How can improvement-led delivery enhance the quality of outcomes for our patients, communities and our health and care workforce?
Our health and care systems have navigated the impact of an unprecedented global pandemic, which has taken its toll on our workforce, our communities and the services we deliver.
Current challenges across the NHS in its immediate aftermath have posed the question of how we use learning to effectively and systematically deliver real-time improvements at scale and at pace on our shared priorities, while developing the capacity and capability of the service to improve over time.
As a result, I was asked to lead the delivery and continuous improvement review in April 2022, to consider how the NHS can develop a culture for continuous improvement while focusing on its most pressing priorities.
NHS England understands that its role is to support and champion providers and systems in delivering for people (both those who deliver and use our services) and cannot do this in isolation.
To this end, while NHS England has co-ordinated this review, its content has been co-designed by engagement with more than 1,000 patients, health and care leaders including clinicians and frontline staff, managers, improvement leads, senior executives across local government, the Voluntary Community and Social Enterprise (VCSE) sector, NHS providers, integrated care systems (ICSs), regional and national teams, and the Care Quality Commission (CQC).
We felt these partnerships were crucial in ensuring that recommendations were driven by those who deliver and receive NHS services, and that this document was relevant and reflective of your experiences.
The outcome of this review is 10 recommendations that have been consolidated into three actions, which collectively have the potential to provide immediate practical support to meet the short- and medium-term challenges outlined.
This document is not intended to be static. In fact, it will be refined and iterated as we receive feedback from its users on how it has been used, and where it can be improved.
Over the last year, I have been overwhelmed by the interest in this work which I believe has the capacity to give not only hope, but real benefit to every layer of our health and care system, every staff member and every patient.
Together we can learn and embed process improvement, building clinical leadership for results and in doing so address the unwarranted variation in care.
We look forward to taking the next steps with you on this continuous improvement journey.
Anne Eden, Regional Director South East, NHS England.
Review findings at a glance
The delivery and continuous improvement (DCI) review considered how the NHS, working in partnership through integrated care systems (ICSs), delivers on its current priorities while continuously improving for the longer term.
We know that focusing on improvement, as an essential component of quality, enables us to achieve more consistent, high-quality care.
The review team explored how we ‘improve with purpose’, using all the assets at our disposal: data and evidence, digital transformation and the skills and experience of our health and care workforce.
Having assessed the current approach to delivery-led improvement both within NHS England and more widely, the review team made 10 recommendations which were endorsed by NHS England’s Executive Group (outlined in this report).
NHS England’s Board has now consolidated these recommendations into three actions:
- Describe a single, shared NHS improvement approach.
- NHS England will set an expectation that all NHS providers, working in partnership with their integrated care boards, will embed a quality improvement method aligned with the improvement approach to support increased productivity and enable improved health outcomes.
- This will require a commitment from NHS England itself to work differently, in line with the improvement approach and the new Operating Framework.
- Co-design with our health and care partners a leadership for improvement programme.
- This will be commissioned and supported by NHS England, enrolling all providers and systems (including primary care) in it to support a whole-system focus on improving healthcare outcomes with our workforce, patients and communities.
- Establish a national improvement board
- This will agree the small number of shared national priorities on which NHS England, with providers and systems, will focus our improvement-led delivery work, with national co-ordination and regional leadership.
- The new board will support more consistent, high-quality delivery of services to improve performance and reduce unwarranted variation.
NHS England’s structures and governance do not yet optimise our ability to focus on a small number of shared national priorities effectively.
Creating the new NHS England gives us the opportunity to bring together specialist delivery and improvement resource in a centrally co-ordinated, regionally-led way, with delivery of improvements through systems.
Effective improvement-led delivery of shared national priorities requires NHS England to invest in a new approach to engaging with clinicians and operational managers at the point of care.
We now need to develop a new model for how we tackle improvement challenges system-wide, sharing our learning and good practice more effectively.
A systematic approach to improvement is embedded in many NHS organisations which deliver consistent, high-quality services with improved patient outcomes.
All evidence-based quality improvement methodologies share common principles.
We now need to support all leaders across providers and integrated care systems to embed those principles in practice.
Improvement methodology is important to support a focus on improved quality and better patient outcomes.
But it isn’t enough.
