Leading Improvement in Health and Care podcast

What does NHS England's Quality Strategy mean in practice?

Penny Pereira

Hello and welcome to Leading Improvement in Health and Care, the podcast delivered in partnership between NHS Alliance, The Health Foundation, and the Q community. In this episode, we're going to be discussing the just launched quality strategy for NHS funded services. I am joined by Frankie Swords, who is the national medical director for NHS England and the Department of Health and Social Care, and Sarah Barley-McMullen, who is a strategic lived experience partner for NHS England. She's also the chair of Long Covid SOS.

So welcome Frankie and congratulations on your new role. I wonder if we could start by just hearing a little bit about your experience and what's brought you to the new role.

Frankie Swords 

Thank you, Penny.

It's lovely to be here. So I'm six weeks in and it's fantastic, actually. I'm really, really enjoying it.

So my background, I'm a consultant physician. I've been a doctor since ’95. I've been a consultant since 2008. And as many doctors do, you kind of fall into leadership. You take on a project and it goes quite well and somebody asks you to do something else and then you do more and more. then actually the more I did, the more I realised I really like it. I was quite good at it.

And as a doctor, your job is to help people, as a medical leader, you get to help a lot more people and you get to help a lot of individual doctors help a lot more people. And you also get to help bigger picture staff like education and training, which is going to help the next generation of people and encouraging innovation. I've seen such amazing innovation in the last few weeks. It's been really, really great. And again, that's research and innovation are going to make the care better for even more people. So it's really cool and I'm really enjoying it.

It's just sort of upscaling a bit bigger and a bit bigger. And I'm trying not to take it too seriously. Otherwise I think I'd be a bit terrified, but yeah, it's going really well so far.

Penny Pereira

So wonderful to hear. And has it made you think differently about quality from the different perspectives you've held?

Frankie Swords

Absolutely. And there are two things I'm slightly obsessed with at the moment – it'll change next week – quality and leadership. And of everything I've done over the years, you know, quality has got to be our North Star. That is what we come to work for.

It's absolutely what the NHS in particular is set to provide quality care. And so I've been astonished really in different roles, how there's variation and how there's things that are working really well over here, just haven't been adopted over there. I think, gosh, now this is... I mean, it's great opportunity to improve things, but it's terrible.

So yeah, I've definitely seen that through every layer. And similarly, I've just seen how it is just all about leadership and culture. It doesn't matter what the question is, that's the answer.

You know, actually, if you're worried about quality, well, what are the leaders of the board? What's the board doing about quality? How often are they talking about it? How much are they prioritising it? Because if they set the tone and they set the culture, then the medical director, the nursing director will be setting it, then every clinical director, every matron, every ops manager will be doing it, every receptionist, every phlebotomist, and that's where we want to get to. Quality everywhere.

Penny Pereira

And so when we think about the vision of the quality strategy, quality is the organising principle for the NHS, what does that mean in terms of leadership?

Frankie Swords 

So firstly, let's talk about what I mean by quality. Particularly with the remit of our quality strategy, we're defining quality as three things.

Care that is safe, care that is clinically effective, and care that provides a good patient experience. And you've got to have all three. It's not enough just to be safe – well, great you're not harming people. Well, that's a pretty low bar, isn't it?

Yeah, you mustn't harm people. We must absolutely minimise that. But it's got to be effective. It's got to actually have the impact, drive the improvement in outcomes that you're seeing.

And even if you do that, if people are having a terrible experience, you might as well go home. So it's really about all three pillars. And so I think one of the most important things about leadership is to remember all three pillars and don't just obsess about one of those rabbit holes. You know, we've got to cover all three.

Penny Pereira

And the strategy also talks about value a lot. And I just wondered how we think about value in the context of quality, how we think about the relationship between value and quality.

Frankie Swords 

I'll give you an example from commissioning because I most recently worked as an ICB executive medical director and we talk about value a lot in integrated care boards.

As a strategic commissioner, you should be ensuring that you put your money where your mouth is. You pay for services that are providing the outcomes you want and that means quality of care, safe care, effective care, good patient experience. And that's value.

And so when we're talking about value-based commissioning, value-based outcomes, there's no tension there between value and quality. They're basically the same thing. We haven't got unlimited resources. We've got to use the resources we have to get the biggest impact on our population. It's got to improve population health. It's got to reduce inequalities.

And that's quality. So I just don't see a tension.

Penny Pereira

Yeah, indeed. I think sometimes we've taken a bit of a wrong path in thinking we can only engage clinicians or other staff groups if we take the money part of the equation out of the conversation because it's not authentic and now actually having conversations about quality alongside value, whether that's from a commissioning or provider point of view, feels really critical.

