Foreground and background

I was struck recently by the findings of the excellent recent OECD review of quality in the UK health care system.

On the one hand the authors were impressed: ‘The UK as a whole puts more energy into quality improvement issues than any other country in the world, and as a result has many innovative policies of international repute.’

But on the other puzzled: ‘Yet despite this, the quality of health care in the UK is no better than average.’

The reasons mooted were, ‘In England the balance between central governance and accountability, and local innovation, needs revisiting,’ with too much top down crowding out local initiatives. The OECD also noted a proliferation of national agencies, reviews and processes addressing quality leading to ‘a somewhat congested and fragmented field of actors’.

A similar conclusion is made in our own recent analysis, A clear road ahead. In this newsletter Tim Gardner – a main author of that report – makes his own assessment as to how policy makers could make better progress.

Scotland on the other hand, according to the OECD, needs to strengthen the top down to balance all the bottom up initiatives. Wales also, the OECD suggested, needs a ‘stronger central guiding hand’ to support Health Boards to make change. Noting the longstanding integrated commissioning and performance management arrangements in Northern Ireland, more exploitation of this is thought needed.

It is interesting that the OECD frames the UK review in this way – about central/local balance. Not so long ago it was fashionable to frame analyses of this type through the lens of competition, prevailing payment physiology, or through more structural factors such as volume of hospitals relative to other providers, extent of investment across sectors, or staffing levels. Yet despite the different balance and approaches across the UK, the OECD noted that no one country systematically outperforms the others on the quality of health care provided.

This, and the recent report from the CQC on the ‘State of Care’ in England, made me wonder if the national/local lens is the most useful one to think about how we are making progress on quality.

Everyone knows that the environment the NHS is working in is challenging across the UK: financial squeeze (as Ben Gershlick describes in this issue); rising demand; other cost pressures; cuts in social care affecting the most vulnerable to name a few. And everyone knows there is a need for national action to tackle these; there is an impressive amount of it across the UK, not least with the NHS Five Year Forward View and key clinical areas in England. But there is also work to be done across the UK on some underlying challenges, including addressing workforce issues, rigidities in professional regulation, making better use of data, integrating health and social care and managing local service change.

It is understandable for providers under pressure to point to problems outside their remit as the main barriers to progress – the environment has never been tougher. Yet the CQC’s report raises awkward questions about why quality in some parts of the English NHS has deteriorated but improved in others (more on this in my recent HSJ blog – subscription only) if life is tough for everyone. For example acute providers with good local management tend to provide higher quality care and have better financial health. Frimley Park Hospital’s management of its close neighbour Wexham Park Hospital, improved the latter’s rating from inadequate to good in only one year. How? By tackling organisational culture and improving leadership and management at several levels, including among clinicians.

And CQC’s observation that managing patient flow was one of the main concerns in its inspections of acute hospitals begs the question of why flow management isn’t central in the NHS’s DNA? The Sheffield Discharge to Assess team, funded and supported by the Health Foundation, has reduced the time taken to discharge patients from over five days to just over 24 hours – over 10,000 patients in the last year have been transferred out of hospital into this ‘active recovery’ service. The team is now training other trusts to do the same. Why aren’t similar approaches more widespread? And if the NHS doesn’t ask this question, won’t the Treasury this autumn? In this newsletter, David Fillingham, Chief Executive of AQuA – and co-author of a forthcoming AQuA/Health Foundation report on flow - addresses some of these issues.

Instead of the national/local lens, a useful framing might be to push to the background our often short term focus on initiatives, innovations or programmes to frame, explain, chart and reassure ourselves of progress. Another way of putting this is the often widespread tendency to foreground ‘intervention’ over the background ‘context’. Yet as we know from our work at the Health Foundation, intervention plus context equals ‘outcome’. That is, whether an intervention is likely to succeed or not may be equally dependent, if not more so, on the environment in which it takes place rather than just the intervention itself.

So instead of asking the question ‘what interventions work?’, it may be better to ask ‘what contexts work and why?. Once identified, the factors that unlock faster change could be boosted with as much energy, thought and profile as is currently given to ‘intervention’.

A key context factor is the workforce, so often the Cinderella area in policy, for example their numbers, skills, values, motivation and health. In this newsletter Rhiannon Barker from the Point of Care Foundation outlines the impact on quality of care of better staff engagement and morale. She also talks about new work, with the Work Foundation and RAND Europe (commissioned by the Health Foundation), to research the links between staff wellbeing, care quality and productivity.

The more complex interventions now being tried across the NHS, such as new models of care, the more likely context matters. In fact context may be over 90% of the active ingredient for the success of any project – a possibility those trying to implement changes, as well as those carrying out formal evaluations need to take more note of.

Finally back to that OECD report and quality of care in the UK. A big uptick for trying and initiative. But there’s clearly a piece missing from the puzzle, and the sooner we can identify that the better.

Jennifer Dixon is Chief Executive of the Health Foundation.