The NHS is at a critical juncture in its 75-year history. With finances as tight as they have ever been, and a workforce stretched to breaking point due in part to spiralling demand from an older and sicker population and a shrinking labour pool, it is clear that things cannot carry on as they are. The time has come to think and act differently – at every level of the health and social care system – and to do so at pace.

The task is a daunting one. Yet the potential exists to radically improve the way care is planned and delivered, and equip the NHS for the challenges ahead. There is no shortage of innovative thinking, especially in the use of new technology and data, while practical solutions to the service productivity and design challenges the NHS faces are in constant development. What is lacking, however, is an infrastructure, strategy and management approach to connect and maximise the impact of these disparate strands, as well as sufficiently mature systems thinking. Too often promising innovations founder, for want of the necessary skills, incentives and pathways to spread and embed them across the NHS.

The new approach to improvement could be instrumental in closing this gap. It recognises that effective innovation and improvement requires a system-wide vision, accompanied by the means and skills to share ideas and learning at scale and to put them into practice in different settings. Robust evidence from the Health Foundation’s own work and from other countries and industries highlights the pivotal role of these factors in driving successful change. Implementing an ambitious strategic approach to improvement is a vital step in securing the future of the NHS and ensuring patients receive the care they need and deserve.

This long read describes five guiding principles that should inform implementing the NHS Impact approach to improvement at provider, ICS and national level to maximise the chances of success in the current climate. We also present recommendations for provider organisation, system and national leaders on the steps needed to translate these principles into sustained improvements across ICSs.

Why it matters and how the new NHS Impact approach to improvement can help

The past decade has seen a marked shift in the scale of ambitions among those leading improvement at the front line and those shaping national improvement policy. What was once largely a front-line activity delivered at a team or service level, has now entered the mainstream of national policy thinking. Particularly in terms of how to deliver significant and sustained change to the way services are planned and delivered across health and social care.

The 2019 NHS Long Term Plan set the bar high. It described improvement approaches and methods as having the potential to ‘improve every aspect of how the NHS operates’ and foresaw the central role improvement thinking would play in the efforts of ICSs to drive system-wide change. This aspiration was prompted, in part, by the notable success some NHS trusts have had in developing systematic, long-term organisation-wide approaches to improvement. NHS trusts in England that have embedded such an approach – often as part of an integrated quality management system – can point to a range of performance benefits, not least a high CQC rating and improved staff experience scores. Replicating this organisation-level success at system level was a key long term plan ambition. Since then, the service shifts that took place at scale during the COVID-19 pandemic have helped to illustrate the achievability of this ambition, many of which were facilitated to some extent by applying improvement methods.

The NHS Impact approach to improvement echoes and builds on the long term plan aspiration and the work of earlier improvement bodies, such as the NHS Modernisation Agency. It articulates – rightly in our view – the importance of taking an aligned and integrated approach to improvement delivery and capability building across organisations and systems. NHS England’s expectation is that ‘all NHS providers, working in partnership with ICSs, will embed a quality improvement method aligned with the improvement approach’. It is an ambitious goal, and justifiably so: underpinning it is a wealth of international evidence that improvement methods can help to tackle the NHS’s most entrenched challenges. Whether this is improving patient flow along urgent and emergency care pathways, strengthening the safety of maternity care and primary care prescribing or tackling variation in long-term condition management in general practice – there are now examples across England of tangible and sustained change driven by improvement thinking and methods. And crucially, this is not just the view of NHS England. There appears to be a growing consensus among regulators and policymakers about the value of improvement approaches as a driver for change, not least in the recent Hewitt Review, which augurs well for the future implementation of the improvement approach.

Equally welcome is NHS England’s recognition that a broad-based coalition of improvement-focused organisations and clinical and operational leaders needs to be assembled to shape, lead and support the implementation of the improvement approach. Bodies such as Q, NHS Providers, NHS Confederation, the Royal Colleges and AHSNs are well placed to share this enabling role, while also, where appropriate, offering practical support, learning and funding to providers and ICSs during their improvement journeys.