Frankie Swords 

And actually you've just given me another little buzzword there and that's transparency.

It's about being honest and that's another thing the quality strategy really tries to do. Actually, let's be transparent. Let's benchmark. Let's share the information. And you're talking about being honest and transparent about value-based discussions, but the same applies across the piece. And the more we can be honest, the more we can share and obviously league tables are a bit controversial, but actually... by being able to see exactly where you are, it does drive up quality. Nobody wants to be at the bottom. Everybody wants to get to the middle of the pack and then you think, no, I want to be at the top of the pack. I want to have the very best outcomes. I want to have the best patient experience. I want to have the happiest staff.

It's a virtuous circle, I think.

Penny Pereira

I mean, you see, this podcast series is all about improvement, which has a lot to do with data. I was really interested to see the recommendations in the strategy around developing a clearer and tighter set of metrics that organisations could pull from. See, having really well-designed metrics is obviously a bit of a gap, and then the ability to be able to turn that into decisions and conversations at a local level.

I just wonder what you think is possible in that space as a result of the strategy.

Frankie Swords 

So there's a few things.

So the metrics have to be important. There is no point measuring something that nobody really cares about. And they also have to be practical. You have to be able to measure them. And sometimes there's something important that we haven't been very good at measuring, patient experience, for example, which is why we're doing all this work to develop PREMs, patient-reported experience measures.

So they have to be important. They have to be practical. They also have to be agreed. because the trouble is if every board is looking at very slightly different metrics, you're not operating across a level playing field. So I think it's really important that we are transparent and say, okay, they may not be perfect, but these are the ones we're going to look at. And we want everybody to look at those because then we can benchmark, then we can really focus.

And boards will know what we're looking at and they'll know how they're being judged. And so they can focus on there. So if we've chosen the right metrics that are important, that will help drive their focus to the most impactful areas.

And then the other thing is you've got to use them. You can't just admire and measure. You’ve got to that data and say, 'It's getting worse, then.' You've got to use that data to drive your improvement activity.

And so that's where hopefully the quality management systems will really help provide a different organisation, every organisation know – are our metrics going off slightly? What do we need to do to intervene early? Let's not wait until it gets really bad. Let's pick up that earlier signal, get in there and improve things.

Penny Pereira

I mean, we were really pleased to see quality management systems in there as the kind of effective implementation mechanism for making this a reality. It's something we're seeing emerge from the service as well as from the evidence base and from policy and some other contexts.

Frankie Swords 

And some people are doing it really well, but other people aren't doing it at all.

So let's make it easy. Let's make it easy for people to do the right thing.

Penny Pereira

Indeed, we're at a kind of early stage in the development. It's probably important to allow them to develop in a way that is flexible to reflect the different circumstances of different organisations, while also keeping this opportunity to have a more consistent language and framework for managing quality. Yeah, it's a really exciting development.

I guess one of the areas that is possibly more tricky to think about a mature quality management system, is what you were talking about earlier. So thinking about systems of care. So what does quality and value mean across a local system?

So many quality challenges obviously are like at points of transition and impact in ways that aren't contained within one organisation. So, I just wondered what you hope the quality strategy might mean for systems and neighbourhood health, for example.

Frankie Swords 

So people don't experience their care in organisational units. Well, actually they do. They do experience it in organisational units, and they experience handoffs and delays and poor communication, having to tell their story over and over. And so what we need to and what we want to get better at is looking at that whole pathway of care for the individual, whether they've seen a social prescriber at their GP as their first point of contact or whether they've seen their GP or whether they've had a crisis and had to speak to a crisis team or gone straight to the emergency department.

It doesn't really matter what the route in was in the first place, but what that entire pathway looks like. So that's what we want to be looking at and that's hard. But that's where the modern service frameworks, I think, I hope, we’ll bring this to life.

So they are trying to look at the end-to-end pathway. And so the cardiovascular disease modern service framework that was published 7 July, I think, has some really lovely examples of that. The other thing I really like about that one is it is absolutely the ten-year plan in action because you look at it and there's a whole section on finding people at risk earlier. So that's your sickness prevention.

Then there's a whole section on improving access and particularly access to rehabilitation. There is your hospital-to-community shift.

And then there's a whole section on innovation and wearables and there's your analogue to digital. See, this is really great. I think everybody loves a ten-year plan, but it is a bit of a beautiful glossy thing. We need to feel it. We need to touch it and taste it sort of thing. And I think the modern service frameworks are going to help do that by doing that whole pathway of care.

