Quality at a lower cost: making it happen

Expectations of the NHS are high: the public have been promised 'High Quality Care for All', patients have been guaranteed maximum waiting times and politicians will want this all delivered within the available funding.

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.

Comments

I think that commissioners of services need to be much tougher when monitoring services being delivered by outside bodies. For example, my organisation delivers transport getting patients to and from hospital. It was only we flagged to the commissioner that we were carrying a high number of patients to a hospital in the west Midlands from gloucestershire that the commissioner relised that the consultant was having all the patients travelling to him rather than the consultant carrying out clinics in gloucestershire as per his contract. The ambulance service who we sub contracted did not flag this to the commissioner.

Our focus has to be on Effectiveness and Efficiency, but the step-change required from Archie Cochrane's day is introduce new ways of monitoring effectiveness and efficiency throughout the system as part of routine day-to-day care, not just in RCTs and occasional surveys. Once we link data on activity and case-mix with outcomes and experience, we will have most of what is needed to monitor performance.

The problem with the NHS (and conventional medicine) is that the treatments do not work to cure the patient. They just make him addicted to the drug, which keeps the NHS staff and Big Pharma in business. CAM is an alternative health service which works (othrwise it would go out of business) The 2 services should be merged by integration, as the Prince of Wales has been advocating. CAM is much more cost effective in curing the patient, and has no side effects, and no deaths by medicine (see garynull.com)

Quality and productivity improvements are not mutually exclusive terms. Should all NHS boards not have confidence that all the care pathways they deliver to their patients have been recently reviewed against best practice both for the standard of clinical intervention, minimisation of patient inconvenience (i.e correct bundling of diagnostics and pre-admission procedures) and efficiency of admin and clinical process. If all our organisations had the level of clinical and managerial engagement necessary to deliver this then the improvements in productivity we must deliver can be achieved as a by-product of good quality care.

The NHS needs to have a serious discussion with itself about what it is there to do and what it is not there to do, less could well be more in a financially constrained environment. Whatever it does do should be of the highest quality and clearly link to a paradigm that embraces a holistic, effective community/preventation based approach to intervention. I fear many current NHS practices are reactionary and disempowering, which is not totally surprising given the high level of dependence on illness models as opposed to good health models.

As a medical manager, I am involved heavily in both making operational management decisions and experiencing these amongst a clinical peer group. There is an urgent need to provide the NHS workforce as a whole with those tools that will bring about, in some cases, radical changes to services while improving their effectiveness and acceptability. Currently, there are varying degrees of good intentions and great ideas but a lack of the practical skills needed to redesign services efficiently and collaboratively at the coal face.

Community based midwifery care has been shown to respond to parents needs, provides higher quality care and is cheaper. What is the King's Fund doing to promote and encourage implementation of that?

Maternity services are a key theme for The King's Fund and so we have several stands of work in this area. In 2008, the Fund published the findings of it's Maternity Inquiry; Safer Births: Everybody's business makes practical recommendations in seven key areas: teamworking, staffing, training, guidance and information relevant to safety, the role of trust boards, and the role of national bodies concerned with safety and maternity services. We have now establshed a Safer Births network of 12 maternity services across England who will work together to imporve the quality, safety and value of maternity care in their areas. The King's Fund also expects to undertake further work in this area in due course including reseach into effective and efficient staffing models for maternity services.