Handling the implementation with care

For all the promise of the NHS Impact approach to improvement, the very real and manifold challenges associated with implementing it in the current climate cannot be underestimated. The main one, of course, is the enormous and ongoing strain on the NHS workforce due to an unprecedented range of recruitment, retention, pay and workload-related challenges. These pressures affect every NHS provider and ICS, and it would be a mistake to assume that all organisation and system leaders and NHS staff are able to engage fully with the improvement approach from the outset, even if it offers the potential to find sustainable solutions to the challenges they face.

The experience of leading sites shows that it is possible to achieve the scale of impact envisaged in the improvement approach, but it will take time. For this reason, implementation needs to be handled carefully and the expectations of NHS England and its national partners about the speed of change need to be measured and realistic. A strategic balance will need to be struck between action to address urgent operational pressures on the one hand and, on the other, ensuring that providers and ICSs have the time and space to build the skills, culture, infrastructure and, crucially, the momentum required to embed the improvement approach in full.

Action is also needed to drive forward some of the policy and practice agendas that affect the delivery of sustained improvement at organisation and system level. Building up the NHS’s management capacity and capability, and unlocking the potential of clinical managers is one priority, which can be achieved in part by implementing the recommendations of the Messenger Review. Another is to build up the NHS’s data infrastructure and data measurement and analysis capability to enable the routine delivery of data-driven improvement, as part of fully fledged learning health systems in every part of the country. Good governance also matters: strengthening governance arrangements for improvement at provider and ICS level, and embedding improvement into their accountability and accreditation processes, will help to ensure improvement becomes part of business as usual. Joined-up progress on all these fronts will have an important bearing on the implementation of the improvement approach.

Clarity is also required on how social care providers, which are not included in the roll out of the improvement approach, will be supported to embed improvement across their organisations and engage in system-level improvement. As a key constituent care sector within ICSs, it is essential that they are able to participate fully, as equal partners, in any future ICS-level improvement-related activity alongside their peers in NHS care sectors. The IMPACT Centre for improvement in adult social care is one way in which the Health Foundation and ESRC, together with the University of Birmingham, is supporting increased investment in improvement research and capability in the sector, alongside its new NHS namesake.

1. Set the right pace for sustained improvement

A key question is the pace at which it is possible to implement a consistently applied improvement strategy at organisation and system level. There are as yet no mature examples of system-wide improvement, at least in the UK, on which to base an answer. When it comes to provider organisations though, such as NHS trusts, the evidence is much richer. It is striking that NHS trusts with the strongest improvement track records have taken 5 years or more to implement their improvement strategy. As pioneers in the field this is not surprising. Without an established roadmap to guide them or a mature evidence base to help make the case for upfront investment, it took time to build confidence among trust boards, regulators and staff, and to navigate unexpected setbacks.

The hope is that the experience of the next generation of providers will be altogether smoother. Not only is the national climate more receptive, but there is now a wealth of insights and learning, such as the evaluations of the NHS-VMI partnership and the Flow Coaching Academy, as well as practical support, on which they can draw. Does this mean that providers will be able to implement their organisation-wide improvement approach more quickly? In some cases, yes. Elsewhere, the picture may be more mixed: for instance, it may prove easier to make progress in building improvement capability than in delivering performance-related gains, such as improved care access or more efficient care processes. Such variation is to be expected: any effort to drive change within health care organisations is complex and requires a number of related actions that take time and careful implementation. The challenge is greater still at system level, given the additional degree of complexity involved, which is likely to lead to even more variation in the pace of improvement delivery.

It is critical therefore that provider boards, local system leaders, regulators and policymakers acknowledge the complexity and uncertainty of improvement work and react appropriately when challenges emerge. Supporting improvement efforts through peer networks or helping to address a capability gap, rather than upping the pressure for results or insisting on radical and disruptive changes to the strategy or personnel, is most likely to be the best response. Given the iterative nature of improvement, and the ebbs and flow that all improvement interventions experience, patient, supportive and courageous leadership over the years ahead is required.

2. Set expectations in ways that build commitment

Setting an expectation that the NHS Impact approach to improvement will be universally applied underlines the extent of NHS England’s commitment to organisation-wide improvement and ensures that provider and system leaders push it to the front of their strategic agendas. The act of making an explicit national commitment to improvement, one that requires action at each tier of the health service from the political centre to the front line, also has practical as well as symbolic value. A similar move in Scotland, for instance, where improvement has been identified at national level as being a key means of delivering public sector reform, is seen as instrumental in helping to achieve a range of improvement-related objectives.

