Commission safety inspections.

In 2013, Stephen Thornton was succeeded by Jennifer Dixon, former Chief Executive of the Nuffield Trust. Jennifer’s background encompasses paediatric medicine, public health and a stint as policy adviser to the NHS Chief Executive.

Under new leadership, the Foundation built on its work to improve health care by adding considerable in-house expertise to develop more influence over national policy, including through areas such as economic analysis and data analytics. And in recognition of the wider social and economic drivers of health and health inequalities, in 2017 the Foundation established its healthy lives strategy – broadening its remit to include health as well as health care. It also retained its focus on improving the quality of health care services, building on the work of the previous decade.

Today, the Foundation continues to build its capacity to fund and influence evidence-based change, using a wide range of methods it has developed and experimented with over time. These include grant funding initiatives, capability building through fellowship and leadership programmes, community building, strategic communications and influencing, research and evaluation, and more recently, funding investor action. It combines these approaches to influence both short and long-term change across the different areas of its strategy, working in partnership with others.

The Health Foundation’s strategic priority areas (2019–22)

The Health Foundation’s strategy during this period is guided by five aims:

• Promoting healthy lives for all
• Data analytics for better health
• Supporting health care improvement
• Making health and care services more sustainable (economics)
• Improving national health and care policy.

Promoting healthy lives for all

In 2017, the Foundation launched its long-term healthy lives strategy. The strategy seeks to change the national conversation to focus on health as an asset, rather than ill health as a burden. It has worked to build evidence on national and local policies and encourage local action, publishing new analysis and developing resources to explore how the circumstances in which we live shape our health – including through its evidence hub on what drive health inequalities.

The Foundation examined these themes in depth in the Institute for Health Equity’s major report Health Equity in England: The Marmot Review 10 Years On. Funded by the Foundation, and published in February 2020, it positioned health inequalities at the centre of public concern at the start of the COVID-19 pandemic. In July 2021, the Foundation published the findings of its COVID-19 impact inquiry, which examined how experiences of the pandemic were influenced by people’s existing health conditions and inequalities in health.

Meanwhile, the Young people’s future health inquiry was the first research and engagement project of its kind, aiming to build the policy, research and place-based agenda to improve the future health of today’s young people. This focus continued in 2021 with the launch of two flagship funding programmes: Shaping Places for Healthier Lives and Economies for Healthier Lives. And more recently the Foundation also moved into active public campaigning by establishing Health Equals.

Data analytics for better health

Rapid innovation in analytics and data-driven technology has had a profound impact across society, and presents major opportunities for health and care. In 2014/15, the board authorised a new data analytics strategy to strengthen the Foundation’s policy work with quantitative analysis and the ability to evaluate core health care reforms, such as the move to integrated care. Since then, the Foundation has developed considerable in-house technical expertise in fields such as data management, data science and statistics.

In moving into this innovative terrain, the Foundation focused on where it could make the most distinctive contribution. This has included nurturing the use of novel data and analytics methods not previously applied in health care, and supporting their use within the NHS. One such Health Foundation programme offered around £4m in funding for NHS analytical teams to use data in new ways that address the biggest challenges facing their organisations.

Supporting health care improvement

The Foundation’s focus on improving health service delivery, and spreading what works, continued to evolve. Work to make a difference through investing in people broadened to include different ways of building capability – such as through the Q Community (see below) and the Health Anchors Learning Network. The Foundation has also focused on improving the flow of patients through care pathways via the Flow Coaching Academy.

Meanwhile, efforts have continued to build the evidence about what works and why – not least through funding THIS Institute and publishing outputs such as the 2018 report The spread challenge, which highlights new approaches to support the spread of innovation. And in 2019 the Foundation agreed a major £15m joint investment with the Economic and Social Research Council to fund a new research centre to increase the use of high-quality evidence to improve and support innovation in adult social care. The new IMPACT (Improving Adult Care Together) centre, based at the University of Birmingham, launched in 2021.

Making health and care services more sustainable (economics)

In 2014 the Foundation began to grow its in-house expertise in economic analysis, producing a number of high-profile and influential outputs over subsequent years. These included Securing the future, with the Institute for Fiscal Studies, which set out the funding and workforce requirements to meet growing demand for care from 2018 for the decade ahead. This work influenced the NHS funding settlement that the government announced that year. Subsequent analysis of capital investment required was also influential in increasing understanding of the wider investment needed in the health system. Meanwhile the Foundation’s 2016 analysis The path to sustainability presented funding projections for the NHS in Wales over a 15-year period. Shortly after publication, the Welsh NHS budget received major investment, with the Health Foundation’s work directly quoted in the budget report as a reason for this increase.

A fork in the road, published jointly with The King’s Fund in 2018, marked an important shift in the Foundation’s work to also include social care. The influential report considered the costs of different social care funding options, public attitudes to these and the implications for funding reform in England.

Building on the Health Foundation’s expansion into economic analysis, in 2020 the organisation launched the REAL Centre – marking a major progression in the Foundation’s sustainability research. In recognition that workforce shortages represent the biggest challenge facing the NHS and social care, the Centre’s main objective is to produce long-term projections for the resources the health system will need relative to the demands on it.

