Organisation objective
- NHS Long Term Plan
- NHS Mandate from government
Working with people and communities
What approaches have been used to ensure people and communities have informed this programme of work?
- consultation/engagement
- qualitative data and insight, for example, national surveys; complaints
- quantitative data and insight, for example national surveys
- partnership working with voluntary, community and social enterprise organisation
Action required
The Board is asked to consider and provide feedback on:
- the scope and approach to developing a proposed Quality strategy
- the need for close alignment with the 10 Year Health Plan and wider work
Background/issue and context
1. The government’s forthcoming 10-year plan will set the vision, strategic direction and priorities for the NHS over the next decade. To support delivery of priorities, we are evolving the NHS operating model to ensure that there is greater clarity around roles and responsibilities.
2. This presents an opportunity to ensure quality is an organising principle for the NHS, leveraging progress and learning that has been made.
3. More than 10 years on since the publication of the Francis Report into Mid Staffs and the recent Darzi review, has revealed a mixed picture on quality. The independent Review into the operational effectiveness of the Care Quality Commission (CQC), by Dr Dash (2024), has also included key recommendations about quality, including the need for the CQC to pay more attention to effectiveness of care and outcomes. Forthcoming reports by Dr Dash are expected to speak to the complex quality landscape and quality responsibilities, quality governance structures and prioritisation.
4. NHS England will seek to work with the National Quality Board (NQB) to develop a clinically-led quality strategy. The NQB comprises senior clinical and professional leaders from across health and care partner organisations and lived experience experts. This will ensure quality has a shared multi-agency approach.
5. The strategy will be developed in parallel with and informed by the 10-year plan, the Dash review, and addressing the learning from the Darzi Review. This will ensure a system wide focus on quality (including safety) to drive improvements in care, experience and outcomes.
6. This paper asks the Board to consider the scope of this work and guide the approach we take including consideration of:
- quality definition and our statutory duties
- the importance of a focus on quality
- developing the framework for quality
- next steps
Quality and our statutory duties
7. The quality strategy will use the definition of quality in the Darzi report High quality care for all (2008) and NQB’s Shared commitment to quality (refreshed in 2021) as basis which includes care that is safe, effective and provide a positive experience for patients:
a. Safe – delivered in a way that minimises things going wrong and maximises things going right; continuously reduces risk, empowers, supports and enables people to make safe choices and protects people from harm, neglect, abuse and breaches of their human rights; and ensures improvements are made when problems occur.
b. Effective – informed by consistent and up-to-date high-quality training, guidelines and evidence; designed to improve the health and wellbeing of a population and address inequalities through prevention and by addressing the wider determinants of health; delivered in a way that enables continuous quality improvements based on research, evidence, benchmarking and clinical audit.
c. Positive experience – responsive and personalised – shaped by what matters to people, their preferences and strengths; empowers people to make informed decisions and design their own care; coordinated; inclusive and equitable. Caring – delivered with compassion, dignity and mutual respect.
8. This definition is enshrined in legislation, with duty on NHS England to act with a view ‘to securing continuous improvement in the quality of services to individuals.’.
The importance of quality to access and value
9. Beyond ensuring safe, effective and a good experience of care, quality is of care is inextricably linked with access and value. The strategy should set out an approach to improving quality with as much rigour as access, performance, finance and use of resources, and also consider them together ‘in the round’ identifying where the strategy needs to feed into wider strategic work. This approach recognises that quality care is better value for money, and that financial and operational decisions must be informed by a clear focus and clarity on quality risks and inequalities impact, including any adverse impacts. The Quality strategy will take into consideration:
a. Access: as a pre-requisite for quality. Access impacts on all 3 dimensions of quality – effectiveness, safety, experience. Maintaining a relentless focus on improving access is therefore central to meeting our quality duty. The quality strategy will consider where issues in access are impact quality and ensure this is fed into the 10 Year Health Plan approach, particularly the vision working group considering how to deliver the statement “I can access the high quality and effective care I need, when and where I need it”.
b. Value: quality of care at every level can increase value including through technical efficiency (eg at a clinical level by reducing errors or readmissions for example) and allocative efficiencies (eg at a population level by maximising health gain). There is a role for integrated care boards (ICBs) as strategic commissioners to support quality through a shift of care upstream and commissioning for quality and maximising value in terms of health gain. The quality strategy should ensure it considers and aligns with the operating model to achieve this.
