I used to play squash. I largely played with my family, and I thought I was pretty good. Three days into university, I happily agreed to a game with a fellow fresher. After 30 minutes of forlornly chasing shots I couldn’t reach, I gave up and went home realising I wasn’t good, I wasn’t even average – I was bad. Very bad.
That complete lack of awareness of my own abilities came back to me last month at the first policy day at the International Forum on Quality and Safety. From Sweden to Saudi Arabia, Uganda to the United States, policymakers from 25 countries assembled to discuss how national policy can best improve the quality of health care. So what did we agree? And how does this influence how we should be thinking about health?
Let’s start with a question which, as the Foundation’s Director of Policy, I probably should know the answer to: what is health policy anyway? This should be an easy question to answer, but the day provided a fascinating contrast between how we conceive of policy in England, and how other countries see it. When asked which policies they would do again, the 25 countries’ list of areas included: use of data, building quality improvement capability, ensuring senior management are aware of improvement approaches, and supporting and spreading innovations.
Rather wonderfully, at the same time as this discussion in a different part of London, our national health politicians were taking part in the Health and care debate to set out the policy areas they would focus on if they were part of the next government. This discussion brought out a completely different set of areas: the role of competition, workforce numbers, funding, and devolution of commissioning. If you tried to form a Venn diagram between these two discussions – supposedly about the same topic – you just about could, but only just.
This contrast between the different faces of policy is an issue we discussed in our Constructive Comfort report. The levers we traditionally look to in England are the external ‘prods’ of organisations in the hope they improve (we term these ‘type 1’ approaches), rather than directly trying to help organisations improve (‘type 2’) in the way set out by a number of international counterparts.
But you may be thinking that it’s not an ‘or’ between these approaches, it’s an ‘and’ – I agree, the real question is getting the right balance. Denmark is a fine case in point with their nuanced approach to regulation, the subject of Clare Allcock’s fine blog last week.
For England, we may think we are fairly advanced in terms of our debate on specific ‘type 1’ policy levers, but we are – and this is where my mind turned to my squash playing days – light years behind some of our peers on ‘type 2’ approaches. In one particularly toe-curling moment, a number of participants questioned whether the write-up of the day should include a statement that ‘every country should have a clear strategy for quality’ because it was far too obvious. In England (unlike, for example in Scotland or even the USA), we don’t have one.
I can’t help but feel that, as an English health policy community, we are far less at ease with quality improvement techniques than our traditional hinterland of regulation, commissioning and so on. It was striking that there were more policy makers at the international day from Malawi than England – despite being held in London. In Uganda, even their Minister of Health goes on training in quality improvement.
So what needs to happen? Well let’s start with the positive: in England we do have a number of green shoots. The Five Year Forward View ‘Vanguards’ programme is embracing a number of quality improvement principles. Monitor’s announcement that they are setting up a Provider Sustainability Unit to help support foundation trusts in making change (and recently appointed an Executive Director) is a step to be welcomed.
However, these promising shoots risk being drowned out by the cumulative impact of the rest of the policy streaming forth from the plethora of NHS national statutory organisations. Above all, what England lacks is a clear quality strategy which provides the connection between how all of these policies will result in high quality health and health care for our population. Such a strategy could usefully come from listening to the views of those currently on the receiving end of national policies – principally NHS organisations and staff – as to what helps, what doesn’t, and what needs to change.
Whoever forms our next government will be keen to leave their imprint on health policy. Before they do so, a period of listening to the NHS and learning from abroad may give them the greatest chance of success – and sparing me further embarrassment next year.