The NHS that Professor Bernard Crump envisages is one where a junior nurse can remind a consultant to wash his hands and the reaction is “thank goodness you told me”. It would be a sign that “this is the way we do things around here” and it is happening in some places at the moment - but not everywhere.

Relationships are one component of the culture needed to make improvements, says Professor Crump, who is chief executive of the NHS Institute for Innovation and Improvement. And cultural issues can be the hiccup in even simple changes, such as getting nurses to wash their own hands. “Often things are deceptively simple,” he says, adding that most problems have a what and two hows - what is the problem, how do you solve it, and how do you make sure that people do it. The last how is the cultural issue. “It's the thing we're worst at in the NHS,” he says. “Making things sustain after we've brought about an improvement.”

The institute is working with the Department of Health on how the tariff system - the way payments occur between commissioners and hospitals - can be used to give people incentives to provide high-quality care. To develop a base for this, it chose nine conditions and went to hospitals with the best and worst quality of care. Some hospitals were among the best for one condition and among the worst for another. “It's relatively rare to find an organisation that's the highest possible performer for everything,” he says. “It's more at the level of the clinical team, the speciality or the directorate that you find excellence or less good performance.

“Sometimes some things are quite hard to get to spread from one ward to the next, never mind from one hospital to another or one country to another. A lot of it is down to the passion, the motivation [and] skills of key leaders.”

Sorry record on patient notes

Over a million patients a year are seen by NHS clinicians who have not been privy to their medical records

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From the good performers, the institute developed care pathways that include advice for others trying to improve their services. The new tariff system, which is likely to be piloted, will include additional payments for delivering very specific clinical items for a range of clinical conditions. It will also change the way the tariff itself is developed.

The present tariff for most procedures is based on the total cost of delivering the procedure across the country, divided by the total number, to develop an average. “We think we could create a cost or a tariff that is based on these high-performing care pathways that we've developed, which would be a more accurate reflection of the resources that an organisation would need to deliver high-quality care.”

As for new ideas, the institute receives about 40 a month, plus approaches at local level through innovation hubs. Most are from clinicians and vary from high-tech innovations to new ways of dealing with everyday problems. Professor Crump finds it fascinating. “We have a very proud tradition in England of inventions that have made an enormous difference across the world. What we've not been all that good at is forming the links with the necessary commercial partners or the people who can take those ideas and turn them into huge businesses or whatever.”

A medic himself, Professor Crump's mother was a midwife and his aunt, who had a big influence on him when he was growing up, was a director of nursing. While he won't be drawn on whether nursing should be a degree-only profession - “I think that's for the nursing profession to determine” - he does not believe that education and caring are mutually exclusive. “It's a false dichotomy to suggest that we need to focus on caring at the expense of the more technical or more educationally demanding parts of the work.”

Born: November 10, 1956, in Burton upon Trent.
Career: Studied medicine at the University of Birmingham; seven years in clinical practice and research; postgraduate training in public health medicine; a decade as director of public health, in south Birmingham and Leicestershire, where he was also deputy chief executive; CEO of Shropshire & Staffordshire Strategic Health Authority, 2002; first CEO of the NHS Institute for Innovation and Improvement, 2005.
What he says: “We think there is really compelling evidence that if you focus on delivering right-first-time, high-quality clinical care, that will be the most cost-effective care.”
Little-known fact: Once sang in the Royal Festival Hall.

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