Beyond Francis and Berwick: sign up to improvement?

We’ve faltered in England. There hasn’t been a medium term strategy for improvement in the NHS based on recognised tried and tested quality improvement techniques, some from other industries with complex high risk systems like the NHS. 

Instead we’ve had a stop-start-stop journey. Collaboratives have come and gone. National agencies such as the Modernisation Agency and the NHS Institute set up and disbanded. People with the necessary skills largely scattered across the service. And the science base to improvement pretty untended and not particularly respected.

Isn’t it now time for something more strategic, on the back of Francis and given the financial squeeze? How about a comprehensive go at some of the things the Berwick group wrote in the report A promise to learn, a commitment to act? At the recent BMJ/IHI International Quality Forum in Paris there was huge enthusiasm for how the Berwick report can help organisations to develop their safety strategies. Clearly safety is first among equals of all the domains of quality – and needs to be a priority for people in policy and practice – but improvement approaches can equally be effective in other domains, such as efficiency.

What then might be essential elements of an improvement strategy for the next 5 years? Here’s my starter for 10:

• develop improvement capability in individuals (particularly frontline clinicians) and teams
• develop boards/CEOs to understand the value of improvement efforts and methods, support teams doing the work, and remove barriers to their progress
• develop improvement capability across providers/service pathways/clinical networks
• some collective focused endeavour, such as collaboratives
• space for teams to learn and network
• develop measures and evaluation methods
• develop the evidence base
• create the space to spread tested projects
• make sure the policy cocktail in which providers operate is helpful. 

You will have more suggestions – we’d love to hear them, you can comment below.

Looking across the UK, it looks to me as if the NHS in Scotland has more of these elements than the other countries, having made concerted efforts over the last 5-10 years. But it is within the English context that the response to Francis and the Berwick report is now being mounted, obviously focused on safety.

Clearly it’s important to support useful initiatives, national and local. And at the Health Foundation we see a lot of progress at a local level, having made hundreds of grants for improvement and safety projects and fellowships over the past 15 years. Our back catalogue has its fair share of successes, through the efforts of deeply impressive teams and individuals.

Whether the focus is on improving safety through better handover such as in East Kent and Birmingham Children’s hospital, applying techniques from other high risk industries, developing a new paediatric trigger tool in Great Ormond Street – there has been a lot of progress.

But we have also seen some familiar blocks too. Sooner or later clinical teams making improvement come up against hospital systems that are suboptimal and inflexible such as IT, workforce issues, payments and budget incentives, culture from the CEO down or other contextual issues. Many projects, even highly successful, do not easily spread. People trained up with skills are not given the space to develop or there is no obvious pathway for development. Some of these issues are because there isn’t a critical mass of people with the capability for delivering sustained healthcare improvement in the NHS.

Developments such as AHSNs and CLARHCs help and may offer local opportunities. And there’s the progress being made by NHSIQ. But now, with the impetus from Francis and Berwick to improve patient safety, there is a great chance to get the English improvement show more fully on the road. A strategy co-produced by a number of people – from national, regional and local organisations – would be a start. 

More on this later.

Jennifer is Chief Executive of the Health Foundation, www.twitter.com/JenniferTHF