NHS Improvement: can Monitor/TDA adapt to the future?

The Secretary of State’s first major speech after the election this week outlined his vision for the NHS in England. Most interesting were clues as to the favoured means to achieve it.

The emphasis was on using data to create more transparency in performance, and a learning environment to help people working in the NHS improve the care they deliver for patients – on the face of it a welcome direction of travel. The newly announced name for a merged Monitor/TDA is tellingly – NHS Improvement.

Clearly there are a lot of routes to achieving change and improvement in the NHS. Secretaries of State, from whatever political stripe, in the past have tended to reach for central command targets backed up by strong arm performance management. As the collateral damage from that approach became more apparent, more latterly regulation has taken its place, along with payment reform and national price setting. Competition as a force for improvement is low priority, as much for pragmatic reasons as any other.

We recently argued in Constructive Comfort that all the approaches outlined above were ‘type 1’ – effectively externally designed prods on local provider organisations to do better. This could be called a ‘compliance’ approach, supporting a world view that it is extrinsic motivation that produces results. In short ‘you won’t, so we will prod you until you will’.

We argued that two other broad types of approaches were underdeveloped in the NHS: type 2 – supporting providers to improve themselves. This could be called a ‘commitment approach’ relying on a belief in ample intrinsic motivation among people working in the NHS. In short ‘you can’t but want to, and we’ll support you’.

And ‘type 3’ approaches directed at individuals not organisations such as through a contract or professional regulation. We argued that in the NHS there was not enough emphasis and thinking on types 2 and 3 and nor on how all the types meshed together coherently.

Arguably Monitor and TDA have largely used type 1 approaches to date and focused on challenged providers. But the task now is to encourage improvement across the board – not just in struggling trusts. Can a merged Monitor/TDA change its spots – can it become an improvement body also offering effective type 2 support to the whole provider pack?

True, both organisations have flirted, at least, with ‘type 2’ improvement: Monitor has in the last year hired an improvement team and TDA is letting a contract worth £9m for Virginia Mason to work with five trusts to help make operational and clinical processes more lean and higher quality. Over this period both bodies have also hired medical directors.

The challenges are high, depending on what ‘NHS Improvement’ is meant to do. First Monitor and TDA will clearly have their work cut out in the next year focusing on those trusts in financial distress. Can they also focus on the near-distressed upwards? Second, they are not used to a wider set of approaches to improvement – those in the type 2 box – and the accompanying world view. Third, as we know from the oft Kafkaesque history of NHS architecture,  national bodies that have been set up as improvement agencies – such as the Modernisation Agency and the NHS Institute – have had a short shelf life, abolished as lower priority than their more macho type 1 counterparts using, shall we say, more traditional tools.

Surely it will be worth the new ‘NHS Improvement’ familiarising itself with the Department of Health archives documenting the activities of the NHS Institute and the Modernisation Agency. At the Health Foundation, our experience of trying to support NHS providers, mainly acute trusts, over the last decade with ‘type 2’ support using quality improvement methods might help. In our recent report, five NHS trusts described their journey towards becoming a learning organisation. As a starter for ten:

• Effective improvement can’t be imposed centrally, but must be designed and owned locally.
• Of the usual quality improvement techniques, such as lean, Six Sigma, Total Quality Management – it doesn’t matter which one, as long as it is used systematically.
• Front line clinical teams need space to look at the pathways of care they deliver and work out with patients and carers how they could be made better.
• The teams need to test change using robust measures which are then fed back to allow course correction and adaptation.
• Context (broadly environment) is often far more important than the intervention, so as much attention on this is needed.
• Success if it occurs comes off the back of hard detailed work done mainly by people working at the front line.
• Improvement takes time and there are few shortcuts (Salford Royal began its journey over a decade ago)
• Collective efforts, such as collaboratives, can help speed change but are only sustainable if led bottom up.

Building this knowledge from near scratch is the challenge ahead for the new TDA/Monitor. There is enough experience now, as compared to a decade ago, within the NHS in England, and increasingly Scotland, to help. The extent that any central body can be effective to help build the NHS as a learning and self improving organisation though is moot, but worth a try.

The temptation will be to do something quickly – to impose improvement in true type 1 style. That won’t work. Building a learning culture needs pull, not push, and from the front line (read clinicians, in particular doctors) and above all involving patients and carers. The ability of Monitor/TDA to build effective networks to help achieve its improvement aims - for example with AHSNs, with provider networks, royal colleges, patient and carer groups, the public and others, will be essential.

The move to ‘improvement’ and ‘learning’ as signalled in the Secretary of State’s speech echoes Don Berwick’s conclusions, was implicit in the approach outlined recently by Lord Carter in his interim report on improving efficiency in hospitals, and has a long pedigree.  Surely this direction is the right one, and to be welcomed.

But given the NHS’s history, and the eye watering challenges ahead, we have to do it differently this time. 

Jennifer is Chief Executive at the Health Foundation