Much of the health care improvement over the past decade has been characterised by high levels of investment in staff, equipment and facilities to help deliver improved access for elective, urgent and primary care. But as the effects of the recession are felt, the real terms increases the service has enjoyed are unlikely to continue. As The King's Fund's recent report with the Institute for Fiscal Studies shows, the scale of the financial challenge facing the NHS over the next 10 years is unprecedented.
So if we can't meet expectations by spending more what are the options?
During the late 1980s and early 1990s I was an operational manager in the NHS and witnessed first hand the NHS's favourite strategy to cope with either declining funding or increasing demand (or both) – 'slash and burn'.
This is simple shorthand for a process by which expenditure is cut in ways that have long-term impact on the quality of care. Classic tactics were arbitrarily closing wards, forcing waiting lists to lengthen, or reducing the cleaning of hospitals, meaning that infections spread more easily. However tempting these strategies might be for managers who have used them earlier in their careers, they will not work now that we have to uphold clear standards under the scrutiny of the public and the regulators.
Another classic reaction would be for each individual NHS organisation to fight for its own survival, making decisions in its own best interests rather than the interests of the NHS, taxpayers and patients.
This, too, is short-sighted.
If, for example, a PCT unilaterally decides to decommission capacity for a particular procedure to save money, in the short term the provider can eliminate only its relatively small variable costs and is left with paying for the fixed costs. Everyone loses in this scenario: patients get more restricted access to care, unit costs for the provider go up, and the PCT has reduced both quality of care and the efficiency of the NHS.
I believe that the only option really available to the NHS is to focus on ways in which reducing costs can also improve the quality of care. For too long the NHS has believed that 'quality costs'. There are examples in almost every area of health care where providing care more efficiently can also improve the quality of care. For example, there is huge potential to reduce both waste in the system (such as the cost of work to correct earlier omissions and errors) and variation in the way care is delivered between teams and institutions.
How can we make this happen?
My own theory is that all change and improvement needs an appropriate mix of 'push' and 'pull' – push to make people sit up and take notice of the need to change, pull to help make change easier by showing there are better ways of doing things. There will be no shortage of push in the system with the Department of Health constraining expenditure by manipulating the tariff and issuing directives, but where will the pull come from? One well-documented mechanism is collaboration between clinical and managerial professionals and organisations.
At The King's Fund we will be launching a new programme of work – Quality in a Cold Climate – which will aim to understand how the NHS can deliver higher quality care at lower cost. We will work with the NHS locally to test out and evaluate the changes. This is one of a number of health care improvement programmes that are specifically designed to help connect organisations and professionals in a way that encourages them to share with and support each other. Combined with specialised clinical, improvement and development input, the programmes will help support NHS teams to improve the quality and value of the care they deliver.
A new financial era for the NHS will require a new paradigm for NHS managers and clinicians; a world in which health care can only be considered to be high quality if it is also efficiently delivered.