Learning from the evaluation of NHS IMPACT, the single unified improvement approach for the English NHS
Launched in April 2023, NHS IMPACT aimed to establish a unified framework for improvement across the English NHS. The independent evaluation was carried out two years after its launch to understand the extent to which NHS IMPACT has influenced and continues to influence the conditions for improvement within NHS provider organisations.
Our evaluation finds that NHS IMPACT has helped shape the conditions for more effective improvement in a range of different care settings and across departmental, professional, organisational, and sector boundaries. It did so across the five interconnected themes of LEGITIMACY, SHARED LANGUAGE, CONNECTING PEOPLE, TRANSLATION AND DIVERSE INTERPRETATIONS described in our earlier blog: Improving how we improve: Can a single, unified framework for improvement shape a systematic improvement approach across the entire English NHS?
In this blog, we offer a more critical reflection on our findings, which we describe as Challenges and Possibilities, as illustrated in the diagram below. These were identified from the research data and are applicable to large-scale improvement approaches beyond NHS IMPACT.
In our health and care systems, there is a growing recognition of how health inequalities affect populations and the significant implications for care models. Ensuring equitable (fair) access to healthcare alone is not enough to tackle the social and environmental factors that prevent good health among communities.
Similarly, our research has identified inequalities in the conditions for improvement among healthcare providers and settings. Context plays a crucial role in shaping the effectiveness of improvement. Factors such as legacy financial position, funding formula, population demographics, organisational archetype, geography, leadership continuity, leadership capacity, and other contextual elements all influence an organisation's ability to realise the potential of improvement. This suggests that we cannot expect the same improvement outcomes for trusts with different contexts.
One of the most prominent improvement initiatives in the NHS over the past twenty years is the Productive Series. Between 2007 and 2012, it established consistent approaches, language, goodwill, awareness, and endorsement by professional bodies, as well as adoption across hundreds of trusts (notably, all without a central mandate). However, despite this considerable level of engagement and awareness, investment and focus on the Productives ceased as the NHS underwent a period of structural reorganisation—ultimately leading to much of the momentum being lost—effectively closing the door on tens of thousands of engaged staff.
It could be argued that NHS IMPACT faces similar challenges to the Productive Series amid significant NHS reorganisation and cost pressures. Our research showed a strong consensus that improvement takes decades, not years, and that sustained focus on NHS IMPACT remains crucial.
Our research identified several tensions surrounding the development and networks of NHS IMPACT. Despite noble intentions to focus network forums more closely and efforts to develop the approach quickly, some members of the improvement community at all levels felt that the emergence of a 'club' culture led to feelings of exclusion or the belief that their valuable voices and perspectives had not been recognised in the work – in some part due to the executive focus. As NHS IMPACT matures, now may be the time to deliberately seek new perspectives, such as patient partners and front-line staff, as a catalyst for ongoing development.
Our research revealed a considerable level of expertise and experience in improvement, particularly process improvement, within the system, especially in environments with more robust management infrastructure, such as secondary care. The more experienced improvement leaders valued the 'agnostic' nature of NHS IMPACT, which allowed for local interpretation to account for expertise, context and history. Others argued there was some risk of duplication due to the lack of prescription, particularly regarding capability-building elements like training materials (which is currently being addressed).
From our personal perspective, in the context of increasing levels of 'grip and control' of our system and the growing specification of work, NHS IMPACT as a centrally hosted programme has shown notable restraint in recognising the still developing improvement knowledge base, the need for local interpretation, the value of sharing proven theory, the expertise within the system, and the importance of people having space to own what they create.
Linked to Tell or Sell, shifts in stance regarding mandating elements of NHS IMPACT, particularly for hospital trusts, left a lasting impression on the improvement community. Importantly, this enduring effect was less about which position was correct (to mandate or not) and more about the implications of the change in position itself.
The use of mandate (positional power as a method of coercing a system) constitutes a significant decision with lasting consequences. It sets the tone for improvement and significantly impacts the theory of change required by local improvement leaders. It is worth considering that the use of mandate, as a theory of change, while prompting rapid responses, has consequences regarding the level of genuine buy-in achieved, with a strong argument that it can foster passivity and lead to issues with engagement and agency in the long term.
NHS IMPACT is part of NHS England, the organisation leading the NHS in England. Among NHS England's key functions are monitoring and supporting performance, planning and setting specifications, and allocating funding. NHS IMPACT is positioned within this framework.
This positioning has undoubtedly helped legitimise the approach with senior leaders in provider organisations. However, it has consequences not only for those who view NHS England and its powerful, predominantly top-down role with caution, but also for important staff groups such as medics and those in non-hospital settings, who have far less familiarity and engagement with NHS England.
Given the rapidly changing landscape of NHS England, questions about the ongoing positioning of NHS IMPACT will be especially urgent and will directly affect how different staff groups, settings, and sectors perceive the approach.
Although not unique to NHS IMPACT, the approach is closely linked to specific high-profile individuals. While this can offer advantages such as credibility, gravitas, and human connection, it can also be argued that it is difficult to dissociate the programme from the people who lead it.
Improvement is a socio-technical endeavour built on networks, relationships, and trust at all levels, as much as on technical application. This, coupled with the argument that large-scale improvement relies as much on communication, campaigns, and peer-to-peer dialogue as on programme implementation, highlights the importance of recognisable and respected lead figures. As always, it is about maintaining a balance, and it is essential to stay aware and open to the challenges related to preserving longevity and openness—whether perceived or actual—to critique and new perspectives.
The full evaluation can be accessed here.
More on NHS IMPACT can be found here.
About the authors:
Nicola Burgess is a Professor of Operations Management at the University of York. She is a leading author in operations management and healthcare, and her research has been published in world-elite international journals. She is also a Senior Fellow at The Health Foundation and a member of the Scientific Advisory Group for IHI and Visiting Academic at Warwick Business School, University of Warwick and Aston Business School.
Nick Downham is an independent improvement specialist and director of improvement consultancy Cressbrook Ltd. He supports and guides teams, leaders, organisations and systems, domestically and internationally, to achieve improvements in Efficiency, Inequalities, Timeliness, Access, Experience and Safety. He has a quality engineering background, has spent nearly two decades working in health and social care and is co-author of Improving Quality in Healthcare (2024), published by Sage https://us.sagepub.com/en-us/nam/improving-quality-in-healthcare/book274113.
