Editor's note: Bob Sang's untimely death has taken away one of the most original and innovative thinkers about the co-production of healthcare. It is not currently clear whether this is Bob's last article. This was written recently for Health Policy Insight, and is published with respect and grateful thanks for Bob's contributions, input and insight.

“A deep, taken-for-granted assumption in our culture is that if you have a ‘problem’ or ‘need’, you get a label: ‘patient’, ‘user’, ‘client’, ‘sick’, ‘disabled’, ‘handicapped’. One consequence of such labelling is the separation of citizens into categories and groups defined by the service models that have been constructed to ‘meet this need / problem’. Very powerfully, at the point of diagnosis and analysis, individuals are defined only by their ‘special needs’ and / or their dysfunctioning, thus excluding their many purposes, roles, capabilities, and aspirations as parents, partners, entrepreneurs, citizens.”
Bob Sang, JIC, Spring 2007 (1)

My aim in this article is to challenge the basis of dominant thinking about quality improvement in healthcare.

In any sector, the concept of quality is contentious, highly contextual, and contingent. In healthcare it is even more so.

I will argue that it is time to re-visit the concept of health gain. After all, if quality improvement does not contribute meaningfully and measurably to improved health, why do we bother with it?

Quality in context
A colleague said to me recently “Wanless, as far as most NHS leaders are concerned, is old hat” (2). My advice to all aspiring NHS leaders is to remember Wanless … and Machiavelli too.

The original Wanless reports (3,4), commissioned by the current Prime Minister when he was Chancellor, focussed on the economic sustainability of the NHS (and later, social care) in the context of the very well-known, but somewhat less appreciated, health policy drivers: population change; epidemiological trends; medical and technological advance; and, of course, economic growth.

In a relatively rich, developed economy it seems that, when it comes to health and care, “you can have anything you want, but you cannot have everything you want” (5). We have to chose from among the many ‘anythings’ now possible in healthcare.

For this reason, the health and care economy is reaching its own ‘crunch’. Recent, much-publicised campaigns in support of ‘top-up’ payments for certain cancer drugs are a symptom of the much bigger ‘crunch’ to come, with a recession hitting tax revenues.

Wanless demonstrated that the current mixed economy of care, grounded in a publicly-funded NHS that remained free to all at the point of need, would not be sustainable for the future unless three conditions were achieved:
• Improved productivity of the services themselves
• Assiduous harnessing of the benefits of modern technologies - especially IT
• A ‘fully engaged scenario’, whereby the public took their full share of responsibility for health improvement through health education, health promotion, and sickness prevention.

More recently, the Wanless team at the Department of Health has recognised the crucial importance of addressing the long-term conditions agenda, very much aligned to the White Paper ‘Our Health, Our Care, Our Say’ (6).

An underlying theme of Wanless was the need to reduce intractable and costly health inequalities; both through establishing fair access to services and through proactive strategies for improving health in impoverished and marginalised communities.

However, Wanless’ conclusions offer scope for further scrutiny and challenge:
• What is meant by ‘productivity’ in a 21st century health and care system?
• What can be done about IT, especially the fast-failing national programme?
• In the face of rising prevalence of long-term disease (especially in disadvantaged communities), how can we improve the underlying health of our ageing population – including our ageing workforce?

Quality improvement will remain a short-term, operational aspiration unless we engage with and begin to address these crucial questions and their implications for service design and development in the next few years.

The [un]changing discourse about quality improvement
“Quality is a term so general and ambiguous as to be almost completely meaningless … Use it as often as you can” - Russell Ackoff

In broad terms, I have lived through and worked with five generations of quality management:
1940s: Management Science (especially Statistical Process Control) that evolved during World War II and was further developed by the Operational Research (OR) movement. Until the 1990s, the NHS had its own OR branch!
1960s: Quality Assurance (QA) – including methods such as Peter Drucker’s ‘Management By Objectives’, usually focussed within a QA function and reporting system.
1980s: Total Quality Management (TQM) – including its applications to purchasing / commissioning; from which emerged Continuous Quality Improvement (CQI)
1990s: Business Process Re-engineering and ‘lean’ thinking, inspired by Deming’s research and writing
2000s: ‘Agile’ and personalised models of production and service, driven by consumer choice - so-called ‘mass customisation’

Having applied these approaches to quality improvement in very different industry sectors, I have learned that it is crucial to have clear answers to these two questions that map out fundamental assumptions:
1. Who, precisely, are the customers of the product / service being provided?
2. And what is the purpose of the quality improvement work and systems?

