For Brexit, read the Health and Social Care Act. That changes in governance alone rarely resolves underlying problems is the story of NHS reorganisation over the past 30 years, and may be a lesson shortly to be learnt by the country as a whole too.
That the English NHS is developing a strategy to support ‘leadership development and improvement’ is positive news. It reflects a welcome acknowledgement that making the NHS more adept at change is the result of a million acts of delicate chiselling rather than the thump of a legislative sledgehammer.
But whether the forthcoming strategy succeeds will depend on whether some tricky decisions are dealt with. From my experience of nearly a decade in government, it's standard practice that such decisions may not even be discussed (there’s a reason why fudge is the policymaker's sweet of choice). As such, here's my take on the three topics most important to the strategy's success, and least likely to be being talked about.
1. Are we prepared to accept a short-term dip in performance in exchange for a long-term increase in improvement capability?
The NHS in England, as with health systems around the globe, is in an era of severe constraint. More demands are placed upon services than they can deliver, resulting in areas of deteriorating performance and/or busted budgets. Amidst this, the development of a new strategy is an explicit signal that the NHS doesn't currently give improvement and leadership development enough priority.
But for improvement and leadership to have greater priority means something else must have less.This is likely to mean that fixes to shore up performance today give way in order to build improvement capability for tomorrow - leaving a performance dip until the fruits of such improvement are ready.
At present, it's clear where priority lies: the King's Fund quarterly survey consistently finds that access targets dominate the concerns of Trust finance directors. It seems unlikely that Ministers and Mandarins alike would be prepared to trade performance now for improvement later, yet, without such a switch, NHS Improvement are left with a strategy which risks - despite noble aims - being seen as disingenuous.
2. Are those leading improvement the cavalry, or a counter-insurgency?
The signs that improvement is now being taken seriously are pretty convincing. We have a rebranded body with Ara Darzi on the Board, and one of the NHS' finest chief executives, Jim Mackey, at the helm. You might find it funny therefore that we're even debating whether improvement is now firmly top of the agenda.
However, speak to many a Trust chief executive (for example, see my blog reflecting on the NHS Confederation conference) about their experience of interacting with the English national NHS bodies and a different story emerges, where 'grip' is more prevalent than compassionate leadership and improvement. Put this way, it is unclear whether those leading improvement are spearheading a united national charge, or mounting a rebellion against it.
This matters. The NHS needs a major cultural shift if it is to become, in Jeremy Hunt’s words, the 'world's largest learning organisation' - and that requires behaviours being role-modelled from the top down. The most powerful intervention the strategy could make would be for the national bodies to very openly practice what they preach, for example in terms of collaborative working and openness about failure.
3. Are we talking Quality Improvement, or means to improve quality?
The UK Improvement Alliance contains many of the UK’s experts on the use of quality improvement methodologies. Used well, such methodologies play a pivotal part of how change happens in healthcare. However they cannot be expected to carry the full burden of whether healthcare quality improves. This larger debate on means to improve qualityincludes the number of staff in a health system, the competence of clinicians, the access to treatments - as well as the use of quality improvement approaches and the development of leadership skills.
Building capability in quality improvement, and developing the next cadre of NHS leaders are both of fundamental importance. Yet their positive impact on quality of care in the coming years could potentially be dwarfed by the negative impact of low spending growth and staff shortages. This consideration of the ‘cumulative impact’ of policy is an area where England has struggled; a forthcoming report from the Health Foundation found that between June 2011 and December 2015 the government initiated over 170 policy interventions to improve quality. The tricky task for NHS Improvement is to work out how this new strategy interacts with the sheer quantity of stuff which has gone before it, and all in an inhospitable financial context.
I remain extremely optimistic about the future of quality improvement methodologies in the NHS, and the positive role a timely, well constructed strategy can play. I’ve been struck at the amount colleagues at Healthcare Improvement Scotland reference Scotland’s Quality Strategy (published in 2010, and refreshed in 2015), and how it’s been able to act as a roadmap across the country.
The prize is there, but getting there means dealing with difficult issues, not ducking them.
Richard Taunt is Director of the UK Improvement Alliance.