Amazing that the NHS has changed as much as it has

Clearly the NHS is under stress. Up until now the quality of care broadly seems to have held up, as QualityWatch – our joint programme with the Nuffield Trust – showed last October. But the cracks are now showing with more hospitals not meeting their four hour A&E wait targets (in summer), and the financial dials turning red across the country.

The issue, of course, is not that the NHS is somehow failing, it’s the punishing budget shortfall relative to the 3-4% real terms growth the NHS is used to. Yes, the budget has been ringfenced, so the NHS is well off compared to other parts of the public sector. And no, the NHS has not experienced the huge cuts seen in the health systems of eurocasualties Spain, Portugal and Ireland. But speak to the Germans, the Dutch and the French, and they are surprised (with a tinge of incredulity) that we are attempting the heroic: 0% real terms growth in funding for an extended period is not doable without significant pain that will spill over into public ire. For more on the funding gap, read Anita Charlesworth's latest blogs.

But the issues are more complex than the level of funding in any particular year or two. A few examples:

First, the bumpy ride of funding, rather than simply the level. Predictable growth pegged to GDP growth over a longer period would surely help, and can’t be beyond the wit of the Treasury and Department of Health to craft.

Second, as politicians only now seem to be realising, structural change can be fast and provide an illusion of progress but behavioural change is slower, and it’s the latter that makes the difference. An intelligent strategy over the medium to longer term would give structural stability and prioritise behaviour change.

Third, it’s important that the policy ecosystem encourages providers to improve quality and efficiency. But in the scheme of things, the overall impact of policy is probably smaller than policymakers would like to think – as suggested by the recent analysis of NHS performance across the UK – or is just very slow burn, as in the case of competition policy. Ditto for greater public involvement and local accountability. Regulation has its place but is arguably more likely to have visible impact in poor performers than the majority. Top down directives have immediate impact, but only in limited areas and risk collateral damage. So some humility is needed here and a recognition of the limits to the national ‘levers’.

Fourth, the emphasis on new technology to bring progress. Yes, this is highly likely, but so often forgotten is the care (or lifestyle) in which technology is embedded and has to function, as the Whole System Demonstrator trial showed. New technology grafted on old behaviours and patterns of care = slow progress.

Fifth, the rising tide of morbidity: there's now a burning need to focus on people’s health and how to improve it, unlocking the potential of individuals to better manage their own health and of communities to support them in doing so. And, yes, some nanny state responses – there isn’t enough action on this.

And sixth, IT and data. We’ve invested in a lot of core IT/data kit in the NHS yet we severely underinvest in its analysis. Come on, let’s sweat our assets more and cultivate a generation of analysts, as well as managers who are interested in numbers.

So, those are the issues that we are dealing with. However under the bonnet of providers – paying attention to behaviour, leadership, management, and the processes of care – is not where policymakers focus. At the Health Foundation we have invested more than a decade in supporting teams in providers (usually acute) to make changes, particularly in safety, efficiency (improving the flow of patients through a service), and person-centred care (read Jo Bibby’s blog for more on this).

And what have we found?

Absolutely no shortage of mission and talent. However there are many barriers to improvement: widespread lack of skills in formal quality improvement techniques to implement changes at team level; lack of information to assess progress; improvement efforts within teams not spreading because of bigger blocks that are hospital-wide and not tackled; a lack of engagement of senior management; a lack of basic processes of care; and in some cases basic issues not addressed across the whole NHS.

Set that alongside queasy churn of senior management and stripped-out middle management, then the question of ‘Why the NHS is slow to change?’ might be better phrased as ‘Isn’t it amazing the NHS has managed to change as much as it has?’

This neatly sets the agenda for the Health Foundation over the coming year. We will continue to support, and learn from, improvement projects in providers. Also we’ll continue to increase capability and build up quality improvement skills across the health system (particularly among clinicians). In doing so we will prioritise safety, efficiency and person-centred care.

We will focus on the external policy and financial environment, analysing how best it might be designed to accelerate improvement in health care, and assessing the impact of recent reforms through our stewardship of the Department of Health-funded Health Reforms Evaluation Programme – new areas for the Foundation. We will be developing our focus far more on improving health in 2015. All underpinned by an increasing investment in using data to illuminate progress.

But importantly all the above will be in dialogue with you. Join us over the next year.

Jennifer is Chief Executive of the Health Foundation.