Neither of these are clear in healthcare.

Recently John Ovretveit, in a study commissioned by the Health Foundation, explores the relationship between ‘improvement science’ (which draws on all of the above) and leadership in health and care. His research “found few good-quality empirical studies of leadership for and quality improvement in healthcare, but a large increase in the literature on the subject” (7).

However, importing definitions of quality from the literature is only one potential solution. Surely we can begin to develop values and criteria that are fit for 21st century purposes and that inter-relate theory and practice; actions and outcomes.

What has not changed in the quality improvement discourse is the ambition to close the gap between providers’ ‘quality intent’ and the outcomes as experienced, observed and assessed by the primary stakeholders: customers; clients; commissioners; inspectors; politicians; citizens; communities; populations … and so on.

In healthcare, the old joke that “the operation was a complete success, but the patient died” illustrates how contentious, contingent and sensitive the notion of 'quality’ is in this sector. Mid-Staffordshire NHS Foundation Trust springs to mind.

Wanless’ analyses have raised the stakes on this debate. Unless quality improvement demonstrably contributes to health gain, then we shall waste the learning from the five ‘generations’ of quality development listed above.

So simply outlining ambitions for quality improvement is not enough. We need a robust 21st-century understanding of what we mean by quality: the values and associated metrics (hard and soft); grounded in a shared understanding of the people, communities and populations to be engaged; and very much shaped by whether ‘patients’ are seen as consumers or as citizens - or as both.

Confused discourse
There is a fundamental confusion within the current policy discourse about what this means. Consider, Gordon Brown’s keynote to the NHS a year ago (8), that set up Lord Darzi’s ‘next stage’ review, High-quallity care for all.

Brown's aspirations for patients and their potential contributions, sitting primarily (but not only) within a consumerist paradigm establish a challenging agenda:
“Choice between providers has been among the forces for changes … real empowerment of patients will come from going further - the driving force: higher patient aspirations, more patient expertise, more trust between clinicians and patient, patients becoming fuller participants and partners in health and healthcare.

“a new choice tomorrow - in partnership with your clinician - about your treatment itself.”

The final line above begs two questions: firstly, what is real empowerment? Secondly, how will we know it when it is achieved? Trying to answer these will be the subject of a forthcoming article on this website.

From consumer to partner
When focusing on quality, what does this transition from consumer to partner actually mean? From an active patient perspective, what quality improvement means will be very different depending on their ascribed role. It is clearly time to move on from this aspiration and ideological confusion; time to clarify a more sustainable model of engagement that focuses on health gain.

Here we see the binary (for which, read ‘confused’) approach to healthcare reform: ‘quality’ will be either driven by informed consumer choice and / or co-produced in partnership with patients and communities.

Either way, following Darzi’s 2008 ‘next-stage review’ (9), it will be ‘clinically led’, ‘evidence-based’ and enhanced by a continuing investment in ‘self-care’ – a positive nod in the direction of Wanless?

Thus in a modern NHS, quality is principally defined as a function of clinical expertise; known best practice; and patient improvement – whether as informed active consumers and / or responsible citizens.

Who could argue with this?

Making quality count
How might we begin clarify the intent and content of quality improvement in 21st-century healthcare?

Patients as citizen-consumers do not only have needs. They have ambitions: for themselves, their families and communities. The iconic and sensitive position of the NHS in our culture is a reflection of these ambitions.