While the REAL Centre produces some analysis with a short-term focus, its main work is on improving the evidence used to inform longer term decision making. It works in partnership with leading experts and academics to help policymakers look beyond the short-term implications of their funding and resourcing decisions. It also aims to stimulate debate and challenge existing thinking through its agenda-setting annual lectures and panel debates. For example, in 2021 acclaimed author Hilary Cottam used the annual lecture to share her own radical new vision for social care, focused on reimagining and redesigning support systems for this century.

Improving national health and care policy

Perhaps the most noticeable change since 2013 has been the Foundation’s ability to influence policy and inform wider debate. Much has been done to track and analyse national policies in England, with a particular focus on the overall direction of the health system and how it is performing.

The Foundation has made a unique contribution by consolidating its knowledge of how change and improvement happen at the front line, together with its understanding of the factors that shape national policies and priorities. This resulted in publications such as 2015’s Constructive comfort: accelerating change in the NHS, which sought to bridge the gap between policy and practice by asking how to design national policy on the NHS to accelerate improvements in health care. This is thought to have influenced the creation of the NHS national improvement, leadership and development strategy.

Following the vision set out for health care services in NHS England’s Five Year Forward View, the Foundation offered a strategic framework for national leaders working to create a sustainable NHS through its publication Shaping the future. The report called for a long-term strategy to articulate and align action across multiple fronts, foreshadowing the 5-year funding settlement announced by Theresa May in 2018 and the 10-year NHS Long Term Plan published in 2019.

The Health and Social Care Act 2012 marked a major shift in the governance of the NHS in England, further fragmenting national responsibilities for quality of care. The Foundation’s 2016 report A clear road ahead set out how to reinvent a strategic framework for quality in the NHS in England. Its work with the various national bodies highlighted the fragmentation and duplication created by the reforms, and set out a practical and feasible set of actions. This influenced the shared commitment to quality from leaders in national organisations subsequently published by the National Quality Board.

In 2018, the Foundation worked with Professor Mike Richards, the government’s former National Cancer Director, to look at progress in cancer care since the launch of the NHS Cancer Plan in 2000. Unfinished business highlighted substantial progress on reducing mortality, improving survival rates and experiences of care, but it also showed that survival rates in England lagged behind most European countries. This analysis was referenced in the NHS Long Term Plan, which committed to a new ambition to improve rates of early diagnosis.

More recent work has focused on tracking and strengthening system performance. Launched in 2021, the policy navigator microsite charts major developments in health and care from the 11th century to the modern day, providing a tool to understand how current policy has developed, and to learn from the past. Meanwhile the COVID-19 policy tracker documents the complex and rapidly evolving response to the pandemic in 2020, examining wider changes to social and economic policy as well as to the health and care system. The Foundation’s 2021 report The NHS Long Term Plan and COVID-19 takes stock of progress in implementing the 10-year vision for the health service and identifies implications for the future as the NHS and government plan the recovery. At a broader level the Foundation’s policy work has been supported through fellowships, including co-funding the US Commonwealth Fund’s Harkness Fellowships in Health and Care Practice and the European health leaders’ network, Sciana.

Since the Health Foundation’s formation, society and health care have faced many changes – some of them fundamental. Devolution, global recessions, advances in technology and digital connectivity, austerity, the pandemic, climate change, and whatever might come next. NHS structures and funding have also been revisited many times along the way, with funds fluctuating over the years. These factors have had and will have profound impacts on health and care.

Over this time there have been demonstrable steps forward in some areas of health and care. The concepts of shared decision making and person-centred care (promoted by the Health Foundation from around 2010) are now widely understood. Quality improvement is today considered mainstream, with most NHS organisations having defined organisational leads or teams in this area. There is also a widespread expectation of participation – not only of patients (for example, in developing patient information) but also staff at all levels. This has led to natural leaders emerging from across health and care – not always those in senior or clinical positions.

But despite the positive changes since the Foundation’s birth in 1998, there has been less progress in other areas, including social care reform and in aspects of public health. COVID-19 has also thrown many of the challenges facing society into sharp focus – not least the cruel and unfair effects of health inequalities. But it has also highlighted some opportunities, including those presented by digital technology and greater public awareness of these issues.

Health and care are operating in uncertain times, and the Foundation will need to be responsive in setting its agenda for the next phase. It will need to continue to learn and adapt creatively, working over both the short and longer term. And by balancing its different approaches such as funding research with practical programmes on the ground, and a focus on understanding challenges alongside working on possible solutions. This will not only include how the Foundation makes the most difference to health and care nationally and locally, but its role in helping to address wider societal challenges such as climate change and promoting equity, diversity and inclusion throughout its work.

But wherever health and care – and society as a whole – are heading, the Foundation will continue to work with others to bring about change as well as draw on its roots of evidence, analysis, independence and its desire for on-the-ground change, as it continues to support health and care in the UK.

The Foundation’s focus will continue to be on accelerating change and improvement at the front line, informing ongoing reform of the health and social care system, and tackling inequalities – to bring about better health for all.

Thank you

Our work would not happen without the dedication, imagination and effort of the many individuals and organisations we work with and support to improve health and care. We would also like to thank our staff, our board of governors and all our delivery partners.

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