Quality in a cold climate: is the NHS on course?

Last week saw the publication of the NHS Operating Framework for 2009/10, new guidance on paying for quality as well as details of PCT allocations and a new formula for calculating those allocations. However, The King's Fund Director of Policy, Anna Dixon questions whether they offer a sufficiently clear and coherent guide to help steer the health service through the more difficult financial times ahead.

Reference:  The King's Fund monthly update, December 2008

It's been six months since the fanfare surrounding the publication of Lord Darzi's NHS Next Stage Review and, not surprisingly, questions are being asked about how much real change is taking place – and if not now, when exactly? If the review and its recommendations constituted a ten-year vision for the NHS, one might have expected the Operating Framework to acknowledge how that will be delivered on the ground. Yet much of the Framework reiterates existing national priorities and fails to link these to the new quality and innovation agenda set out in the Darzi review, other than to reiterate the policy levers for quality improvement. If NHS trusts were hoping for a clearer  roadmap setting out the first stage of a long journey towards a safer, high quality NHS, they will have been disappointed.

On the one hand the Operating Framework gives significant local discretion for PCTs to lead change as Karen Lynas sets out in her Q&A for Chief Executives. On the other hand it's not clear how we’ll know when or whether sufficient progress has been made to deliver the vision of high-quality care.

Indeed the purpose of a one-year Operating Framework is not clear in a more devolved NHS in which priorities should increasingly be set and agreed locally, albeit within an overarching, high level strategy. For PCTs wanting to set out ambitious commissioning strategies focused on the longer-term goals of delivering high-quality health care, raising population health, and leading innovative service redesign, one year planning cycles are unhelpful. PCTs need clear strategic direction. Instead, they are now faced with the competing visions and priorities – at regional level from their SHAs, from the centre via Lord Darzi's NHS Next Stage Review and now also from the centre the latest set of priorities in the Operating Framework.

Added to this is the uncertainty created for many PCTs by the fact that the new resource allocation formula puts many in a different position in relation to their target allocations. Some, such as Heart of Birmingham, which might have expected to enjoy significant increases in funding are losers under the new allocation formula. While there is no indication that the government plans to move towards the new target allocations quickly, it is certain to mean that PCTs who are over target under the new formula can expect a tighter fiscal future.

New mechanisms for PCTs to commission for quality announced in Darzi and detailed in guidance published alongside the Operating Framework are to be welcomed. Yet the setting of a national tariff four years ago was supposed to free up commissioners and providers from negotiating on price to concentrate on quality.

Everyone knows this hasn’t happened, in part because of the information asymmetry between commissioners and providers. Quality measures cannot be included in contracts if there is no data on which to monitor them. The lack of clinical input into commissioning is also likely to have been a factor in this – if quality measures are to drive improvements in patient care they must be clinically relevant.

Thus if the new commissioning for quality agenda is to be effective it needs to be supported both by relevant data and clinical engagement. There has never been a greater need to invest in the collection and analysis of quality data – in future, payments, performance management and accountability will rely on it.

Whatever the notional allocation targets, real allocations to the NHS from 2011 will be tighter for everyone. This means that efficiency and productivity will have to join quality as driving forces in the NHS. If Darzi’s vision is to be realised these savings need to be achieved not by the traditional methods of freezing posts, delaying care and cutting back on ‘administration’ but by genuine redesign of services and setting clear priorities. Providers and commissioners must ensure they have the leaders in place who can deliver value by ensuring that even as money becomes tighter, care improves. This is not an impossible task – poorly designed services ultimately waste money. The onus now is on local NHS leaders to create a shared vision for their health services that reconciles the various policy directives and then to set a course that will get them there, despite the stormy financial waters ahead.

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