Quality improvement and value for money in the NHS

30 May 2012

Reform roundtable on quality and value in health on 29 May. Introduced by Jim Easton, National Director for Improvement and Efficiency, National Commissioning Board.

Improving value for money in the NHS is the greatest public policy challenge of this Parliament. After decades where spending was increased to pay for rising demand, now the NHS will need to deliver productivity savings of 4 per cent each year of this Parliament. This level of productivity improvement is unprecedented and has been famously described by Stephen Dorrell as the “Nicholson Challenge”. The Government’s response to the Nicholson Challenge has been the Quality, Innovation, Productivity and Prevention (QIPP) initiative – where savings made in improving organisational efficiency and management costs will fund investment in more productive and higher quality models of care. To explore the Government’s progress in securing more for less in the NHS Reform convened a roundtable seminar with Jim Easton, National Director of Improvement and Efficiency at the National Commissioning Board. The seminar was sponsored by the healthcare consultancy, Finnamore, and was held under the Chatham House rule. These were the headline points:

Two years into the “Nicholson Challenge”, good progress has been made but the NHS has now reached the critical stage in the timetable to save £20 billion. In the first two years savings have been made through targeting “low hanging fruit”, reducing back office costs and driving up the tried and tested levers to improve efficiency in organisations. However in the next two years the NHS will have to redesign services on the front line to deliver sustainable improvements in productivity and quality. The objective is a transformation of the healthcare business model akin to the change achieved in mental health services in the 1980s, which saw care moving out of bricks and mortar institutions and into the home and community.

Quality improvement is the key to this transformation. There is overwhelming evidence that suggests that the existing model of care does not ensure high quality and has led to many failures of clinical quality and patient care – Mid Staffordshire hospital being the most high profile hospital scandal in recent years.

Yet while there is professional and even political agreement behind closed doors on the quality imperative to change services, too often the “future dare not speak its name”. Clinical and political leaders have rarely championed the new and even more rarely highlighted the poor quality that arises from outdated and inefficient models of care such as District General Hospitals.

A culture change is essential, among politicians, professionals and the public. What is need a renewed commitment to the service, rather than the facility. The national debate on quality improvement has to move away from the language of inputs and extra spending to one of outcomes. Clinical leadership has come at the expense of patient leadership and too often quality improvement has been seen through the eyes of medical institutions and the professions. One day strengthening patient voice (and choice) will mean that the public will marching for better quality instead of campaigning to protect “failing hospitals”.

Better quality care does not need to be discovered. Many high performing providers, such as Salford Royal in England and John Hopkins in the United States, are already achieving clinical outcomes that are far superior to the average. The key is to improve the spread of best practice. As well as the need to align incentives to quality outcomes rather than simply funding activity, a culture change is needed. While “copying” is common in other industries, in medicine it is almost seen as cheating.

A culture of innovation and learning and a system that rewards excellence is achieved through creating a market, which was described as an “engine of intolerance of mediocrity”. As well as enabling exit of inefficient and unsafe providers, competition will enable new entrants to introduce new models of care into the system.

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