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Citius, Altius, Fortius – Johnny Marshall

If you have not been bitten by the Olympics bug, and therefore are not waiting in nervous anticipation for the Paralympics to alleviate your withdrawal symptoms, then you might like to look away now….

Throughout London 2012 there have been high quality performances, both on and off the various fields of play, that have taken our breath away. Events that had previously gone unappreciated have burst in to our homes through a plethora of media channels. My unexpected guilty pleasure was the team rhythmic gymnastics (don’t knock it until you’ve seen it!) – oh to have that sort of handover in healthcare!

So in the hiatus between Games it was timely that the road to quality returned to take pride of place at the NHSCB Future Design Group. The opening conundrum focused on the observation that whilst the evidence is clear that improvements in quality are more likely to occur when formal improvement methodologies are adopted, these methodologies are failing to connect with frontline clinicians, or vice-versa. Throughout London 2012 we have been presented with back stories of successful athletes that repeatedly demonstrate behind every great team performance sits great leadership, methodology, sacrifice, drive and commitment.

So who will be responsible for quality improvement in the new NHS? With the Francis report just round the corner and the National Quality Board draft report hot off the press this is going to be the source of much debate in coming months. In reality it is less about who is responsible and more about what are we each responsible for. Today we were focusing on the NHSCB as a system leader and a commissioner. So what needs to change?

If we are to get best value for the population we serve then bold leadership from NHSCB, in partnership with CCGs, around the totality of quality rather than individual elements or isolated perceptions will be an important step in delivering improved population focused outcomes. The style of that leadership will need to be different from the dominant pacesetting style of the past and one that enables each part of the NHS, and each individual within the NHS, to be more effective. During London 2012 the British Track Cycling Team was perhaps the pinnacle of such a team approach. No “Magic” wheels but a 1% improvement in a large enough number of areas to deliver the highest levels of performance at just the right time. Each member of that team united around a common purpose, clear about exactly what their role was and fully equipped to deliver it in a self-directed way.

A key part of Team Quality in the NHS will be the Care Quality Commission (CQC) overseeing essential quality standards for registered providers through its regulation framework whilst NHSCB and CCGs will be able to drive performance through contractual mechanisms. In a quality improvement environment today’s improvement is tomorrow’s registration standard so close team working between these organisations will be pivotal to sustaining improvements in quality. At present it is less than clear as to how this will work.

One key area of collaboration will be around common quality measures. During London 2012 success has been measured on a number of different outcomes: gold medals, silver medals, bronze medals, world records, Olympic games records, national records, personal bests, season bests, doing your best (especially if you were in team GB and being cheered on by the home crowd – or was that collusion?).

However, measuring team success seems slightly more difficult to reach agreement on. So whilst most of the world’s medal tables are based on the number of gold medals won, in which Team GB came third, the U.S. adopted a table based on total medals won, in which Team GB came 4th. Team Canada finished 36th or 13th respectively depending on the measure of success used. Team Grenada looked best in the gold medals per head of population at about 1 per 100,000 but finished 50th and 85th respectively by the other measures. Getting the quality measure right really counts.

Without wishing to stretch this analogy too far does this then raise the question of how should the NHS measure its success around value? By the end of London 2012 the media stories started to move towards the enduring legacy and future investment in both elite and grass roots sports. It soon became clear that behind much of the success also sits investment. Investment in elite athletes delivers more success and success breeds more elite athletes in that sport. Investment in grass roots sport gives opportunity to more future elite athletes. Elite sport funding investment decisions are made after each Olympic Games ahead of the next. There is a finite amount of money to be distributed amongst an increasing number of causes all competing to be given a chance to compete at the highest level. Some sports will receive large sums of investment and others none, based on their performance and likelihood of delivering medals in the future.

So should success in the NHS be based on the number of gold standard services it has (where bronze still represents significant success rather than failure) or on a total count of quality and therefore value across the whole population? What represents better value within the NHS? It is investing to deliver the equivalent of 29 golds, 17 silvers and 19 bronze medals or investing to delivering 65 or more silvers……and does it even work like that?

As well as the medal counts the information on each athlete’s performance is readily available in an intelligible comparable format and subject to detailed analysis. As commissioners of healthcare having the same detail of information on provider performance would be a far cry from our current experience and watching Team GB’s track cycling team pouring over the data from each race to maximise performance in the next served to illustrate how important information and methodology can be. Armed with the right information commissioners would be better placed to identify areas of genuine underperformance and target their efforts in challenging and supporting quality improvement in specific elements of the supply chain. Although not everything we value is easy to measure. I really enjoyed Team GBs success in the dressage but its scoring looked quite subjective to me!

I will leave the final, if slightly modified in italics, prophetic word to providers on quality improvement in the NHS to Dave Brailsford CBE, performance director of British Cycling, “The NHS Commissioning Board has delivered and there can be no excuses now. There are not many nations in the world that have the same backing. It’s scary because all the obstacles have been removed and there is nothing for us to hide behind.”

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