Penny Pereira

Yeah, I mean I guess the hope for the quality strategy is that it is underpinning the vision for the ten-year plan so that the totality of this future exciting vision is accompanied by the reassurance and the inspiration about what quality will mean in that future context.

Frankie Swords

Yeah, and it's about making it easy to do the right thing. So helping all of the providers, every layer of our system know whose job it is.

Okay, so firstly oversight of the quality of an organisation, it is the board's job, but actually it's also everybody's job. You know, it's not an add-on, it's not something over there – the board is ultimately responsible, but it is the job of every individual. So firstly, you know, who's responsible for what?

And secondly, well, where should you be focusing? And the MSFs [modern service frameworks] are really good on that. They really say, do you know what? This is where the evidence shows that we can make the biggest impact. So focus on this bit. Don't worry so much about that bit now. That's a nice to have that can come later.

These are the things that will make the biggest impact, improving healthy life expectancy, reducing inequalities. And this is the evidence-based intervention that you should be using for that need.

So I'm all about making it easy to do the right thing. And hopefully the quality strategy and the MSFs and the cancer plan that sits alongside it really help people bring it to life and it's one place where all the resource is, so the one place to go to find out actually, I'm not quite sure which is the most important… oh, it's this bit – right; good; thank you.

Penny Pereira

I think one of the other things that the quality strategy is promising is to streamline and kind of rationalise some of the recommendations that have accumulated over many years. I wonder if you could say a little bit more about how that will work in practice and yeah, what the kind of practical difference it will make to organisations.

Frankie Swords 

So right now we're piloting and trialing it and working out how best to do it.

But what the vision is that we will end up with first, let's have better quality recommendations. So let's make sure the recommendations that come out are actually going to have the impact that they're intended to. So often you see a recommendation that's well, introduce some more mandatory training.

Yeah, okay, great. (Penny: It’s not evidence based.) That's like 72 things I have to do. There's no evidence it's going to make any difference.

We're already doing too much. So let's have higher-quality recommendations and then let's prioritise them. Let's actually say that this is the one that's going to make the biggest impact and it's possible, it is practical and it's scalable.

So prioritising them. We talked about value earlier and we also need to understand the cost because there are some interventions that are really easy and some that are worthwhile but really expensive, going to take ages. So let's have a transparent way of prioritising them.

So we're going to make the recommendations better. We're going to prioritise them. And that also means deprioritising some, because if we say actually, you know, that really isn't going to make a difference, we're not going to prioritise that one now.

So that is: make them better, make them count, and then streamline them, seam them. Okay. If we've got, you know, we're tripping over recommendations at the moment, but if we've got lots and lots of recommendations in an overlapping area, then actually let's bring them together and do it once.

And then finally, we need to get better at tracking. If this is what we said we'd do and we agreed that we would do it, have we done it? And if not, why not and when?

Penny Pereira

I guess going back to what you were saying at the start, there's also how do we make it easy to use this greater standardisation of recommendations and metrics to also address the variation in practice.

So we know we can state what good looks like but making it as easy as possible to actually share and learn between places. What have you seen that works or promising in that area?

Frankie Swords 

There's a lot of learning networks and there's a lot of specialty clinical networks where that learning is shared and cardiovascular disease is a nice example of that.

But I don't see systematic learning at the moment and I don't see a systematic sharing. It's great when you hear of good ideas, but every time I hear of a good idea, I think, well, it's a shame I didn't know that last year. So, I think there are increasing means by which we can share good ideas, but there's also, it's not just a nice to have.

As I said earlier, the quality strategy is about actually, if quality is our guiding principle and we've got somebody doing it better and we've got unwarranted variation, somebody's not doing it as well over here, actually, you've got a duty to level up and learn from each other. So, I think it's about systematising it and simplifying the landscape.

Penny Pereira

Yes, we've been bringing together the national leaders around improvement and quality management across the UK and Ireland for some time. In Scotland and Wales, for example, they embed the idea of a learning system, so a systematic way of learning at the heart of their quality-management system. And see it's something in the key community and in NHS Alliance that we're trying to make a contribution to.

But I think just as you say, it's the practicality, it's making it easier that's going to make the real difference with this quality strategy. And perhaps there's an opportunity to take this as another point in time where we can try and move on the both the culture and the practicalities of sharing and learning between places.

Frankie Swords 

I absolutely agree. In fact, I'd go further. I'd say this is a call to action. We have to do this.

