From compliance to commitment: should the NHS look to the Danish on how to accelerate change and improvement?

I had the good fortune to visit Denmark earlier this month to talk at a seminar for leaders from the health regions in Denmark. It’s a time of great change for the Danish in their approach to health care quality improvement and the Danish system has many similarities with the NHS, albeit on a smaller scale. Both provide residents with publicly financed health care that is largely free at the point of use. Both face similar challenges: an increasingly elderly population, more people suffering from chronic conditions, significant unwarranted variations in quality and a tightening financial position.

As with the NHS, these challenges are putting the Danish health care system under tremendous pressure. Both systems have recognised the need to change the way in which care is delivered, and have developed plans based around the Institute for Healthcare Improvement’s triple aim framework to create a sustainable future for the service. However despite these similarities on what needs to change, how the Danes are planning to tackle these challenges is significantly different to the approach being taken in England.

So, what is so different? In England we continue to primarily rely on familiar tools such as targets, payment incentives and, increasingly, regulation and inspection to nudge or prod providers to change and improve. In Denmark they have taken the bold move in announcing this month that they are phasing out their hospital accreditation scheme – in place since 2005 – in favour of an approach strongly focused around quality improvement methodology and person-centred care. As Bent Hansen, President of Danish Regions said in announcing the changes:

'Quality work must be simplified and focused. The time has come to strengthen it by putting the patient at the centre, rather than focusing on compliance with a variety of standards. Accreditation has been justified and useful, but we move on. We need a few national targets to be met locally with strong commitment from the staff and with room for local solutions.'

But what does this mean in practice? Are the Danes are abandoning regulation altogether? No they aren’t – they're very clear that this is not about abandoning standards or oversight of the quality and safety of health care. They recognise that there have been discernible benefits to accreditation, helping to focus leadership attention on quality, resulting in necessary standardisation and ‘professionalisation’ of quality improvement work. Indeed, they are just in the process of developing an accreditation scheme for primary care providers.

However, in Denmark they’ve listened to staff and the feedback that, despite the improvement gains, the approach in hospitals has also resulted in excessive bureaucracy and has failed to instill genuine commitment to quality improvement among frontline staff. The Danish government and regions have now recognised that to get beyond minimum standards of quality in hospitals – to a position where there is a genuine culture of continuous quality improvement among staff – they need to do something different.

As Dr Jens Winther Jensen, ‎Chief Executive of North Denmark Health care Region, said:

'We need to have to have a different balance of approach, moving away from command and control towards more trust in staff and the patient voice.'

The Danish government and health care regions are currently working up the detail of the new national quality programme, in discussion with frontline staff, to ensure there is there is a better blend of approaches. This will include oversight of quality and safety based around a few national quality targets, but with more freedom and support for frontline staff to make changes and improvements that matter to patients – such as access to and systematic use of real-time data to make evidence-based improvement decisions.

So, what can we learn in England from this? As we set out in our recent report this is not about wholesale abandonment of the approach the national NHS bodies currently take. It’s about recognising that the current set of policy approaches is unlikely to create the transformational changes the NHS now requires, and taking action. We need a better blend of organisational levers, proactive support and focus on NHS staff leading improvement to make successful change more likely.

More focus on proactive support (for individual staff in particular) has the potential for far more impact in improving the quality of local services and supporting change than organisational levers seeking to nudge or prod providers. This is particularly so in enabling staff to break through what they have told us are key barriers to change: creating motivation for change; boosting the capability and skills of staff by introducing them to practical quality improvement methodology and tools; as well as giving frontline staff the time and space to work with patients as partners to improve their local services.

The Danes have decided on the best way forward for their hospital sector based on the international evidence that health care organisations and systems are much more likely to deliver sustained transformational change through commitment than through compliance. Staff have fedback that the current system has created unnecessary bureaucracy, meaning clinicians have less time to focus on really improving care for patients. And the Danes have made a different decision for primary care, judging that the advantages of the accreditation approach, such as focused leadership attention and standardisation, currently outweigh the potential disadvantages.

So perhaps the decision for the NHS is not about whether we should abandon regulation. Perhaps it’s about understanding when, for different sectors, the disadvantages of regulation outweigh the advantages, and crucially, how would we know?

In England there is currently no systematic way for NHS staff or organisations to provide real feedback on the cumulative effect of regulation or national policies as a whole. We have recommended that the Department of Health, as steward of the system, should conduct a transparent annual exercise with frontline staff to understand and communicate the costs and benefits of collective national policy. National bodies can then take action to remove expectations that aren’t helping to deliver change and improvements for patients.

At a time when the NHS needs its staff to be bold, innovative and willing to take risks while moving to create change and improvement at a pace and scale not seen before, perhaps we should be taking a leaf out of Denmark’s book?

Clare is a Senior Policy Adviser at the Health Foundation, www.twitter.com/clareahealth