Developing the framework for quality
10. Regardless of whether we are thinking about quality at the level of a clinical team or at population level, a clear framework to support and drive improvement is needed, based on a balance of quality improvement, planning, control and assurance (a quality management system), implemented at every level. This must cover hard (such as financial incentives) and soft levers (such as engagement). The Quality strategy development will, among others, use the framework for developing quality set out by Lord Darzi:
- Set direction and priorities: setting clear quality priorities and an agenda for the system and desired outcomes and performance data.
- Bring clarity to quality: set and deliver clear quality standards for services. For example, we have demonstrated within the domain of safety that we can make very significant gains by the consistent application and monitoring of known evidence, ie National Institute for Health and Care Excellence approved interventions. We can achieve more by ensuring we use agreed evidence-based standards across the system to support adoption of best practice.
- Measure and publish quality: use data effectively to monitor quality, drive improvement and mitigate risks. Ensure we make the most of what data we have, using it consistently and transparently, and addressing any key gaps (building on Insightful Board publications).
- Recognise and reward quality: recognising and rewarding improvement in the quality of care and service through financial and non-financial recognition (eg enhanced reputation or prestige). We will review and strengthen levers and incentives for improving quality (NHS Quality Accounts, CQUINs, regulation, good practice and improvement) to drive improvement. This is dependent on embedding a mature and dynamic approach to risk management based on the right data and clear governance structures to mitigate risks to quality and incentivise priority outcomes on quality.
- Build capability: improving leadership, management, professional and institutional culture, skills and behaviours to provide quality assurance and improvement.
- Safeguard quality: using regulation to improve health and care, to guarantee minimum acceptable standards and to reassure the public about quality of care.
- Stay ahead: developing research, innovation and planning to provide progressive, high-quality care. This should also specifically aim to harness the benefits of big data and artificial intelligence.
11. Recent inquiries have highlighted the importance of acting quickly using a range of these levels, to address quality failings and to act on the signals from staff, people using services and unpaid carers. Being clear on how we listen and act on this feedback, on what good looks like (including how our performance and regulatory frameworks support this), is needed. In addition, how we bring together and visualise data across services to better support quality is key to improvement and preventing service failings.
Next steps
12. We are taking the following approach to development:
- develop the strategy in partnership with NHS and partners via the National Quality Board
- ensure that the approach to quality is aligned to the development of oversight, assurance, performance and regulatory frameworks
- ensure alignment with wider work including the 10 Year Health Plan, Dash review and findings from the Darzi review including supporting engagement with stakeholders on quality (further detail in annex 1)
Annex 1: alignment with 10 Year Health Plan and wider work
1. Quality will be considered and engaged upon as part of the 10 Year Health Plan development, and embedded as a core outcome that the plan sets out to achieve. The work and resource to develop the Quality strategy will be an integral part of the development of the 10 Year Health Plan vision workstream 2 in particular “I can access the high-quality, effective care when I need it”.
2. Quality will be a key theme in the enabler workstreams, including “finance and contracting”, “data and technology” and “accountability and oversight” (see annex A for further areas of potential alignment).
3. Specific engagement and policy work on quality will also be undertaken alongside the 10 Year Health Plan engagement to develop evidence-based policy recommendations to address known issues. This will ensure that the Quality strategy can enable delivery of the 10 Year Health Plan, as well as a refreshed patient safety strategy sitting beneath it.
4. The Quality strategy development will also need to align with wider work, including the review into the operational effectiveness of the Care Quality Commission and other forthcoming findings from the Dr Penny Dash reviews and other NHS England work in train.
Interdependencies with wider work
External inquiries/reviews:
- Darzi review and 10 Year Health Plan
- Dr Penny Dash reviews
- cross-cutting themes from inquiries
- existing National Quality Board (NQB) guidance
NHS England strategy and spending review commitments in development:
- NHS Oversight Framework
- Performance, Improvement and Regulatory Framework
- Strategic Commissioning Framework
- Management and Leadership Framework
- development of productivity measures
- NHS England Quality Committee integrated quality report
- NHS England clinical audits and Registries strategy
- review and strengthening of listening culture
- review of NQB Risk response and escalation guidance
- Refresh of Patient safety strategy
- national action plans and strategy, eg maternity, safe staffing
Publication reference: Public Board paper (BM/24/44(Pu)