So let's do this and let's try and make it as easy as possible to do this well.

Penny Pereira

So as this quality strategy goes out into the world, what is the leadership opportunity, the leadership call to action for people from different parts of the health sector?

Frankie Swords 

Well, the strategy is really explicit that quality must be owned across all NHS-funded care. It makes it very clear who's accountable for what.The board of a provider, be that a local authority, independent sector provider, a VCSE, NHS, doesn't matter. The board of that provider is responsible for the quality of care it delivers.

But the commissioner, so that's generally speaking the ICB, as strategic commissioners, they should only commission services which are high quality and delivering the value and outcomes that their population needs and that will reduce healthcare inequalities.

So I think, as leaders across all of those institutions, it's very clear who's accountable for what and that you must take quality absolutely seriously. It should be your guiding star.

Penny Pereira

That was Professor Frankie Swords explaining why the NHS needs to have quality as its organising principle.

Now Sarah Barley-McMullen brings a lived experience perspective on what high-quality care actually feels like for patients.

Sarah Barley-McMullen

I was an academic for 17 years, based in the Midlands, working in higher education. And I was also leading work on inclusion, equality and organisational culture in some charities as well. But then Covid came. In 2021, I developed Covid, I then went on to develop Long Covid.

And within 18 months, I had to take ill-health retirement from my career. And so for me, quality is really about how it makes you feel. The data is important, but it's about whether my clinicians are talking to each other. It's about how quickly I got the referral, how quickly the care is coming about, how easy it is to access that care, how easy it is to talk to somebody, how easy it is to feel heard and not feel patronised. So that's really where I'm coming from. It really is about how it makes you feel. Quality is about how it makes you feel.

And I think this strategy comes at exactly the right time because I think over recent years, the NHS has faced extraordinary pressures and much of the national conversation has been around waiting lists and productivity, maternity care, workforce pressures, financial recovery, all of those sorts of things. And they're really important and they matter. But they aren't why the NHS exists.

From my point of view, quality is the reason the NHS exists.

Penny Pereira

Having seen the final output from the quality strategy, I mean it's long, isn't it? It kind of brings home just how complex and how many things there are that are going on at a national level, all of which are no doubt important from a technical point of view. But my mind kept going, as I think yours is, to what's going to happen differently as a result of this strategy at a local level.

And indeed the strategy is clear that it's locating accountability and responsibility with local organisations for really making the difference around quality. I keep thinking, how do we use this as an opportunity to really make the shift to that different experience of feeling safe, feeling like your care is effective?

Sarah Barley-McMullen

You know, think clinical excellence can, or does and can save lives, but the experience of care shapes whether people feel safe enough to seek help in the first place.

You know, the experience of whether they can trust a professional and stay engaged in their own health, that is really what needs to be addressed. We need both, don't we?

We need the excellence of clinical care, but also whether people can stay engaged. And as someone who's experienced both excellent and fragmented care, I know quality isn't simply about the treatment that you receive.

Penny Pereira

You were talking about the need for care that is beyond individual kind of services, in the context of thinking about neighbourhood health of some of the other policy directions. Do you have a sense of what that could look like, how that could be different from a quality perspective, an experience perspective?

Sarah Barley-McMullen

I think the three shifts in the 10-year plan, because that's essentially what the quality strategy has to deliver, isn't it? So from hospital to community, analogue to digital and treatment to prevention. They're incredibly exciting and for someone like me, I can see huge opportunities there, but none of those shifts automatically improve quality on their own.

And technology doesn't improve quality, community care doesn't improve quality, and prevention doesn't improve quality. Surrounding all of those things, it's people. It's people that improve the quality by engaging in those and bringing other people along and encouraging people to see their own health as something that they can improve themselves. From one perspective, but from the other perspective, it's really about understanding that the NHS has a responsibility to see quality as relational. as well as, you know, as metrics.

It's things like if we move care closer to home, but people still don't feel listened to, then it's not going to work. If we introduce brilliant digital technology, and I think some of the things on the NHS App that you know, we've had some more updates recently, I think they're brilliant. But my mum struggles to open the app. That is partly a generational issue. It's sort of a digital poverty thing as well, but there's nobody other than me that she can talk to about that. So if digital technology excludes people who need those services most, then we've missed the point of improving digital technology.

And if we focus on prevention, but that doesn't involve community shaping it and community leaders becoming involved, then we've missed the point.

So for me, one of the biggest opportunities here is changing how we think about patient feedback. And historically, we've often collected feedback to measure satisfaction or demonstrate compliance or produce reports.

