Introduction and summary

In the past few decades, much of the national policy discourse on NHS organisations that provide health care in England has focused on how they perform against a core set of quality and financial targets. The policy focus has been on deploying a range of regulatory and payment levers to try to ensure compliance with these targets, or pursuing structural reform to boost performance and tackle variation between providers. As a result, much more attention has been paid to ‘what’ providers have done than to ‘how’ or ‘why’ they have done it, and much more emphasis has been placed on externally driven, rather than internally driven, change.

In recent years, however, there have been signs of a shift in approach. National frameworks and concordats such as Developing People, Improving Care and Shared Commitment to Quality have looked beyond performance metrics to the capabilities and capacity needed within provider organisations to drive improvement. It is important to measure, recognise and incentivise quality, these documents argue, but this must go hand in hand with a strategy for providers to build the knowledge, skills and infrastructure that are needed for the consistent delivery of high-quality care and for continuous improvement. Similarly, the Care Quality Commission’s (CQC) examination of how NHS trusts rated as outstanding have embedded quality improvement (QI) across their organisations highlights the importance of building the right skills and culture among staff.

The NHS long term plan recognises that successful delivery ‘will rely on local health systems having the capability to implement change effectively’ and commits to ‘supporting service improvement and transformation across systems and within providers’. This includes an initiative, in partnership with the Health Foundation, to increase the number of integrated care systems that are building improvement capability.

This report summarises the evidence on building improvement capability to support this evolving agenda, primarily within the context of the NHS in England. It draws on the learning and insights that the Health Foundation has generated over the past 15 years from funding and evaluating improvement at team, organisation and system level.

Part I describes what is meant by an organisational approach to improvement and why it matters. An organisation-wide approach can ensure that local activities are aligned, coordinated and appropriately resourced, helping to avoid the fragmentation and duplication often associated with working only at the microsystem level. It also provides the strategic constancy of purpose, momentum and infrastructure necessary for multifaceted, cross-organisational initiatives to emerge.

Most of the NHS trusts in England that have an outstanding CQC rating have implemented an organisational approach to improvement. Part I also provides case studies of three of these trusts: East London NHS Foundation Trust, Northumbria Healthcare NHS Foundation Trust and Western Sussex Hospitals NHS Foundation Trust.

Part II describes the six steps of the improvement journey that trusts must go on to put in place an organisation-wide approach:

  1. assessing readiness
  2. securing board support
  3. securing wider organisational buy-in and creating a vision
  4. developing improvement skills and infrastructure
  5. aligning and coordinating activity
  6. sustaining an organisation-wide approach.

It also sets out the different approaches trusts can take to building their capability: building ‘from within’; seeking support from commercial and not-for-profit bodies and consultants; and seeking support from peer organisations. In addition, it outlines some investment considerations.

Drawing on analysis of peer-reviewed improvement literature and the Health Foundation’s own improvement programmes and publications, Part II also sets out the enabling factors that contribute to the success of an organisational approach. These fall into four broad categories: leadership and governance; infrastructure and resources; skills and workforce; and culture and environment. It further describes some of the key organisational barriers to improvement.

Part III describes recent approaches that national bodies in England have taken to support and encourage the building of improvement capability, and looks at how what is required to make further progress. Ultimately, providers and local health and care systems themselves are responsible for taking forward this agenda, though policymakers and system leaders have an important responsibility in supporting them to do so.

National bodies with regulatory, performance-management or support responsibilities should speak with one voice about organisational improvement and develop a shared model of change. They should also do more to encourage and support organisations with established improvement pedigrees to share their learning and expertise. Another priority is ensuring that trusts and local health and care systems have the resources, time and autonomy needed to develop capability-building programmes. Although building improvement capability has long-term benefits, the improvement journey can require significant upfront investment, so there is a strong case for national support to help more providers and systems get started. And given the very different starting points and requirements that different providers have, it is essential that this support is flexible.

Finally, the Appendix lists some key Health Foundation publications for further reading on the challenges of quality improvement and building improvement capability.