As a man whose garden consists of some desiccated hydrangea, a wilted rose bush and a few sorry looking raspberry canes struggling through cracked London clay, I hesitate to make the following analogy. But better gardeners than me tell me that if I want the urban idyll I picture in my mind’s eye, I need to invest more time in cultivating the soil, as well as being thoughtful about the seeds that might be the best fit for my somewhat unforgiving earth.
As national health care system leaders develop plans for the next ten years of the NHS through the NHS long-term plan, is there anything to learn from my green-fingered woes? Could more investment in the provider ‘soil’ help enhance the prospects for seeds sown by national programmes and innovators to flourish and grow?
One solution would be the development of a provider capability-building fund to enhance the capacity, skills and knowledge of health care organisations to improve quality themselves. This would enable more effective delivery of the ideas that other long-term plan working groups will generate.
Enabling more reliable delivery
For policymakers besieged with calls on resources, why focus on the less visible work of strengthening providers’ ability to improve quality? Firstly, doing so can help enhance the prospects of reliable delivery of other national priorities.
New national programmes will only succeed if the organisations charged with delivery of these plans have the ability locally to implement them. Programmes that identify variation such as Getting It Right First Time, Right Care, or NICE guidelines that set out evidence-based recommendations for health care, need mechanisms to turn their insights into real change on the ground. Yet, all the evidence shows that ability to implement programmes and evidence-based practices is highly variable, resulting in variations in the quality and safety of care that patients experience.
Secondly, the development of a dedicated provider capability-building fund will support the uptake and spread of innovation. Strengthening providers’ ability to problem solve for themselves enables staff to develop and adapt ideas to their local situation and needs. Great hopes are often invested in new innovations, technologies or processes; whether that’s a new blood test for cancer, online consultations with a GP, or an early warning system that can help identify sepsis and enable early intervention. Under any reading of the challenges facing the NHS, this kind of innovation is essential.
All these interventions require clinical teams to have the time and skills to implement and adapt them to work in the context of their hospital, clinic or community, with their partners, colleagues and patients. This is the work of continuous improvement and ‘adaptive change’ which the National Advisory Group on Health Information Technology in England, chaired by Professor Robert Wachter, described as critical to realising the productivity benefits of new technologies. Yet policymakers often pay far too little attention to what it takes to make new interventions work effectively, not just in the context of a well-funded and run clinical trial or pilot, but towards achieving these benefits for all patients, all of the time, in every provider.
What approaches could be taken?
We should look at the characteristics of health care organisations that we already know have the capacity and capability to deliver high quality care. The work of the CQC has developed a comprehensive picture of quality nationally, and has so far identified eleven organisations that they judge as ‘outstanding’. Many of these, such as Salford Royal, East London and Western Sussex, use a structured quality improvement method as part of a strategic approach to delivering high quality care.
So how might we move from fewer than a dozen of these ‘positive deviant’ outstanding organisations to thirty or forty such providers by 2028? The long-term plan offers a unique opportunity to achieve this, but will require investment.
Three methods to boost capacity and capability should be considered, based on different organisations’ starting points:
- Internal development. Build quality improvement capability from within. This is likely to be an option most suitable for organisations that already have some expertise and experience; most trusts will only be able to pursue this route after some initial capability building.
- External support. Use external support to build capability and boost capacity initially, before transitioning to an in-house model. This kind of consultancy-style support has been used by East London with the Institute for Healthcare Improvement, and the group of five trusts working with Virginia Mason.
- Peer-learning. Incentivise and enable high-performing organisations to form alliances with more challenged organisations to support their improvement. This approach is grounded in evidence that transferring organisational knowledge and expertise is rarely straightforward, but several studies have suggested that management practices are easier to learn through access to individuals who have experienced them first hand. Examples of these approaches include Salford Royal’s work with Pennine Acute, or Western Sussex’s partnership with Brighton.
What can be done now?
Alongside investment in specific clinical and prevention programmes, system leaders should allocate funding to build this underpinning provider capability. Through a provider capability-building fund, trusts in England could bid for support to accelerate their organisational capability-building efforts.
In some cases, even relatively modest sums could enable organisations to accelerate this agenda. A return on investment would come from their enhanced ability to deliver national quality and efficiency programmes, and, over time, a reduction in reliance on external consultancy expenditure.
A sensible approach would be to start by funding a small number of organisations and independently evaluate their impact before investing larger sums. The Healthcare Improvement Studies Institute, led by Cambridge University in partnership with the Health Foundation, has indicated that it would be prepared to consider supporting a research and evaluation programme to support a provider capability-building fund. This would be at no cost to NHS Improvement or NHS England, and would develop and refine the three possible routes to support the mechanisms above. It would then use a large-scale field experiment to test which of them yields the best gain at what cost. Rolling out support for improvement capability in this way would have the benefit of greatly enhancing the evidence-base for any future improvement work.
With stronger improvement capability – and evidence about how best to build it – the NHS will be better placed to reach its 80th anniversary with a stronger set of organisations with well developed, systematic approaches to identifying problems, developing and testing solutions, and better equipped to deliver higher quality care for all. The development of the long-term plan offers a unique moment to signal a renewed commitment to enhancing the capacity and capability of those NHS organisations that directly deliver care to patients; nurturing the soil within which new ideas and practices to improve care must take root.
Will Warburton is Director of Improvement at the Health Foundation.