Significantly, NHS England has also struck a balance between obligation and empowerment. Rather than setting out a detailed, standardised methodology in the improvement approach, it describes a set of overarching components. This will allow providers and ICSs to build naturally on their existing improvement assets and skills instead of having to bend their approach to fit a national template.

But setting expectations of providers and systems also carries risks. Chief among them is the risk that some providers and ICSs may not have the bandwidth to engage with the improvement approach in a meaningful way. This may lead to displays of superficial compliance instead of an authentic commitment to organisation and system-wide improvement. This risk is particularly acute if compliance is incentivised, such as through the new Well-led Framework and the NHS Oversight Framework assurance process. Meanwhile, some providers and ICSs may implement the improvement approach in narrow, top-down fashion without a nuanced understanding of what it takes to create a culture of improvement and learning. This would not only lead to disappointing results but would likely breed cynicism about improvement approaches, damaging current and future efforts.

To guard against these possibilities, it is important for NHS England and its partners to acknowledge and respond to the differences that exist in the improvement culture, capability and capacity between the various health care sectors, and with the other public, private and third sector bodies that now partner with the NHS. For example, the way in which mental health care providers approach improvement is shaped by factors that are quite different from those that drive improvement in primary care. This leads to variation in how improvement is conceived and in how people are supported to drive change.

There are also marked differences between providers within each care sector in terms of the maturity and focus of their improvement capability and capacity. Finding ways to close this knowledge and experience gap and develop a shared system-wide language around improvement is key, such as by creating opportunities for knowledge exchange, like those offered by Q. Peer networking within specific sectors may also have the added benefit of surfacing sector-specific challenges and strategies relating to the implementation of an organisation-wide improvement approach.

Creating opportunities for honest conversations about providers’ and ICSs’ ‘improvement readiness’ between providers, ICSs, NHS England and their national partners is vital. Ideally, these conversations should focus on providers’ and ICSs’ capacity to deliver organisation and system-wide improvement, and to carry out the detailed planning work it requires. It may not be feasible for them to do either in the short term, but they may be in the position to implement some preparatory work – such as an audit of existing improvement skills – that will allow work to start in the medium term. In short, a collaborative and flexible approach is needed from NHS England to ensure that providers and ICSs are not put in a situation whereby they need, in effect, to game the system.

3. Enable learning across systems

A commitment to learning underpins successful efforts to drive organisation and system-wide improvement. The creation of opportunities to develop, share and analyse learning, and an expectation by leaders that people will prioritise learning and reflection, are hallmarks of high-performing organisations and systems. This requires an outward-facing mindset at individual, team, organisation and system level that includes a desire to pull in ideas and insights from elsewhere, and a willingness to share experiences in an honest and thoughtful way. The way in which learning is exchanged also matters. Effective peer learning requires clear, mutually agreed expectations and behaviours along with careful facilitation. In other words, learning does not happen by accident: it requires the right appetite, behaviours, planning, resources and convening infrastructure to be in place.

Embedding a culture of learning across and between ICSs can contribute significantly to the effective implementation of the improvement approach. There is a lot that is not yet known about how to plan and deliver improvement at a system level, so it is important that ICSs pay attention to identifying and sharing the learning from the roll out of their improvement strategies, methods and practices. The Health Foundation and the Q Community provide a range of resources and opportunities that can be helpful. Meanwhile, NHS Confederation, the Health Foundation and the Q community are scoping ways to boost learning and improvement in and between local systems over the coming years.

The fact the improvement approach offers a set of overarching components rather than a detailed, prescriptive template – something that gives each ICS the latitude to forge their own distinctive improvement strategy geared to local needs – underlines the importance of creating a robust learning culture. As they develop and refine their own strategies, the opportunity for ICSs to reflect on the very different approaches adopted by ICSs across the country will be invaluable.

