News Desk-January 20, 2021. To avoid quality improvement efforts becoming a disjointed (or worse, conflicting) set of initiatives, organisations also need to put in place systems to co-ordinate different improvement projects and ensure that learning is shared between them (Bohmer 2016; Dixon-Woods and Pronovost 2016). The NHS, like all other health care systems across the world, sometimes fails to deliver high-quality care. Journal of Geriatric Cardiology, vol 11, no 4, pp 329–37. All health and care systems should be seeking to improve these aspects of care for people using their services, on a continuous basis. There are many opportunities in the NHS to deliver better outcomes at lower cost (improving value), for example by reducing unwarranted variations in care and addressing overuse, misuse and underuse of treatment. Leadership vacancies in NHS trusts remain widespread with 37 per cent of all surveyed trusts having at least one vacant post for a board-level executive. Available at: (accessed on 8 September 2017). AoMRC website. I’m still amazed people are prepared to put themselves forward for these roles. A review of evidence on which improvements to quality reduce costs to health service providers. Coventry: NHS Institute for Innovation and Improvement. Funding Report for Week Ending 1/3/2021. The review confirmed that there are significant opportunities to improve quality and reduce costs in health care – mainly because of the high cost of poor-quality care to patients and the health system. Improving quality and reducing costs are sometimes seen as conflicting aims. In this honest account of the realities of leadership in today's NHS, Nick Timmins talks to 12 departing. Some NHS organisations that have adopted a systematic approach to quality improvement and invested in developing the skills and capabilities of frontline staff have demonstrated increases in staff satisfaction and retention rates and lower sickness and absence rates (Ross and Naylor 2017; Jones and Woodhead 2015). Ambulatory Heart Failure Clinic: University Hospitals of North Midlands NHS Trust. The survey showed that leadership vacancies are widespread, with director of operations, finance and strategy roles having particularly high vacancy rate and short tenures. London: The King’s Fund. But more could be done to extend these leadership and development offers to the other professional roles experiencing high churn and where there are concerns about the pipeline of future leaders. Available at: (accessed on 8 September 2017). This is likely to be different from data collected for overall performance assessment and management (Raleigh and Foot 2010). The NHS faces the challenge of improving quality of care while coping with the biggest funding squeeze in its history. Boards and executive teams also need to have a good understanding of how change happens in complex systems (see the subsection ‘Make quality improvement a leadership priority for boards’ above). Fillingham D, Jones B, Pereira P (2016). NHS England (2017b). NHS Right Care (2017). These included ensuring recruitment panels have black and minority ethnic representation and developing in-house mentoring and reverse-mentoring programmes. Available at: (accessed on 8 September 2017). Learn More public. These include: Many NHS organisations have started to use quality improvement techniques in discrete projects. It is important to recognise, however, that most errors happen as a result of the systems people work in, not the people who work in them. BMJ Quality & Safety, vol 25, no 7, pp 509–17. Leaders with authority but with no accountability is the most dangerous form of leadership in the World. The quarterly monitoring report (QMR) reveals the views of NHS trust finance directors and clinical commissioning group finance leads on the productivity challenges they face, and examines some key performance data for the NHS in England. Available at: (accessed on 8 September 2017). Quality improvement: theory and practice in healthcare. Programmes to support you at all stages of your leadership journey, Addressing race inequalities in the NHS needs engagement, commitment and a plan, As the Fund prepares to publish its report on workforce race inequalities and inclusion, Richard Murray reflects on. There are many examples across the NHS showing that even relatively small-scale quality improvement initiatives can lead to significant benefits for patients and staff, while also delivering better value. Suzie Bailey explores diversity in the NHS – and why there is still more to do. The Health Foundation (2013). Early identification of patients at risk of developing end-stage kidney disease: Heart of England NHS Foundation Trust. They demonstrate that even relatively small-scale quality improvement initiatives can lead to significant benefits for patients, staff and health system costs. Better value in the NHS: the role of changes in clinical practice. Smith M, Saunders R, Stuckhardt L, McGinnis JM (eds) (2013). Evidence tells us that there are a range of opportunities to improve value in the NHS (Alderwick et al 2015). NHS leaders must therefore work to model and build these cultural elements. Mandating participation in quality improvement training, without first making the case for it, runs the risk that it will be perceived as simply ‘another thing to do’ or a further ‘box to tick’ (Academy of Medical Royal Colleges 2016). London: The King’s