Is the NHS entering treacherous waters?

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The performance of the NHS in England is holding up well in most areas despite unprecedented financial pressures and the disruption caused by major and continuing organisational change. This is one of the conclusions of the Fund’s new report on how the NHS is performing under the coalition government half-way through the current Parliament.

The report also highlights evidence that some trusts are in financial difficulty and are facing challenges in maintaining the quality of their services. With the prospect of several more years of austerity and further cuts in social care budgets, the NHS is entering treacherous waters. The risks for patient care could hardly be higher.

The government’s approach to these challenges has been to signal its intention to rely less on process-oriented targets to drive performance improvements and to focus much more on outcomes. The recently published NHS Mandate also reiterates the commitment to give clinical commissioning groups the freedom to bring about change bottom up instead of it being driven from the top down.

Equally important is the belief that increased transparency will contribute to sustaining the quality of care and supporting improvements in services identified as priorities in the Mandate. The unanswered question is whether this combination of outcomes, devolution and transparency will be an effective substitute for performance management in the extraordinarily challenging times that lie ahead.

What is not in doubt is that much will depend on the ability of experienced leaders to focus on the quality of patient care and financial control to ensure that performance does not slip back. It is critically important that this is done through an approach that looks at the whole system of health and social care on a city-wide or county-wide basis. The challenge this presents is that many of the current levers and incentives are focused on organisational performance, and create barriers to organisations working in partnership.

As in high-performing organisations in the private sector, effective change means working across a series of dualities, including:

  • empowering frontline leaders while also strengthening leadership in organisations and local and national systems
  • promoting competition in areas of care where it offers the greatest potential benefits, while supporting collaboration and integration where organisations and services need to work together to improve performance 
  • valuing the role of clinicians in leading change and at the same time recognising the vital contribution of experienced managers
  • continuing to promote the development of high-performing organisations alongside the imperative to work across whole systems.

In making the case for a combination of different approaches, we are arguing against simplistic approaches to driving change in the NHS, which typically alternate between top down versus bottom up, competition versus collaboration and a range of other false dichotomies.

Having spent the first half of the Parliament legislating for radical changes to the organisation of the NHS, the government now needs to focus on the mundane but much more important challenge of implementing and executing the service changes on which its record will ultimately depend. Much hinges on the ability of the new ministerial team to work with leaders at all levels, and to engage thousands of clinical staff in rising to this challenge.

As we have argued in our report on Transforming the delivery of health and social care, the government must also implement overdue service changes and new models of care at a scale and pace never seen before. Failure to do so will inevitably result in more organisations finding themselves in deficit and the quality of care being compromised. It is on these issues that the public will assess the government’s record on the NHS at the next election.


Malcolm Wootton

FLi Ltd
Comment date
13 December 2012
We have developed a revised method for hip replacement that could save ~£400m per year in the NHS.
Do you think anyone is interested?

Dr Michael Crawford

Comment date
30 November 2012
The rise in emergency department waits is a good measure of the problems acute hospitals are facing. The 4-hour ED wait target made people looking for healthcare via this route very competitive in the allocation of acute hospital resources; we are in a pretty pickle if even these patients are now out-competed.

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