interviews

The future for NHS improvement

The way the NHS handles improvement is changing. NHE spoke to Jim Easton, the National Director for Transformation on the NHS Commissioning Board, and an architect of QIPP.

At one NHS Confederation conference not so long ago, Jim Easton recalls, six different exhibitors had the words ‘NHS’ and ‘improvement’ in their titles – but that landscape is now changing, as he told the 2012 conference.

Speaking to NHE soon after the conference, he said the improvement function in the NHS will be streamlined into a smaller body, with a tighter focus and more emphasis on working with partners in the deliver of change-support products and solutions.

He told us: “We’re taking the opportunity to think about the best shape for the support people need in tackling the tremendous challenges that face us in driving quality and productivity.

“The good news is we have a really strong inheritance: bodies like the NHS Institute, which has some fantastic achievements like the Productive Series. There is a long and slightly hidden history of it developing many thousands of NHS leaders and clinical leaders with improvement skills. At most organisations, leaders and frontline staff will talk routinely about ‘lean’ or ‘redesign’, and all that has come from that work. It’s inherent in organisations like NHS Improvement, who’ve got that fantastic work on leading frontline clinical change.

“But there are also things we want to change; there’s a new group of leaders in CCGs on the pitch, with new demands. It’s fair to say there’s a desire for more customer focus in delivering what frontline organisations need. So, if you talk to foundation trust chief executives, some are fantastic advocates of the work they’ve been doing, but others less so, and they feel maybe it doesn’t meet their frontline needs in delivering their care.”

‘Root-and-branch redesign’

Ever since the review of NHS arm’s-length bodies soon after the Coalition came to power, it has been clear that change is coming. Easton said: “We’re going to take the chance to take those improvement bodies and work with them to do a root-and-branch redesign: protecting what they’ve got that is fantastic for the future, but also being unafraid to completely change them and develop new areas in terms of frontline support.

“For those people leading organisations, departments or teams, what is it they think we should protect – and what should change? There’s an open door for people to get involved, through me, in that rapid process of getting this new organisation in place. So, come the autumn, we want to re-launch a new, leaner organisation which is going to be of immense value to the rest of the NHS.

“Some of the DNA will be the same; we’ve got some people regarded as the best in the world. But it needs to look and feel different in terms of being really responsive to the challenges that people face.”

Easton told us the precise structure and branding of the new organisation is yet to be decided, admitting the current landscape of organisations involved in improvement work is “pretty complex”.

He said: “I’m not particularly interested in some fancy-pants branding that doesn’t mean anything. It needs to do what it says on the tin, which is how we get great support to local organisations and to frontline staff to tackle the changes.”

Laser focus?

We asked whether the new body should look at improvement across everything the NHS does – or prioritising the main challenges facing the health service.

He said under the new structure, he wants clear ‘streams’ of products relating to common messages relevant both to senior leaders and frontline staff – the “shared issues”. “But,” he said, “we also want to leave some space to respond to particular challenges individual organisations have got, so we can develop some bespoke solutions.”

He wants seven or eight key streams, he said, such as delivering better outcomes, integration, delivering QIPP, world-leading commissioning, and so on. If they are as good as things like the Productive Series, “people will fall over themselves around the world to use them.”

Leadership

The leadership and improvement functions both fall under Easton’s purview and involve some similar issues.

He said: “We do get the same kind of questioning with both, and occasionally cynicism – people wondering ‘why is it the role of the centre to be providing this support?’ And I would be really happy with a system that didn’t need this: one in which the system was organising its own support. Maybe we’ll get to that, but right now there’s a strong case, if the capabilities are of really high quality, for a place where the NHS can work together to develop the right solutions and get them disseminated quickly and effectively within the family.

“My aim is that it’s something that will allow people to accelerate some of the sleeves-rolledup clinical change they need to provide: high quality care at the frontline with the money we’ve got. And that it becomes the go-to place for the system to get advice and support or contribute to that change.”

