Accelerating improvement in the NHS

As I write this, Theresa May has just announced a funding increase of £20.5 billion per year to NHS England’s budget by 2023/24. That’s an increase of around 3.4% per year above inflation. A long-term funding settlement is welcome, but falls short of what the NHS will need.  

Our recent joint report with the Institute for Fiscal Studies projects the NHS will need 4% annual real growth over the next five years to stay as is, and nearer 5% to modernise given the backlog from the last decade. As GDP growth is likely to be (much) less than half of that, and other areas of public spending can hardly be raided more, that will mean tax rises or more borrowing. And as the speculation continues about where the funding will come from and how it will be spent, people at the NHS frontline continue to work in extremely challenging circumstances.

Delaying consideration of broader areas of health spending such as public health, capital investment and staff training until the next spending review means it is unlikely we will see any progress in these areas before 2020 at the earliest. It is hard to see how the NHS will be able to modernise properly or deliver wide-ranging improvements. Still the bigger questions remain, how to widen access to treatment, and improve quality and efficiency? So, despite the funding challenges let’s think about what might accelerate improvement in the NHS.

In a recent lecture I mooted that the winds that brought Working for Patients and ended with the Health and Social Care Act 2012 were blowing themselves out. By that I meant that we can now see the limits of relying on extrinsic motivation to make progress, whether using regulation, command or financial incentives – mostly applied to NHS institutions. For the future, we need to go beyond these limits as pressures on the NHS and care system grow. 

The Five Year Forward View signalled a change. In particular permission for more collaboration and local initiative across different agencies in an area, and an emphasis on preventive health. Advances in computing, digital tech, and information flows will help. Clearly we are in the early stages. But the direction is towards, as someone said to me recently, care that is ‘flat, digital, patient-centred’ as well as more coordinated.

This means whatever we do in future to make progress the thrust of policy must be to support frontline staff, rather than just prod institutions. That is why our recent annual event focused on the ‘human element’ – the people who work day in day out to deliver patient care.

Anyone who switches off at this point might look at Nick Bloom and John Van Reenen’s work over the last decade. Good management was the single most important factor to explain marked differences in productivity across a large range of global businesses, large and small. See here for a nice summary. 

And management featured heavily in Matthew Taylor’s tour de force keynote presentation at our annual event on good work, based on his recent review for the government. Even if you put your faith in tech in future, without effective management you can say goodbye to diffusion and spread across the NHS. 

As Professor Mike Richards noted in a panel discussion, the single most important factor predicting the quality of care rating of a hospital in England is the staff survey results. Many trusts are trying to improve happiness and ‘zing’ among their staff, for example Leeds Teaching Hospitals NHS Trust, as Anna Edgren-Davies explains in the newsletter.

Upping the dose of quality improvement activity in frontline clinicians must be another strategy – helping them apply structured approaches to making improvement. This is the focus of our new joint series with the BMJ, which started last month. In one of the first pieces, Jeffrey Braithwaite explores what it would take to turn the NHS into a learning health care system. Penny Pereira in our newsletter sets out what a strategy for building capacity at scale would look like in the UK.

Finally none of this would be worth a row of beans unless the patient is centre stage. At our event Dr Claire Lemer, in a powerful short film about her experience as a patient, demonstrates why that is so. Cllr Jacqui Dyer MBE, with long experience as a user of care, and in working with a diverse community in Lambeth to improve mental health and wellbeing, along with Dido Harding, the new chair of NHS Improvement also discussed how a deeper understanding of patient and staff experience can help health care professionals to improve patient care. 

So how much difference will a 3.4% increase in funding make? It’s a welcome increase but will mean an NHS that is just about managing. It will also keep up the pressure to look for better solutions.

Dr Jennifer Dixon (@JenniferTHF) is Chief Executive at the Health Foundation