Our quality improvement efforts need to be focused on our most pressing operational and strategic challenges, within an overall focus on quality across planning, improvement and assurance.
There are further opportunities to support our most challenged organisations and systems more consistently and effectively.
During the DCI review, people told us that NHS England’s recovery support programme works well and marks a positive shift from the previous special measures regime.
We increasingly need to focus on earlier intervention for support and sustainable improvement.
NHS England can do more to provide credible and practical support for improvement-led delivery.
NHS England has a key role to incentivise a universal focus on embedding and sustaining improvement practice across our providers and integrated care systems.
This includes regulatory incentives alongside clearer and more timely offers of support.
Background to the delivery and continuous improvement review
In April 2022, Amanda Pritchard requested a review of the way in which the NHS, working in partnership, delivers effectively on its current priorities while developing the culture and capability for continuous improvement.
Led by Anne Eden, NHS Regional Director South East, with a steering group chaired by Sir David Sloman, Chief Operating Officer, NHS England, the review team co-developed 10 recommendations with health and care leaders that have been consolidated into three actions.
- NHS England’s Executive Group commissioned the review to make recommendations as to how the NHS, working in partnership, both delivers effectively on its current priorities and continuously improves for the longer term.
- The DCI review team ran a series of engagement events, containing core questions and key lines of enquiry, with a wide range of stakeholders including chief executive officers (CEOs) at ConfedExpo.
- 100-Day Discharge Challenge launched.
- A series of engagement events were held with stakeholders, including local government, provider and integrated care board (ICB) leaders.
- Large co-designed collaborative event, co-delivered with experts by experience, held with provider and ICB leaders to further test and refine the review’s interim findings.
- Overall engagement with more than 1,000 health and care leaders.
- Endorsement of the review’s final lines of enquiry by NHS England Executive Group.
- 100-Day Discharge Challenge concluded.
- Winter Collaborative launched.
- The review’s findings were presented at the NHS England leadership event with ICB and provider chief executives.
- The review reported its findings and 10 recommendations to NHS England’s Executive Group.
- NHS England’s Board consolidated the 10 recommendations into three actions.
The three NHS England actions
Three actions formed from the consolidation of the DCI review’s initial recommendations:
1. NHS improvement approach
What is it?:
Universal application of one shared high level ‘NHS approach to improvement’ to draw and build on the best approaches to organisational quality assurance, planning and improvement and to support increased productivity and enable improved health outcomes.
What does it mean?
All NHS providers, working in partnership with their integrated care systems, will embed an improvement method and culture aligned with the NHS improvement approach.
This includes acute, community, mental health, primary care and ambulance providers.
2. Leadership for improvement programme
What is it?
A leadership for improvement programme, commissioned and supported by NHS England, enrolling all providers and systems (including primary care) in it to support a whole-system focus on improving healthcare outcomes with our workforce, patients and communities.
What does it mean?
It will create a more standardised approach to supporting providers and systems with shared priorities across England.
It will help to support our most challenged organisations and systems more consistently and effectively by offering focused board level training.
3. National improvement board
What is it?
A board that sets the direction for improvement-led delivery across the NHS, working with our partners.
The scope and remit of the board will be informed by the new Operating Framework, with a focus on local delivery through system-working, with regional leadership and national co-ordination.
What does it mean?
It will agree a small number of shared national priorities and oversee the development and quality-assure the impact of the NHS improvement approach across all providers and systems.
The NHS improvement approach
Drivers and enablers
- Co-production with people and communities
- Clinical leadership
- Workforce, training and education
- Digital transformation (including federated data platform and model health system)
- Addressing health inequalities
Building a shared purpose and vision
Our workforce, trainees and learners understand the direction and strategy of the organisation/system, enabling an ongoing focus on quality, responsiveness and continued learning.
Building improvement capability
All our people (workforce, trainees and learners) have access to improvement training and support, whether embedded within the organisation/system or via a partner collaboration.
Developing leadership behaviours for improvement
A focus on instilling behaviours that enable improvement throughout organisations and systems, role-modelled consistently by our boards and executives.
Investing in culture and people
Clear and supported ways of working, through which all staff are encouraged to lead improvements.