Not just salami-slicing

Easton has spoken in the past about the difference between managers using service redesign to add value and take out costs – what QIPP should be about – and those who are actually just going for short-term cost savings and abandoning quality.

Asked for an update on QIPP implementation, he said: “On one level the QIPP story is fantastic news; we continue to hit, in aggregate terms, and in virtually every place, all our main performance and quality markers, and the NHS overall continues to improve. A year and a half into this period of difficult restraint, we could easily have been telling a different story. That speaks volumes for the work people have done locally.

“Underneath that, the picture is more nuanced. You see some organisations struggling to hold onto the quality framework for QIPP and some commissioners complaining about it. You see some people struggling in the transition from the earlier saving element, the efficiency element, to achieving more substantial service change.

“Our focus is on how we get more support to people to deliver quality and efficiency together, because even if it was the right thing to deliver just financial efficiency – which it’s not – people are running out of road on that.”

After QIPP – more QIPP?

What about the future: after the current productivity challenge period is over? Many commentators have noted that rising demand and constrained budgets mean the principles of QIPP will become the new normal.

Easton demurred, saying: “For those people who thought QIPP was a blip, anyone looking at the Chancellor’s Autumn Statement or the overall economic position knows that the run-up to the next comprehensive spending review is bound to be a challenging time for all public expenditure.

“We think we need to start having the conversation as a system about extending beyond the initial four year period of QIPP to thinking about how we get the NHS in shape.”

Aligning NHS improvement with the QIPP challenge

Easton continued: “We’re determined to learn from some of the mistakes from the past. Firstly, we need a place where we’re looking forward and looking around the world at what is ‘best in class’ in terms of change in health care systems and we think the new body should do that – horizonscanning.

“We want really practical changesupport products that are helpful at the frontline. If we think integrated care is the way forward, it’s all very well talking about ‘at a global level’ but what are the seven or eight packages of support that we could get working routinely and make available to accelerate change locally?

“We think it should help develop some of that with early implementers across the NHS, so we’re going to support people putting ideas into action.

“It should not try to gear itself up to be the only supplier of change-support or be big enough to try ‘do change’ across the whole NHS,” he said – and suggested the NHS Modernisation Agency, despite its strengths, was sometimes guilty of this.

“The new improvement body is going to be relatively small – smaller by some margin than the sum of all the constituent parts.

“It should get support from partners who can help it deliver at scale.”

He said potential partners could be the likes of the Academic Health Science Networks, AQuA in the North West, or NHS Quest, the qualitybased organisation – “or indeed some of the commercial players”.

“Next, helping people to measure and evaluate – which is a big weakness across our system – whether we actually understand what works.

“We need very practical things that end up with a product on your desk or in your clinical office and people who can help you make a difference: not telling you what to do if only you were clever enough, and second-guessing your work or doing interesting abstract thinking. In your real day-to-day operations running your trust, you need tools – tools which belong to the NHS that you should be able to access more cost effectively than other support packages –that should just help you get where you need to be more quickly.”

Global horizons

NHE spoke to Easton in the same week another large UK organisation, Network Rail, launched an international consultancy business, to raise global profile – and global revenue.

Easton noted that while he wants the new improvement body to look globally for best practice, the reverse also applies – the NHS Institute already has a “small but very valuable international arm” that does a lot of work in Canada, Scandinavia, Australia and New Zealand.

He said: “If you walk round most hospitals in the UK you’ll find the Productive Series has been really valuable and is kind of endemic – although many chief executives will claim they don’t use it, even though it’s live and really active in their organisation. It’s part of our cultural overlay. But internationally the Institute is held in absolutely high regard and many of the other constituent parts are approached by international groups. As we try to tackle the QIPP problem through this change, given that that’s an international challenge, there’s huge interest in what the NHS is learning and some opportunity for us to get value for the NHS by exporting that.”

But he added: “We’re not in the business to make money from international work – our business is to support the NHS. The value in it will be ‘how does it support the NHS’, either in bringing in new knowledge, or by reputation gain, or frankly some income that we can re-use towards our R&D capacity to develop the NHS.”

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