In his famous book, The Tipping Point: how little things can make a big di¡erence, Malcolm Gladwell describes the phenomenon of the ‘tipping point’.1 This well-known American phrase outlines the moment when an idea, trend or argument crosses a threshold (‘tips’) to become accepted and spreads. Many small things often combine and conspire to produce a big change. In this editorial I want to use this marketing and change management theory to explore where quality is going in the NHS
In his famous book, The Tipping Point: how little things can make a big di¡erence, Malcolm Gladwell describes the phenomenon of the ‘tipping point’. This well-known American phrase outlines the moment when an idea, trend or argument crosses a threshold (‘tips’) to become accepted and spreads. Many small things often combine and conspire to produce a big change. In this editorial I want to use this marketing and change management theory to explore where quality is going in the NHS.
Let us consider the present state of the NHS quality system. It is worth celebrating the introduction of comprehensive systems for quality in the NHS in an epoch-making move in 1997. This consisted of a national system of standard setting (National Insti-tute for Clinical Excellence – NICE), a system of monitoring and inspection (Commission for Health Improvement – CHI) and a local system of implementation (clinical governance). A number of other bodies have since been established, including the National Clinical Assessment Authority (NCAA) and the National Patient Safety Agency (NPSA). However, a number of problems have emerged and there is now a perception that more needs to be done to develop and integrate the quality initiatives.
In brief, the problems can be summarised as follows:
• reports of NHS trusts being burdened by regula-tion and inspection
• concerns about targets and how they can distort clinical priorities
• worries about fragmentation with multiple agen-cies and bodies
• questions about e¡ectiveness of inspection and the ratings system for NHS trusts.
In e¡ect there is a mismatch between the rhetoric of ‘a culture of excellence’ and the day-to-day reality of performance management and inspection. Broader issues relate to tensions in the doctor–manager relationship. Clinician disengagement, particularly from primary care organisations, is a major talking point. Despite major increases in resources, some patients and healthcare sta¡ remain sceptical that improvements have taken place. From a patient perspective, fragmentation of care, personal and system discontinuity, and disruption of care remain key issues when they access care in the health and social care system.
Progress is hard to prove. The key judgement must be whether that all-important ‘culture change’ has been realised in the NHS – ‘where excellence can ourish’. Are the government winning the hearts and minds of healthcare professionals?
There are signs that these concerns are heralding a change in emphasis in health service policy, with the intention of reducing the burden of inspection. That a new direction in monitoring and inspection is emerging is best seen in the proposals announced by the shadow Commission for Healthcare and Audit Inspection (CHAI).
The key elements of CHAI’s vision include:
• emphasis on improvement
• information-based assessments
• local presence
• assessment from the patient’s viewpoint across pathways of care
• targeted and proportionate visits by CHI
• working in partnership with other regulators to provide single assessment
• publicly accessible information.
It is also to be welcomed that CHAI wants to draw upon the best practice and experience in other countries, with the aim of becoming the best in the world. This is clearly a very ambitious agenda that will be challenging to deliver. However, I believe that, if executed correctly, it o¡ers a promising way forward.
The two proposals that caught my eye are ‘local presence’ and ‘information-based assessments’. Local presence is, in e¡ect, a form of devolved standard setting and accountability in health communities. This o¡ers an opportunity for greater ownership and partnership working. The emphasis on using ‘intel-ligent information’ for the routine monitoring of quality is particularly appealing, especially if it includes looking at how NHS organisations use information strategically. If implemented in the right manner, the system would be very di¡erent from what happens at present. As a clinician, I welcome the emphasis placed on intelligent information. There are vast amounts of data captured in primary healthcare of uncertain quality and for uncertain purposes. If a concerted e¡ort were made to collect and use information intelligently, this would be very wel-come.
All this is with a view to reducing the burden of inappropriate inspection and assessment and improving the meaningful practice of quality. CHAI explains that the reduction in scale and scope of visits is not intended to signal a lighter or softer touch from CHI – there will still be a stringent system of assessment – but that this will be based on rigour and on the principle of continuous assessment based on intelligent information
The world of the Tipping Point is a place where the unexpected becomes expected, where radical change is more than a possibility. It is – contrary to all our expectations – a certainty.
The emphasis by CHAI on improvement through encouraging the development of a culture of learning
is indeed a very powerful statement and this is reflected in its proposals. This vision for CHAI if correctly implemented could combine to produce the one big change that is needed – winning the hearts and minds of healthcare professionals and managers. Have we reached a ‘tipping point’ in the NHS quality system?
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