Patients are becoming ever more engaged in improvement, on a number of fronts:
• As monitor-evaluators and critical friends - through the new local involvement networks (LINks), etc - see also Health Select Committee Inquiry Report, 2007 (10)
• As self-managers and personal budget holders (e.g. the ‘Staying In Control’ pilots and the Expert Patient Programme) - users as commissioners
• As the co-producers of health and service improvement (e.g. the Health Foundation’s ‘Co-creating Health’ programme, etc).
• As advocates and facilitators, enabling others to participate who would otherwise be marginalised or unheard (11)

As people engage through adopting and developing these new roles, so the nature of the dialogues within health and care also change. Such narratives are evolving, principally between the NHS and people living with long-term conditions and disabilities, who generate over 80% of NHS activity.

Similar developments are also occurring in maternity services, children’s services, and in end-of-life care. Initiatives such as cancer networks and falls collaboratives also depend on the full engagement of ‘patients’ as citizens and as consumers: the co-producers of service improvements and improved productivity.

Each of the above cases offers the possibility of creating mutually-defined quality improvements, which are not only relevant to the individual service, but adaptable to the wider NHS as well as to effective implementation within the diverse local socio-economic contexts in which the NHS operates.

So, what do these developments tell us about the core business of the NHS? What is it supposed to produce as its contribution to a safer and more sustainable national social economy? Put another way, what are the quality improvements for which we share accountability?

I would like to suggest three ‘R’s:
• Resilience: the health gains associated with sustaining good health and achieving successful recovery when injury or disease impacts on daily living
[socio-medical]
• Reciprocity: a co-created, negotiated management of the risks inherent in healthcare interventions
[civic-economic]
• Respect: valuing the different knowledges gained through personal and professional development and through living with the factors and forces that impact on health and wellbeing
[cultural]

In the future, we should be able to harness a fourth “R’ – Rigour, as we realise the benefits of a fully-integrated, personalised health record system – the current tribulations of NHS Connecting For Health notwithstanding [clinical-cultural].

From a citizen-consumer’s perspective, such measurements achieved through these means will serve a complementary set of ambitions that relate to health gain at a fundamental level. These might include:
• A safe and healthy start to life for babies, their mothers, and families in all our communities;
• A trusted, urgent response system available across our complex social geographies – for times of crisis, trauma and accident;
• The means to prevent deterioration and / or sustain recovery for people living with long-term conditions and disabilities;
• A decent end to life.
All of the above depend on teamwork, interagency co-ordination of reliable data and collaborative leadership. These overarching criteria could be used to inform the debate about quality improvement priorities and measures.

Above all, they open up the opportunity for local people to become full partners in the quality dialogue, linking their ambitions for health gain to the assessment of services and healthcare practice. The latest framework from the national ’18 Weeks’ team support this direction of travel: focussing on achieving health gain at every phase: prevention, intervention, and recovery (12).

However, we must also remember Machiavelli’s advice in The Prince: “The innovator makes enemies of all those who prospered under the old order”.

There is a real risk that the quality improvement agenda will remain dominated by the ‘old order’, and that the constituent elements of the proposed annual ‘Quality Accounts’ that every trust and provider must publish (about safety, patient experience, and the effectiveness of care) will remain interpreted within a narrow medico-managerial paradigm.

It is this very paradigm that is pushing the NHS towards the edge of unsustainability. This paradigm, founded on a throughput model of costed medical activity, translates productivity as clinical efficiency - and, in so doing, fails to encompass the holistic, multi-factorial nature of patients’ ambitions.

While this paradigm may just about work for 4-hour waits in emergency medicine and some planned care, it does not work that well for 21st-century health and care. The cracks are already becoming visible.

Recent publication of policy guidance on the development of community services (13) illustrates how far the development of these crucial services is falling behind the development of the acute sector of care, which is continuing to receive a high proportion of commissioners’ budgets.

The longer-term consequences of this growing imbalance will be rising demand for acute services, as both preventative care and rehabilitative home care struggle to respond to the growing numbers of people living with long-term conditions and disabilities.

Co-creating quality improvement: we are in this together
To be blunt, the NHS reforms of the past decade have largely failed to address the underlying challenge of sustaining 21st century publicly-funded healthcare in this developed economy. The challenge is that 80% of all work in the health and care systems is generated by less than 10% of the population – people living with long-term conditions and disability. Such people, as they get older, experience increasingly complex (co-morbid) and unpredictable health.

What might health gain look like for these people, when framed within a co-production paradigm?

