Ben Bray Research Director, Sentinel Stroke National Audit Programme
With so much attention focused on money, it might be tempting to conclude that quality improvement is a luxury the NHS cannot afford. The dominant story of the NHS is now - like for much of its 68 year history - firmly one of financial control, cost savings and desperation to balance the books.
There’s a logic which can be followed here. The level of financial strain on the NHS is hard to understate: 85% of NHS acute trusts are in deficit, and even the Department of Health is unable to keep within its budget. Other areas of the public sector (with arguably as big an impact on health outcomes as health services) are even more under the cosh: secondary schools are facing their steepest funding cuts since the 1970s.
So, against this backdrop, surely the priority for resources should be on keeping wards open rather than on in-house improvement teams, learning collaboratives or improvement training for staff? “False economy” doesn’t do justice to the magnitude of error this would be.
Cutting improvement resources means reducing the capacity of the NHS to improve productivity, reduce waste, implement change and be more clinically effective at a time when these things are needed more than ever. Improving clinical and management processes and making quality the central strategic focus offer significant opportunities for increasing productivity, as shown in NICE’s collection of over 130 quality and productivity case studies. It’s also much more motivating for NHS staff than a narrative based entirely on short term cost control. This poses challenges to policy, which has a major role in removing the barriers that make change hard, as well as freeing up resources for improvement.
We know that many well intentioned efforts to improve care processes, design new pathways or implement change are stymied not by money, but by non-financial barriers to change. For example, we make collecting and using data for improvement hard, bound by well-intentioned but burdensome regulations. The NHS is swimming in data and yet the availability of actionable, useful information for improvement is, on the whole, extremely poor. There might also be areas where resources spent in the name of quality could better be deployed in a different manner. For example, the NHS could spend a bit less on regulation and compliance, and a bit more on improvement. Why do we spend money on the Friends and Family test when there is still no national system for continuous quality improvement in primary care?
Messaging is crucial. Last week NHS Improvement reportedly asked Trusts to include learning and development within their back-office cost cutting plans. Stories abound of NHS bodies being asked by their overseers to slash any ‘discretionary’ improvement spending. Let’s be clear: trying to increase the rate of improvement at the same time as cutting its resource is stupid. If we have any chance of significantly raising efficiency across the NHS, the importance of investing in improvement needs to be put in neon lights no-one can miss.
But if quality improvement is going to play a major role in responding to austerity, there are equally challenges for us leading improvement work. We need to look critically at what our current quality improvements deliver, and, to be blunt, do it better. What might this look like?
We need focus more on problems where the NHS can make maximum impact with its limited improvement capacity. A health system that is struggling with very large problems of, for example, capacity and flow in emergency care, might benefit most from targeting efforts on the those areas where improvement has the most to offer. Too many improvement efforts fizzle out for lack of momentum and scale, fail to provide robust evidence of impact and waste resources in reinvention rather than replication. How do we work together across the country to confront perceptions and help improvement deliver on its potential?
Improvement should also more explicitly target productivity and efficiency as primary goals. This can be hard – getting good quality data on the effect of process improvement on productivity is not easy. Many data analysts in the NHS spend their working lives in the depths of finance departments and might find their skills put to equally good use in helping quality improvement projects measure and improve productivity and efficiency. The work of Future Focused Finance in connecting finance professionals with service delivery provides a great start which could be built upon.
No doubt these are all easier said than done, but as we enter a time when all the spotlights will be on the bottom line, quality improvement has never been more important. It’s time for us working in improvement to raise our game in response.
Ben Bray is a public health registrar and clinical academic at the Farr Institute of Health Informatics, University College London. Follow Ben on Twitter: @benthebray