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The Decline in Quality of Care in the NHS and the Importance of the Ratchet Effect and New Incentives 

The worst life expectancy amongst rich OECD countries1, widening health inequalities2, cancer survival lagging the best performers3 and now a four-fold increase in emergency care deaths.4 There is no doubt that in many if not most important areas of care the NHS is failing to improve quality.  

Yet there are hundreds, probably thousands, of programmes to improve quality underway within NHS providers. Our experience of these programmes suggests that many follow the principles of the national Getting it Right First Time (GIRFT) programme. This provides clinicians and managers with comparable data to encourage them to improve their own performance to match that of the best.5     

We often ask participants in quality projects how they have succeeded in improving.  The answers are usually some combination of senior sponsorship of the project, investment in project managers, good culture, hard work and accurate outcome data. When we ask why things go wrong, the answer usually is withdrawal of senior sponsorship, staff moving on to other jobs or burn out.  

It is much harder to find out what are the new processes and systems that they have adopted to make those improvements. This appears to be because those processes are not clearly defined or measured. SOPHIA enables teams to understand, improve and make routine complex step-by-step processes that ensure improvements happen and can be maintained without super-human efforts.  

It is notable that other process-reliant industries – manufacturing, logistics, power generation, education – are regulated to demonstrate how processes are being improved and having an impact on outcomes. Uniquely in healthcare, there is little or no focus on the processes that deliver the better outcomes.    

The ratchet effect of locking in improvements is now possible using SOPHIA. However, there remains another obstacle to improvement – what is the reward for doing so? Professional pride is a powerful force but is it enough to sustain the effort required to improve, standardise and automate care?  

Our suggestion that financial systems currently locked into historical patterns of spending need to reward overall improvements in clinical outcomes and reductions in health inequalities to assist the technical process of improvement that now, at least, has a chance of becoming sustainable. 

1 https://www.kingsfund.org.uk/insight-and-analysis/long-reads/whats-happening-life-expectancy-england

2 https://www.kingsfund.org.uk/insight-and-analysis/long-reads/what-are-health-inequalities

3 https://www.cancerresearchuk.org/sites/default/files/cancer_in_the_uk_overview_2024.pdf

4 HSJ 28th May

5 https://www.sciencedirect.com/science/article/abs/pii/S0263931923001163

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