Take, as an example, the clinical contribution to a person’s recovery from a period of depression. Both treatment and outcome will be contingent on a number of factors: home and social life; income; management of other chronic disease; diet, etc. …

The collaborative management of long-term conditions, with all the inherent complexities and unpredictabilities, should enable people to improve their management of the associated clinical risks and engage with making the most of other life-improving challenges – worthwhile relationships, meaningful employment, caring responsibilities, active citizenship, and so on.

Quality improvement is necessarily co-created. It is measured by the gains people make in their whole lives, and the consequent added value for families, communities, populations, and the economy. By working with those most at risk of high dependence on healthcare services, clinical teams can enable people living with long-term conditions and disability to continue active, co-productive lives.

Such continuous quality improvement depends on clinical teams and their organisations working with patients / users and their carers on three inter-related tasks:
• A mutual appreciation of the health gain that individuals are seeking to achieve on their improvement journey
• Identification of the risks and risk factors that can be assessed and addressed en route
• A joint action plan

Initiatives like WRAP (Wellbeing Recovery and Action Planning) in mental health; care planning in diabetes; ‘Staying In Control’ in learning disability; the Health Foundation’s ‘Co-creating Health Programme’ are all developing such approaches. These ensure that quality improvement is both a personal and a collaborative inquiry, accessible to all who choose to engage with it.

Such an inquiry should extend to all aspects of the co-production of the health system - from the professional curriculum and management education to the growing self-management movement; and beyond to commissioning and to services’ design and development.

At the heart of these transformations will be the emergence of a new narrative, grounded in a holistic appreciation of peoples’ needs, rights and ambitions. It will mean people co-producing the micro-quality improvements that contribute to measurable macro-level health gain.

A transformation of this nature requires mature dialogue at every level: especially the front line of care. ‘Leading for Quality Improvement in Healthcare’ (14) calls for a fresh start, grounded in the emerging activities and initiatives where patients themselves are engaged as full partners. That means partners seeking the personal and collective health gains that make life well worth living, building on the co-productive dialogues proposed above.

The Health Foundation’s Leadership Fellows programme has made a positive contribution to an approach to leadership development that promotes such a partnership: both through its seminars, which emphasise these themes; and through the active engagement of patient quality advisors (PQAs) – leading active patients - who contribute to the workshops where Fellows undertake an appreciative review of their own leadership roles and work.

This is about the beginning of a new beginning.

Author
Professor Bob Sang FRSA is advisor to the Health Foundation’s Leadership Fellows’ and ‘Closing The Gap’ programmes. He is also director of Sang Jacobsson.

This article was produced as part of the Health Foundation’s Collaborative Inquiry into Quality Improvement (York, March 2009), facilitated by Tim Sims and Fiona Reed.

References
1. Sang B (2007) A Citizen-Led Coalition for Integrated Care. Journal of Integrated Care 15.3
2. In Sines D et al (2009) Community Nursing [Sang B, The Involved and Involving Community Nurse, Chapter 21]

3. Wanless, D (2002) Securing our future health: taking a long-term view. London HM Treasury.

4. Wanless, D (2004) Securing good health for the whole population: population health trends, Norwich. HMSO

5. Elizabeth,S, et al (2000) Ordinary Wisdom, King’s Fund

6. Department of Health (2006) ‘Our Health, Our Care, Our Say’, ISBN 0106737328

7. Ovretveit J et al (2008) Leading Improvement Effectively, The Health Foundation

8. Brown, G (2008) Speech on the National Health Service, King’s College London – Gordon Brown, 8th January

9. Darzi, Professor the Lord (2008) High Quality Care for All, DH Gateway Reference 10106

10. Health Select Committee (2007) Patient and Public Involvement in the NHS, DH, HC278.1

11. Sang B (2002) Modernising PPIH. British Journal of Healthcare Management 8:10

12. Department of Health (2009) Judging the success of 18 weeks, DH www.18weeks.nhs.uk

13. Department of Health (2009) Transforming Community Services: enabling new patterns of provision, National Electronic Library for Medicines

14. Health Foundation, 2009 ‘Leading for Quality Improvement in Healthcare’