Fund. ’We’re here and you’re there’: lived experiences of ethnic minority staff in the NHS, Shilpa Ross explores some common experiences from our research into what it means to be an ethnic minority. This challenge is significant and, in some parts of the NHS, quality is deteriorating rather than improving: waiting times are increasing (Murray et al 2017), the numbers of people waiting to leave hospital are at record levels (NHS England 2017a) and services in the community are struggling to meet demand for care in the face of budget cuts and staff shortages (Robertson et al 2017; Maybin et al 2016). A reduced appetite for risk was mentioned as a factor in the appointment process by both applicants and decision-makers for director-level posts. Future Hospital Journal, vol 3, no 3, pp 191–4. Enable and support frontline staff to engage in quality improvement. A recent review (Furnival et al 2017) identified eight broad dimensions of quality improvement capability – including the effective use of data and analysis (see the subsection ‘Use data effectively’ below), systematic use of improvement methods and processes, and a core focus on meeting the needs of service users. Health Expectations, vol 16, no 3, pp e36–e47. A recent review of approaches to improving quality in the NHS found that, while improving quality remains a stated priority, implementation is weak (Molloy et al 2016). Quality improvement – training for better outcomes [online]. There was some evidence that leaders were taking more action to pursue greater equality and diversity. But the most common suggestion for improving the development of future leaders focused on the need for better regional talent management, similar to that previously provided by strategic health authorities. A review of the literature on healthcare professionals’ views on quality improvement initiatives. ‘The model for understanding success in quality (MUSIQ): building a theory of context in healthcare quality improvement’. We need the autonomy, not regulatory control, to do them. Finding ways to free up staff time to take part in improvement work or training is another necessary step. NHS England, Health Education England, Public Health England, Monitor, Care Quality Commission, NHS Trust Development Authority (2014). Available at: (accessed on 1 September 2017). The size of the workforce Some 1.2 million full-time equivalent (FTE) staff work in the NHS, 1.1 million work in adult social care and at least a further 46,000 work for independent health care providers. Perspectives on context: a selection of essays considering the role of context in quality improvement. NHS leaders have a vital role to play in making this happen – leadership and management practices have a significant impact on quality. Medication safety in the NHS [online]. The Kings Fund has published a new report, The courage of compassion: supporting nurses and midwives to deliver high-quality care. “Services are stretched to the limit. The NHS atlas of variation in healthcare: reducing unwarranted variation to increase value and improve quality [online]. Home; Headlines; Survey; NHS Performance Data; About the QMR; QMR 14 | January 2015 Share on Twitter; Share on Facebook; Share on LinkedIn; How is the NHS performing? London: The King’s Fund. But the support of senior leaders in the organisations involved is important in getting a project off the ground and creating time for staff to design and test new ways of working, as shown in example 5 on dementia care in Sussex. NHS Right Care (2010). There is generally widespread support and enthusiasm for involving patients, service users and their carers in quality improvement efforts and ensuring that change is ‘co-produced’. ‘Quality improvement savings tracker worksheet’. Available at: (accessed on 8 September 2017). Clinical teams wanting to improve quality will require disaggregated data on processes and outcomes of care, as well as time trends to allow analysis such as statistical process control (time series analysis used to identify variation beyond predictable limits). More attention should be given to addressing the environment NHS leaders operate in. Current sustainability and transformation partnerships (STPs) in the NHS in England are one way to encourage this kind of joint working. It is also possible to encourage participation by using more formal measures – for example by including involvement in quality improvement as part of required professional development activities, or by visibly reporting data on performance between peers (Dixon-Woods et al 2012, 2011). ‘Delayed transfers of care data 2017-18’. Does improving quality save money? NHS trusts face worryingly high levels of senior vacancies, Rt Hon Jacqui Smith argues that getting the right leadership team in place – and keeping them there, Transformational change in health and care: reports from the field, We interviewed 42 people who were involved in leading, supporting, delivering, receiving or witnessing transformational change. Health Affairs, vol 30, no 6, pp 1185–91. Available at: (accessed on 8 September 2017). Early evidence suggests that the programme is identifying significant opportunities to improve value, through changes to procurement practices, productivity and quality. But there is relatively little information on current vacancies and tenure in the NHS, and the factors that are influencing them. Only 7 per cent of very senior