Part III: Support for organisations on the improvement journey

National support for organisations in England

Despite the policy focus on externally driven change in recent decades (via mechanisms such as regulation, targets and financial incentives), there have been consistent efforts to facilitate organisational improvement since the publication of The NHS Plan in 2001. Each successive national improvement agency has encouraged organisations to develop coordinated improvement programmes that encompass every service they provide, along with the necessary supporting infrastructure. Many national improvement programmes have been created since 2001 in support of this aim. An example is the Leading Improvement in Patient Safety programme (2009–2013), which was described by the NHS Institute as a ‘comprehensive programme designed to help NHS trusts build the capacity and capability to eliminate harm’. Participation in these programmes has been an important staging post in the improvement journey of many trusts with established improvement pedigrees.

Over the years, however, messages from national bodies on how to deliver improvement, and what to prioritise, have not always been aligned or consistent. In 2016, in an effort to address this challenge, the National Improvement and Leadership Development Board, which brings together the 13 key health and social care arm’s-length bodies and provider membership bodies in England, published a national framework (Developing People, Improving Care) to guide action on developing improvement skills and leadership development in the NHS. Designed to ensure that the national bodies responsible for driving, supporting and regulating quality are able ‘to engage across the service with one voice’, it sets out the cultural conditions for change and stresses the need for collective action to deliver them.

Much of the activity at national level focused on building the capability for improvement within organisations is currently led by NHS Improvement. One of its core objectives is for every provider organisation to ‘implement effectively a recognised continuous improvement approach’ by 2020. To help achieve this, NHS Improvement has implemented a series of national training and support programmes (Box 5), and developed improvement resources. For example, in 2017 it published a guide that describes how providers can identify the type and level (or ‘dose’) of improvement skills they need to develop at each level of the organisation. This work at NHS Improvement is similar to an exercise led by NHS Scotland in 2013–2015, which aimed to assess the state of QI infrastructure in Scotland by mapping improvement activity and identifying strengths and gaps.

Moves to bring about NHS England and NHS Improvement together as a single organisation are likely to have important implications for the improvement activities of local providers and systems. A new Director of Improvement post has been created as part of this restructuring. As well as enabling the integration and alignment of national programmes and activities, this should help to set consistent expectations for providers and local health systems. As part of this agenda, NHS England and NHS Improvement will need to consider the right balance between directly providing improvement programmes and support themselves, and commissioning them from external bodies while supporting trusts and systems to take such opportunities up.

The CQC, which monitors health care providers, has identified the promotion of innovation and improvement as a key strategic goal. It has issued guidance to CQC inspection teams stating that they ‘should always assess the presence and maturity of a QI approach within a provider organisation’ and has worked with NHS Improvement to develop a joint ‘well-led framework’ to inform inspections and trusts’ internal development reviews. The framework aims to increase the emphasis that trusts place on developing organisational culture, improvement and system working. Furthermore, the CQC also seeks to capture and share learning from trusts that have met the ‘well-led’ criteria.

Box 5: Some national support and training programmes involving NHS Improvement

Getting it Right First Time (GIRFT)

This programme is designed to improve medical care within the NHS by reducing unwarranted variations. GIRFT identifies changes that will help improve care and efficiency, such as the reduction of unnecessary procedures. Having begun as a pilot within orthopaedic surgery, the GIRFT methodology is now being rolled out across 35 surgical and medical specialties.

NHS partnership with Virginia Mason Institute

This programme is a 5-year partnership between the Virginia Mason Institute and five NHS trusts to support them to develop a ‘lean’ culture of continuous improvement. It began in 2015 and is now being evaluated by Warwick Business School (with Health Foundation support).

Lean programme

This 3-year programme, open to all types of provider organisation, was launched in early 2018. It aims to support seven providers to deliver a lean management system which recognises the context and needs of their organisation.

Quality, Service Improvement and Redesign programmes

Quality, Service Improvement and Redesign (QSIR) programmes are aimed at clinical and non-clinical staff involved in service improvement within their organisation or wider system. They train participants in the use of tested improvement tools and approaches, such as process mapping and measurement for improvement, and encourage reflective learning. Options include a 1-day improvement fundamentals course; a 6-month improvement practitioner course; and the QSIR college, which is a train-the-trainer course.

Leadership for Improvement board development programme

The programme focuses on teaching boards what it takes to lead improvement in organisations. The first cohort of the programme will run from January 2019 to March 2020.

The National Institute for Health and Care Excellence has produced resources to support improvement, for example its QI resource for adult social care aimed at commissioners and provider organisations.

How can we make further progress?

Ultimately, providers and systems themselves are responsible for delivering this agenda. Unless trusts have the appetite to plan and deliver organisation-wide improvement programmes, and to give them the priority they need to succeed, and unless leaders see it as a core element of good organisational management, little will be achieved. Policymakers and system leaders should expect trusts to engage in QI and build their capability for improvement. The inclusion of this area in CQC inspection guidance and their well-led framework is therefore a positive development. However, as this report makes clear, policymakers and system leaders also have a responsibility to support this agenda.

First, national bodies with regulatory, performance-management or support responsibilities must speak with one voice about organisational improvement and develop a shared model of change., The Developing People, Improving Care framework is an attempt to realise this ambition. This approach should be sustained over time, and the commitment expressed in the framework matched with action. For instance, wider, national change programmes must complement this work, rather than creating conflicting initiatives that make it harder to provide the local leadership required for sustained organisational improvement. An awareness of the time needed for a mature, organisation-wide improvement programme to become embedded will be crucial, as will a commitment to supporting NHS trusts and systems as they make this long-term journey.

Second, the NHS needs to do more to encourage and support organisations with established improvement programmes to share their learning and expertise. The improvement stories of trusts like East London NHS Foundation Trust show how important visits to pioneering trusts such as Salford Royal and Tees, Esk and Wear were in motivating board members about QI. However, the outreach offers of most leading NHS providers are not as well developed as those of US providers, such as Virginia Mason. Strengthening and expanding the outreach programmes and formal consultancy offers of high-performing trusts would therefore be valuable. Encouraging and enabling trusts with proven improvement track records to build relationships with and support their peers has the potential to deliver greater long-term value to the NHS than the short-term use of commercial management consultancies.

And finally, trusts will need the resources, time and autonomy to develop capability-building programmes. Despite the medium- and long-term benefits of building improvement capability, the improvement journey can require significant upfront investment. At a time when organisations are under significant financial pressure, this investment can be a barrier for many trusts and local systems. There is therefore 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. A critical part of this is supporting providers in assessing their current needs and readiness for change. Evaluation is another key part of the picture, to help organisations and systems understand the impact of their capability building and to help the NHS better understand the most effective strategies.

The NHS long term plan makes a welcome commitment to ‘supporting service improvement and transformation across systems and within providers’ by ensuring that they have ‘the capability to implement change effectively’. It includes an initiative, in partnership with the Health Foundation, to increase the number of integrated care systems that are building improvement capability. The Health Foundation will work with NHS leaders to design and take forward this programme of work. Also important is The NHS long term plan’s announcement of a ‘duty to collaborate’ between providers and commissioners, which sees ‘thriving, successful organisations’ helping their neighbours develop their own capability. This duty will also underpin system-level efforts to build improvement capability, which will be vital to achieving The NHS long term plan’s ambition of creating integrated care systems across the country.

§§ NHS Modernisation Agency (2001–2006), NHS Institute for Innovation and Improvement (2006–2013), NHS Improving Quality (2013–2016), and now NHS Improvement.

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