I think the future needs to be much more exciting than that. Patient feedback should be about real-time sources of intelligence that help us improve continuously. Don't just hand something out. Give someone something but also give them a relationship with a person at the same time.

So it's about something and someone because we need connection and we need to learn from each other and work together on this. So it's not just about data that you take to a meeting, to a high-level meeting and pat each other on the back to say, great, we've done this, we've done this. It's about going out to where people really are, especially where people are struggling and the people that aren't often listened to and reached.

We talk about giving underrepresented communities a voice. Those people have a voice. It's our responsibility to give them a platform so that they can speak and people listen to them because people don't.

Penny Pereira

It’s great to hear you reflecting on it. As I'm understanding it, you're saying that the three shifts, they have huge potential to improve quality, but only if it's understood collectively and holistically, and if it comes with a commitment to co-production and equity. So the means by which we aim to get there in terms of the future vision set out in the ten-year plan will be quite important to determining where we actually end up.

Sarah Barley-McMullen

Completely. And the thing I speak about most is the fact that lived experience isn't just somebody turning up and telling their own story. Lived experience is a distinct form of knowledge, of expertise that somebody has around their condition, what makes it better, what makes it worse, their access, the barriers that they face, how their condition is seen in a clinical environment, whether it's taken seriously or not.

And that's very typical of Long Covid. It was for years and years with ME/CFS. And again, I'm using my personal experience as examples.

But people with lived experience are experts in their own right. And I don't think you can have strategic leaders and clinicians without having lived experience and their expertise. You have to have all three in order to ensure that quality is there and quality does the job it is supposed to do and enables the changes that need to happen to actually make a difference for patients and for staff because things need to be better for staff as well.

Penny Pereira

The quality strategy goes with the Darzi definition of quality, of experience, effectiveness and patient safety. And then through the quality strategy itself, there's a lot of references to value. I'm interested in how we could understand value, again, more holistically, in a way that includes the valuing the time and resources of the people who are experiencing care as well as those who are delivering it.

I just wonder if you could help us think about this so that we're thinking about the value dimension to quality.

Sarah Barley-McMullen

I think poor quality is one of the most expensive things in healthcare because it means that waiting lists drag on, it means that people don't engage as well so their care becomes more expensive and more prolonged.

But I think when people don't feel heard, when services don't communicate, when conditions aren't recognised or understood and where care isn't personalised, people don't come back. and their conditions deteriorate, they lose confidence, they disengage, and that creates additional appointments, additional investigations, avoidable admissions, complaints, poorer outcomes, all of those things.

Quality and inequality are inseparable, I think. A lack of quality is often a symptom of inequality, and inequality begins where understanding ends. So quality and value are intrinsically linked from that by default. And quality then can create value, I think.

Value isn't just about value for money, it's about valuing the person as an individual, their culture, their heritage, their identity, who they are. There's some great examples of waving Progress Pride flags, LGBTQ Progress Pride flags outside hospitals and some people have rainbow lanyards.

I will always thank somebody for wearing a rainbow lanyard because it makes me feel a little bit safer. But in terms of valuing everybody, what are the small things that could be done that would have a huge, huge impact?

Penny Pereira

I mean, I'm loving what you're describing is a vision of quality as the organising principle for the NHS in a way that would be felt by all those different touch points, all the little like interactions which make up healthcare. And that that's ultimately what's likely to determine whether people feel like the health service that they're experiencing or they're working in feels high quality.

Sarah Barley-McMullen

You know, that's what makes me feel as though I've had a quality experience. As well as staff, you know, do they feel as though their leadership is enabling them to do their job to the best of their ability? And that means taking into consideration who they are, their identity, their culture, the pressures that they're under and ensuring that they're okay.

Some of the best experiences I've had are from just, think, naturally caring people. Some of the worst experiences I've had are from people who are stressed, clearly very, very tired and often working on their own.

Penny Pereira

I guess that is part of the responsibility for leaders and ultimately policymakers is how do you create the environment where people get to be their best? Like both people who are using services and people who are delivering them. Not many people I suspect go into the health service if they're not like wanting to be there providing high-quality care, but I know I'm not always able to bring care to the interactions I have when you're under pressure and haven't got the kind of team environment that supports.

Sarah Barley-McMullen

At all those things as well.

Penny Pereira

That is all we have time for in this episode. Thanks again to our guests, Frankie Swords and Sarah Barley-McMullen. You'll find plenty more about quality and the quality strategy on the Q community website.

We'll be back soon with another season, and if you have any thoughts about what we should include in that season, please do get in touch.