Embedding a quality management system
Embedding approaches to assurance, improvement and planning that co-ordinate activities to meet patient, policy and regulatory requirements through improved operational excellence.
Context to the review: The evidence for improvement-led delivery
What is improvement-led delivery?
Improvement-led delivery involves a whole-system (or whole-organisation) focus on quality, using evidence-based quality improvement methods to increase productivity and deliver better health outcomes for patients and communities.
It is underpinned by the use of data and measurement to achieve these outcomes.
Improvement-led delivery and people and communities
In organisations where improvement-led delivery has been embedded, the needs of people and communities have remained at the centre and resulted in the following:
- Increased engagement
- People (patients and staff) have been involved in new improvement projects focused on organisational priorities, with outcomes informing the future of service provision.
- This has contributed to reduced health inequalities and PALS complaints and improved feedback.
- Increased patient awareness
- Results of improvement initiatives are made visible to patients and in turn accelerates implementation.
- Evaluation of improvement ideas
- Patients are able to support testing and evaluation of improvement ideas, before they are delivered more widely.
University Hospitals Sussex
University Hospitals Sussex NHS Foundation Trust’s fall reduction programme oversaw a 30% reduction in in-hospital falls.
East London NHS Foundation Trust
East London NHS Foundation Trust saw an increase in accepted referrals for early intervention psychosis from 21% to 62% using improvement principles.
Improvement-led delivery and our health and care workforce
Our health and care workforce are tired, having supported people and communities through one of the toughest periods in the NHS’s history.
Organisations where improvement-led delivery has been embedded have noted the following:
- The workforce, including clinical leaders, have been engaged and equipped with the tools, routines and autonomy to drive improvements.
- Purpose and direction
- The workforce is aligned in how their work feeds into the organisation and / or system’s strategy, contributing to improved staff survey scores.
- Improved staff morale
- They are encouraged to work on a small number of priorities that align with national and regional priorities.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation Trust finished in the top five and three nationally in the NHS Staff Survey for questions related to empowerment to make changes and improve.
Surrey and Sussex Healthcare NHS Trust (SASH+)
SASH+ improvement work is embedded across the organisation, with leaders ranging from AfC Band 4 to executives able to train and coach their own staff.
What is the evidence?
Improvement-led delivery is a long term approach to delivery that facilitates stronger organisational governance, productivity and positive cultural change over time.
Many parts of the NHS have a long tradition of embedding approaches focused on quality improvement:
Alder Hey Children’s NHS Foundation Trust
- Jumped from a baseline patient experience score of 59% at the beginning of the approach in 2020 to 92% in August 2022.
- 20% reduction in administration and prescribing errors for 2021-2022.
- HR time-to-hire fell from 68 to 28 days.
Surrey and Sussex Healthcare NHS Trust
- Consistently rated ‘Outstanding’ by CQC since 2019.
- SASH+ improvement work is embedded across the organisation with leaders ranging from AfC Band 4 to executives able to train and coach their own staff.
- Collaborative quality improvement award in 2021 for their ICU clinic, increasing patient experience.
Berkshire Healthcare NHS Foundation Trust
- Rated ‘Outstanding’ by the CQC since March 2020. CQC commented that “staff across the trust felt valued and there was a real focus on doing what was best for staff, patients and carers.”
- NHS Staff Survey results were in the top 20% of scores.
- Reduced prone restraint use in adult acute and children settings by 61% in 15 months.
University Hospitals Sussex NHS Foundation Trust
- Transitioned from ‘Quality/Financial Special Measures’ to ‘Outstanding’ on all sites in all domains in 2019.
- The CQC noted exceedingly high ‘buy in’ from staff.
- Fall reduction programme oversaw a 30% reduction.
- Reduced 24 hour delayed discharges by as much as 75%.
East London NHS Foundation Trust
- Consistently rated ‘Outstanding’ by CQC.
- A Total Quality Management System has been embedded. This applies across quality planning, assurance and improvement.
- Increase in accepted referrals for early intervention psychosis utilising improvement methods.
The Leeds Teaching Hospitals NHS Trust
- Rated ‘Good’ by the CQC, improved from ‘requires improvement’.
- Transitioned from a £100m deficit to a £19m surplus.
- 26% reduction in falls across the organisation – equating to approximately 65 falls per month and 780 falls per year.