managers were from a black and minority ethnic background, which is far lower than representation in the NHS workforce and local communities. improving the broader health and wellbeing of the population, giving all staff the opportunity to contribute and act on ideas for improvement, using many small-scale trials and tests as a way to learn and improve, ensuring a continuous focus on the needs and experiences of the people served by the system (, having clear goals for improving quality (and making them a top priority), regularly reviewing quality performance in meetings. shares their experiences and reflections. National Audit Office (2015). Sustainability and transformation plans in the NHS: how are they being developed in practice? Learn More public. Rather, it is the process of having a systematic approach to quality improvement and applying this consistently that is important (Ross and Naylor 2017). Available at: (accessed on 20 September 2017). Skip to main content. Data should be used to identify quality problems, define indicators for improvement and track the impact of different interventions on quality of care. A systematic narrative review of quality improvement models in health care. Note: if the five examples of quality improvement in the NHS are not displaying above, you can access them here. This report by The King's Fund has been co-authored with The Health Foundation. London: The Health Foundation. Developing people – improving care: a national framework for action on improvement and leadership development in NHS-funded services. A clear road ahead: creating a coherent quality strategy for the English NHS. Ultimately though, interviewees cautioned against placing too much focus on formal talent management or development programmes, and several noted a more effective talent pipeline alone will not reduce vacancies as long as the current operating environment and treatment of leaders is unchanged. 4,300 were here. Higher vacancy rates and shorter tenures were found in trusts experiencing the most challenged levels of performance. The challenge now lies in delivering the plans and making tangible improvements in NHS care as a result. London: The Health Foundation. The term ‘quality improvement’ refers to the systematic use of methods and tools to try to continuously improve quality of care and outcomes for patients. ‘Board engagement in quality: findings of a survey of hospital and system leaders’. The Kings Fund report, commissioned by the Academic Health Science Networks (AHSN), charted the journeys of eight innovations from creation to widespread use. Timmins N (2017). King's Fund annual report 1988, King Edward's Hospital Fund for London annual report 1988. Available at: (accessed on 8 September 2017). ‘The association between health care quality and cost: a systematic review’. Our report draws on NHS Providers’ annual quantitative survey of leadership vacancies and on qualitative interviews and a roundtable The King’s Fund conducted with NHS trust directors and national stakeholders. The report will also explore the issues in social care in more depth than we are able to here. This will help bring quality patient care further forward into the 21st century. Our report examines the approach being taken by some clinical commissioning groups (CCGs) and local systems where traditional notions of commissioning are no longer guiding their way of working. The management of adult diabetes services in the NHS: progress review [online]. New England Journal of Medicine, vol 375, pp 709–11. Azad N, Lemay G (2014). The current pressures on the NHS mean that, now more than ever, there needs to be a strong focus on delivering better-value care and putting quality and safety at the heart of the health policy agenda (Ham et al 2016). British Heart Foundation (2015). It has been estimated that productivity gains of between £1.1 billion and £2.3 billion could be achieved across England by improving or redesigning acute processes (Monitor 2013). WRES Implementation Team at NHS England, looks at race equality progress over time. Armstrong et al (2013) identify a number of tips for successful patient involvement in improvement projects, including (but not limited to): A range of tools and approaches can also be used to help achieve these aims, such as the Patient and family-centred care toolkit. Journal of Healthcare Management, vol 53, no 2, pp 121–34. A ‘revolving door’ approach to leadership also undermines the credibility leaders have with staff in their own organisations and with external stakeholders. This, again, highlights the key role of senior leaders and boards, described in the subsections ‘Make quality improvement a leadership priority for boards’ and ‘Share responsibility for quality improvement with leaders at all levels’. STPs and other local partnerships could also help NHS organisations to ‘act like a sector’, bringing together professionals from different services to agree standard procedures and processes to improve care (Dixon-Woods and Martin 2016). We have argued that transformation is best brought about ‘from within’, led by frontline staff and service users, and that it … A summary of the King IV Report on Corporate Governance™ for South Africa, 2016 Overview. BMJ Quality & Safety, vol 21, no 9, pp 737–45. its lessons for leaders and make a start. By Michael West et al - 23 September 2020 Data visualisation NHS workforce . NHS has culture of