Where has service improvement come from? - healthcare

Improvement methodology is certainly not a new concept. Wherever there is a desire to make things better, there will be people working to find the best ways of doing it. In the business world there are always innovative people searching for new ideas or new products, and trying to find ways to produce them more cheaply. It is, therefore, not surprising that there have been a number of different quality improvement models used within the field of industry, particularly manufacturing, since the beginning of the twentieth century. The car industry is particularly renowned for innovation and improvement. This dates right back to the time that Henry Ford developed mass-production techniques for his new Model T, which allowed a car to be constructed in an incredible 93 minutes in 1911! Improvement methodology became more widely recognised and acknowledged in the 1950s when Toyota’s Taichi Ohno founded the Toyota Production System. In the latter half of the last century, Japanese manufacturers were renowned for successfully producing innovatively designed cars that were superior, yet cheaper than their American competitors. In the 1980s America responded to this competition and it was around this time that the work of American quality systems expert W. E. Deming proved to be the stimulus for what we now know as the modern quality and process improvement movement (Hunt, 2010).

Service improvement methodology has really only been applied within the NHS in relatively recent times. Between 2006 and 2013, the NHS Institute for Innovation and Improvement (NHSI) developed initiatives such as the Productive Ward Series, to help NHS teams to redesign and streamline the way they manage their work. The aim of this initiative was to improve the quality of care by reducing unnecessary waste of resources, therefore freeing up more time to care. It used efficiency techniques previously developed within car manufacturing and the aviation safety industry, and adapted them for use in the NHS. This type of innovation has led to the promotion and development of a continuous improvement culture within the NHS over recent years.

Despite the relative infancy of service improvement methodology within the NHS, quality of care has been firmly on the agenda for a number of years. In 1998, the Department of Health (DoH) white paper ‘The new NHS: modern, dependable’ first described clinical governance as ‘a system for ensuring that clinical standards are met and that processes are in place for continuous improvement’ (Scally and Donaldson, 1998). Subsequent to this publication the NHS spent the next ten years developing systems and processes to underpin clinical governance, with every healthcare professional made accountable for playing their part in delivering it. Yet, despite all of this effort, when Lord Darzi reviewed the NHS in 2008, he identified the need to make the NHS safer, more clinically effective and more personal. Looking forward ten years to the NHS of 2018, Lord Darzi indicated that the NHS is likely to be substantially different, with greater emphasis placed on prevention, individual empowerment, quality of care and integration of services. He stressed the need to ‘unlock local innovation and improvement’ and to ‘empower frontline staff to lead change that improves quality of care for patients’. To make it really clear to everyone what people should expect of the new NHS, Darzi introduced the NHS Constitution. This document sets out the ‘commitments to patients, public and staff in the form of rights to which they are entitled and pledges which the NHS will strive to deliver, together with responsibilities which the public, patients and staff owe to each other to ensure that the NHS operates fairly and effectively’ (DoH, 2013a).

The drive for innovation and improvement over recent years has been supported by the introduction of the Quality, Innovation, Productivity and Prevention (QIPP) challenge (DoH, 2013b). QIPP is a resource for everyone working in the NHS, public health and social care for making decisions about patient care and the use of resources. It was designed to support the NHS to make efficiency savings that can be reinvested back into the service to continually improve quality of care. Andrew Lansley, who was the Secretary of State for Health at the time, emphasised the need for healthcare providers to do things differently:

‘All those who work on the frontline should be thinking carefully, and imaginatively, about how we can do things differently. The QIPP process is a home for this in the NHS and the way that we can implement the best and brightest ideas across the service’.Andrew Lansley, Secretary of State for Health, 2010

The threat that has to be managed during this time of change is that drives for efficiency may compromise the quality and safety of the care provided. It has been in the midst of this emerging drive to think innovatively about service delivery that a number of high profile scandals have become apparent. The events that unfolded at the Mid-Staffordshire NHS Trust clearly illustrated how things can go very badly wrong within an organisation that is under pressure to become more efficient. The inquiry report by Francis into the events at Mid-Staffordshire (Francis, 2013) proved to be a watershed moment for the NHS, with around 280 recommendations proposed by the report. The catastrophic series of events that Francis highlighted illustrated how an organisation can lose track of the values laid out in the NHS Constitution and allow safety and quality to be dramatically compromised in a culture driven exclusively by achieving financial balance and reaching targets.
Whilst the future sustainability of the NHS demands that we find ways to deliver health care more efficiently, simply cutting costs will not be the answer. Public sector consultant Rob Worth (2011, p. 7) advocates that service improvement is the best way to reduce costs, stating that ‘good work costs less’. He stresses that cost cutting always leads to deterioration in the service, which, in turn, leads to higher costs when dealing with the many consequences of bad service. He explains that history clearly shows us that if we focus on improving the quality of services by designing processes that deliver value for the service user and get rid of waste wherever possible, this, in turn, delivers considerable cost savings.

Therefore, it is in the light of the Francis Inquiry Report (2013) that service improvement should be viewed. If we are to successfully redesign processes and working practices in order to both save money and improve quality, there has to be a formal way for staff to identify where improvements can be made and to manage the implementation of those changes. These improvements can be driven by the desire to improve the quality of care and by the desire to use resources as efficiently as possible. The two are not mutually exclusive. Service improvement methodology provides the tools that healthcare teams can use to find the right way forward under challenging circumstances.