These DCI review’s 10 recommendations were presented to NHS England’s Executive Group in October 2022.
Create a more standardised approach to shared priorities across England
1. NHS England’s Executive Group will agree a small number of more consistently executed priority improvement initiatives, offering national co-ordination and regional leadership to support delivery.
2. NHS England will consolidate capability and expertise into a national priority improvement function, whose role is to co-ordinate action on a small number of pan-national improvement priorities on a rolling basis.
3. NHS England will test the model for the new priority improvement function through delivery of a winter collaborative. Action co-ordinated through the winter collaborative will be codified into more standardised approaches to delivery and improvement to support the spread and scale of learning.
Embed continuous improvement-led delivery across all providers and integrated care systems
4. NHS England will set an expectation that all NHS providers, working in partnership with integrated care boards, will embed a quality improvement method aligned with the NHS improvement approach.
5. NHS England will collaborate with partners to co-develop leadership development products that support health and care boards, executives and the wider workforce to embed the NHS improvement approach in their organisations and systems.
6. NHS England will work with the CQC to align the revised CQC well-led with the improvement approach.
7. NHS England will critically review the NHS oversight framework, to incentivise providers and systems to embed improvement-led delivery.
Support our most challenged organisations and systems more consistently and effectively
8. NHS England’s Support for Challenged Systems team will work with and through the regions to more consistently co-ordinate intensive support. This will include continued collaboration with other regulators and royal colleges to ensure consistent support and no duplication.
9. Further develop peer support between providers and systems, including through enhanced support for provider collaboratives programmes and pre-existing provider peer support networks.
10. NHS England will review the balance of national and regional resources between intensive support, pathway programmes and general capacity building. This will include an assessment of how national and regional teams more consistently support organisations in segment 3 and offer longer-term support to organisations exiting segment 4.
Proposed timeline for implementing the three actions
- NHS England Executive Group approval of the DCI review’s 10 recommendation actions.
- Learning from the winter collaborative codified; next priorities set by NHS England’s Executive Group
- Publication of the DCI review report
- Launch of the national improvement board and announcement of the NHS improvement approach*
- First meeting of the national improvement board.
- New NHS England transition completes, and new operating model is established into business as usual
- Publication of the new single assessment framework (CQC) including the new well-led framework.
- DCI review recommendations inform work to revise the oversight framework
- Co-design and delivery of ‘rapid improvement initiatives’ by the new NHS England rapid improvement team.
*19 April 2023: Publication of this Delivery and Continuous Improvement Review at NHS England’s NHS leadership event with ICB and trust CEOs.
DCI review method and engagement process
The review team gathered evidence and insights directly from more than 1,000 people across the health and care system.
Participants who have provided their insights and feedback include:
- lived experience partners through NHS England’s experience of care team
- ICB chief executives and non-executive directors (NEDs)
- provider chief executives and NEDs
- clinical leaders and people working at the point of care, such as nurses, GPs, consultants, and pharmacists
- strategic roles including operational, improvement and transformation specialists
- Arm’s-length body (ALB) partners and collaborators, such as AQUA, CSUs and Health Data Research UK
- networks, think tanks and academics, such as Q community, The King’s Fund, and The Health Foundation
- national bodies, such as CQC, local government representatives, and NHS Confederation
- regional groups, such as local health and social care partnerships, and Academic Health Science Networks
- NHS England national and regional teams.
Emerging insights were reported to the review’s fortnightly steering group chaired by Sir David Sloman and Anne Eden.
During the course of the review, we provided inputs into several concurrent work programmes, seeking to align our emergent findings where appropriate.
- the operating framework programme
- the creating the new NHS England change programme
- Finance and productivity board
- NHS England business planning and guidance.
The review team did not undertake original quantitative research or analysis. It focused on collating and considering existing research and evidence to inform our recommendations.
While we have set out implementation plans to sit alongside these recommendations, we recognise that:
- our recommendations are closely interdependent with the ongoing NHS England change programme, which will shape how NHS England’s operating framework is realised
- full implementation of our recommendations across the NHS (and, in time, health and care systems) will require ongoing co-design between national and regional teams with leaders in systems and providers as well as wider partners, using a collaborative approach centred on learning.
Publication reference: PAR2137