bullying, racism, discrimination and sadly has a culture of rewarding those who collude with the system than those who challenge the system or leaders. Available at: (accessed on 8 September 2017). I work at this front line however the patient/carer role is often percieved as problematic and difficult and not functioning in ‘partnership’ . ‘Ten challenges in improving quality in healthcare: lessons from The Health Foundation’s programme evaluations and relevant literature’. As long was there is a system of lack of governance and poor accountability, patients, staff and NHS will suffer. Washington, DC: National Academies Press. HC 489. Available at: (accessed on 8 September 2017). The Ambulatory Heart Failure Clinic at the University Hospitals of North Midlands NHS Trust was a response, in part, to local heart failure patients’ wishes for a service that allowed them to remain in their own home (example 2). Identifying and removing steps that do not add value for the patient, or delay their access to care on return home, can help to improve patient outcomes and experience while freeing up clinical time (Fillingham et al 2016; The Health Foundation 2013). NHS England website. Now, more than ever, local and national NHS leaders need to focus on improving quality and delivering better-value care. These provide a starting point for leaders seeking to embed quality improvement in their work. Timmins N (2015). James C, Savitz LA (2011). History. The right medicine: improving care in care homes [online]. However, it can be difficult for clinicians to engage in quality improvement (Wilkinson et al 2011). Interventions that ‘worked’ in one place are rarely easy to replicate in others. This ‘displacement of rewards’ means that providers investing in service improvements may see their return on investment fall to another part of the system, or their income fall if they have reduced activity that they were previously paid for (Leatherman et al 2003). In some cases, they have done so without the explicit support or encouragement of senior leaders within their organisation, or without any meaningful resources (Bohmer 2016). The King’s Fund. Dixon-Woods M, Martin GP (2016). And if measurement systems are poorly designed, they can create perverse incentives such as ‘gaming’, where targets are achieved but the intended changes in practice are not (Bevan and Hood 2006). Health Affairs, vol 34, no 8, pp 1304–11. Gardens and health 8 The case for gardens should not be reduced solely to ‘the business case’. Several interviewees mentioned how recent regulatory or political interventions to remove leaders for failing financial or performance targets suggested that individual leaders are sometimes held to account for system-wide problems. Develop the skills and capabilities for improvement. Yet many have found it challenging to match Southmead’s impact. You can explore these documents on this website, download them for your own use and embed them on your own website. Regional talent management functions – largely absent since the abolition of strategic health authorities – should be rebuilt in the new joint NHS England and NHS Improvement regional teams. This report is authored by Lord Warner, a former Labour health minister. Kaplan HC, Provost LP, Froehle CM, Margolis PA (2012). Press Release 23/09/2020. If one was asked to summarise King IV™ in one word, ‘transparency’ would come to mind. The expert panel provided its final report to the government on 14 February 2020 (the King Review). GOV.UK website. I think that the commentary about what it means for the profiles of candidates is really important (p36). ‘Conceptualizing and assessing improvement capability: a review’. Available at: (accessed on 8 September 2017). The literature is also hampered by a lack of high-quality evaluations. The ERF is a key policy instrument that the government has relied on since 2014 to encourage the uptake of abatement technology in Australia. There needs to be a more modern approach to partnership working across the system which involves remodelling of the work being done and redone at the frontline which I would like to be part of modernising. ‘Our NHS people matter’ – five years of the Workforce Race Equality Standard (WRES), As the fifth annual Workforce Race Equality Standard (WRES) data report is published, Yvonne Coghill, Director of the. London: Faculty of Medical Leadership and Management. Current NHS leaders were self-described ‘cautious optimists’ who believed that the route through the challenges of NHS leadership involved them, as senior leaders, promoting and demonstrating the behaviours that would make these roles attractive for subsequent generations of leaders. By Suzie Bailey, Michael West - 30 April 2020, By Yvonne Coghill, Director of the WRES Implementation Team at NHS England - 14 February 2020. They starve either because they cannot eat or cannot absorb the nutrients from a normal diet. NHS leadership is insular. Quality improvement in mental health. The potential benefit is even greater if quality improvement techniques are applied consistently and systematically across organisations and systems. NHS Right Care (2015). Jan 3, 2021. Jan 1, 2021. The King's Fund says that in the past two years, the focus has rightly shifted to improving patient safety and quality of care as well as treating more people at home rather than in hospital. 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