A case in point is the variety of ways in which the responsibilities for leading, convening and delivering improvement are understood and negotiated in each ICS. In some ICSs improvement is seen largely as a provider-led enterprise with provider collaboratives serving as the engine for system-wide collaboration. In other areas, ICSs are expecting to play a more prominent role in convening and coordinating improvement, or are considering the case for developing in-house capacity to support improvement initiatives or train provider staff. Understanding how and why each approach has been adopted by providing space for cross-ICS dialogue and learning, and capturing the improvement journeys of individual ICSs, can only strengthen the way in which each ICS and its partners collectively lead improvement.  

4. Build capability at provider and ICS level to navigate and reconcile competing priorities

A characteristic of effective leadership is the ability to navigate between competing or sometimes contradictory strategic and operational priorities and goals. This is especially the case in health care in the UK, a sector in which provider and system leaders have historically had to reconcile the tensions between a complex range of targets and priorities over which they have had varying levels of ownership and control. Every new local or national policy, strategy or framework, however well designed, has the potential to create fresh tensions that leaders then have to decide how to navigate. The NHS Impact approach to improvement is no exception.

For provider and ICS leaders a key tension relates to the national improvement priorities on which providers and systems are expected to work. Having national priorities provides opportunities for collaboration and learning across systems and can help to galvanise action and create a sense of common purpose, not just between ICSs, but between ICSs and national bodies. But they can also quickly absorb much of the available strategic and operational capacity of providers and ICSs. National priorities may also encourage a disproportionate focus on meeting the immediate targets associated with them, potentially at the expense of longer term improvement-related goals and more systemic solutions to challenges. To avoid this, providers and ICSs need to achieve a balance between the long-term work of embedding organisation and system-wide improvement – which sits alongside a range of interconnected local long-term strategic challenges – and the need to meet national priorities that are often accompanied by short-term goals. This strategic ambidexterity – the ability to manage the tension between short-, medium- and long-term priorities – is a crucial leadership capability. It is a strategic skill that almost all high-performing organisations with mature organisation-wide approaches to improvement possess. In the highly politicised environment in which NHS provider and system leaders operate, where local performance challenges can and frequently do have national political ramifications, strategic and political astuteness has emerged as an increasingly important leadership skill.

Another challenge for many provider and ICS leaders is how to reconcile the myriad locally driven priorities for improvement that exist. Meeting them all is often unrealistic, especially in the current climate. Some of these priorities are interdependent and hard to untangle, while others are difficult to dislodge due to their political sensitivity. Other priorities may prove easier to jettison, and there may be scope to thin out the thickets of interconnected priorities. Doing so – with the goal of achieving a smaller and more manageable set of well-aligned local improvement priorities – requires strong negotiating and political skills, a well-developed understanding of how the organisation or system operates and strategic confidence.

Yet the benefits that will flow from a rationalisation of priorities are considerable. As well as providing clarity to staff, it will ensure that organisations and ICSs do not spread their improvement resources too thinly or overload their strategic and operational capacity. Another benefit is that it will give leaders the headspace to tackle unexpected challenges while monitoring the delivery of their overall improvement strategy. The downside is that it may necessitate difficult conversations with stakeholders who expect certain issues to be reflected in organisation and system level strategic improvement priorities. No one finds this task easy, but it is often less taxing and contentious in organisations and systems with a well-established and authentic strategy for engaging and involving staff and the community in the identification of organisational improvement priorities.

The strategic capabilities needed at provider and ICS level to address the tensions described take time to develop. What often helps is the presence of supportive system partners and national bodies that are willing to give local leaders the space to build and refine them. It is clear, therefore, that NHS England and their national partners have a key part to play in creating an environment in which strategically confident and ambidextrous providers and ICSs can flourish.

5. Align national policy around the NHS Impact approach to improvement

The NHS Impact approach to improvement has the potential to make a real and lasting difference to the way every part of the health care system operates and, most importantly, to how care is conceived and delivered. But it will only achieve an impact on this scale if it is seen as the defining way of doing things by providers, ICSs and national bodies. For this to happen, much depends on how NHS England and its national partners engage with the improvement approach. If it is viewed simply as another piece in an already crowded national policy landscape, one that has to jostle for political attention among a host of other measures, then it is hard to see how it will gain the profile, resonance and momentum to succeed – especially as another general election approaches.

The challenge for NHS England and its partners is not just to ensure that the improvement approach is aligned with other national policies, but to align other policies and strategies around it. The improvement approach is ideally suited to this central role. The quality management system concept, which is a cornerstone of the improvement approach, provides a strategic and operating framework for the NHS that could help to align and coordinate action across policy fronts – everything from developing new care models to digital and technology innovation to workforce reform.

Equally important is an alignment of expectations and roles across national bodies and their regional arms. At present, provider and ICS leaders are under pressure to deliver on a long list of competing national improvement priorities that sometimes demand progress at an unrealistic pace in complex health care systems. A measured, pragmatic and consistent approach from all policymakers is essential, backed up by the acknowledgement in the NHS Impact approach to improvement that it takes time to embed a comprehensive and integrated improvement strategy. This needs to be accompanied by a joined-up delivery approach that provides clarity about the respective roles of national bodies and their regional arms and providers and ICSs. This should set out steps to ensure that the activities of ICSs and NHS England regional offices are aligned and complementary. It should also emphasise that the central role of national bodies is to create a national climate conducive to improvement and foster the development of ‘self-improving systems’, rather than to lead its delivery at organisation and system level.

Taken together, there needs to be recognition that the NHS Impact approach to improvement implies a profound change nationally as well as locally that will be cultural as well as technical. 

The NHS Impact approach to improvement is an important and well-conceived set of actions and goals. Not only does it reinforce the importance of many of the facilitators of effective organisation and system-wide improvement that the Health Foundation has long viewed as critical to a well-functioning NHS, but it offers a pathway to ensuring their wider uptake. Yet for it to fulfil this potential, it is important to address the issues described here that will affect the way in which the improvement approach is perceived and implemented by local leaders.

Finding the space to explore these issues using the guiding principles presented here is key to successful implementation. If the approach is embraced by all those who are committed to sustainable improvement in the NHS, it could emerge as a dynamic entity that it is refined in light of the experience and evidence accumulated by local systems and national bodies as they engage with it.

For national bodies

Take a measured and pragmatic approach to implementing the NHS Impact approach to improvement. Providers and ICSs face an unprecedented range of financial, delivery and workforce challenges and have varying levels of improvement maturity. NHS England and its partners need to be flexible and pragmatic about the pace of implementation. Creating fora for open dialogue between local systems and the centre about how to manage implementation challenges and what support is needed is vital.

Align national policy around the NHS Impact approach to improvement. Given the broad transformative power of improvement approaches and methods – something recognised in the NHS Long Term Plan – the NHS Impact approach to improvement should be seen as a centrepiece of national policy. It is vital therefore that national policy on workforce, performance, service capacity, transformation and funding is aligned around the improvement approach. Just as importantly, the improvement approach should embrace and support improvement in the social care sector. Finally, national bodies should ensure that their professional cultures and ways of working are consistent with those described in the improvement approach.

For provider organisation and ICS leaders

Take time to understand what is needed to embed the NHS Impact approach to improvement. Key to the implementation of the NHS Impact approach to improvement in each provider and ICS is a deep knowledge at operational level of local care pathways and systems and the relationships between them, coupled with a well-developed understanding at board level of how to lead improvement across complex systems. Ringfencing time for operational teams and boards to build this knowledge, alongside tailored training if necessary, will help to meet this need.

Prioritise action to build ICS learning cultures. Provider and ICS leaders should consistently reinforce the value of peer learning and take steps to embed it across their local systems. In this, careful thought should be given to how peer learning opportunities are framed, facilitated and resourced. While budgets are stretched, there may be ways to repurpose and align existing resources to ensure that vehicles for learning have the requisite status, impetus and support to flourish. Creating time for people to learn together will pay dividends in terms of boosting morale as well as surfacing practical opportunities for improvement.

Build the strategic confidence and ambidexterity needed to reconcile competing priorities. The ability to reconcile short-, medium- and long-term strategic priorities and rationalise complex, interlocking improvement goals is an essential skill for provider boards and integrated care boards. Work to strengthen this ambidexterity and the confidence to deploy it should be prioritised.