UK: Quality And Cost: Can The NHS Ever Balance The Duel Challenge?

Last Updated: 12 September 2014
Article by Karen Taylor

Most Read Contributor in UK, August 2017

The 2013-14 financial year ended with around a quarter of NHS trusts and foundation trusts in deficit1. While surplus cash and carry-overs helped to plug some overspends, the NHS, in aggregate spent £165 million over plan. Without some form of redress, budget pressures and increasingly unrealistic saving targets are expected to push NHS hospitals to breaking point in the next few years. 

Indeed, the results of a June 2014 poll of health and social care leaders published recently by the Nuffield Trust, indicated that over two-thirds felt that NHS providers would have to go into deficit in order to provide a high quality service, and almost half consider that the NHS will no longer be free at the point of use in ten years' time. Despite these concerns, a third said NHS care had improved over the past year.2

Many NHS hospitals face increasing tensions in their need to deliver services with reducing budgets while maintaining quality. In 2013, numerous independent reviews of service failings, such as the Francis report and Keogh report, as well as Don Berwick's review into patient safety3and the Care Quality Commission's new hospital inspection regime, put quality centre stage. The significant number of quality improvement recommendations emanating from these reviews and inspections can often feel like an additional expense, so it's timely to consider the evidence base for hospitals in terms of the relationship between cost and quality - in other words: the business case for quality?

Much of the evidence for a business case for quality originates in the United States (US) whereprivate providers, who dominate the US healthcare market, tend to have a greater focus on the bottom line. However, the Health Foundation has conducted research on this topic and while reporting a lack of robust costing evidence, they highlighted some interventions that showed increased (and maintained) quality at a reduced cost4. The most promising interventions tended to focus on:

  • clinical variation – ensuring good practice is understood and followed by all
  • collaborative working – engaging multi-disciplinary teams across numerous settings (primary, secondary and social care) to tackle a particular quality issue
  • reducing waste – by for example, reducing delays and cancellations, as well as improving discharge regimes

The 2013 Berwick review states when referring to quality and safety: "in the end, culture will trump rules, standards and control strategies every single time". Findings from the Health Foundation support this view as most of the UK evidence around delivering cost savings through quality improvement came from organisations with a strong culture of quality improvement.

While culture is notoriously difficult to change, there are examples over-seas where quality improvement has become ingrained in the organisation's culture. The healthcare system of Jönköping County Council in Sweden has an international reputation for excellence – delivering low cost, high quality healthcare. Consistent leadership and communication of the core value of quality improvement over the last 20 years is a stand out feature of the Jönköping model5. Alongside this consistent message is significant investment in a dedicated quality improvement centre (set up in 1997 with an annual cost of £1.4 million) which allowed them to achieve:

  • vertical integration of a quality improvement approach to healthcare, supported by extensive training. All staff undertake formal training in change management and understand that quality improvement is an expectation of their employment - they are expected to have at least six improvement ideas per year. An expectation reinforced by the terms and conditions of employment where two per cent of remuneration is linked to delivery of improvement projects
  • a focus on involving patients and the wider public in the design of local healthcare. Helping to design patient centred care by inviting patients to be the 'voice in the room' when discussing service improvement

A number of broader differences in the Jönköping healthcare system are also interesting to note:

  • there is cohesion between the delivery of healthcare and public health and social policy. Smoking and alcohol are very tightly controlled and 'green activities' (walking, cycling etc) encouraged by government
  • citizens are required to co-pay the first £180 for medication, £15 for each primary/secondary care consultation up to a cap of £120 and £8 per day spent in hospital. Out-of-hours calls carry a higher charge than in-hours calls. This helps reduce inappropriate prescribing and avoidable attendances, and promotes quicker discharge from hospital.

Evidence suggests with the right conditions, a business case for quality can be made. To respond to continued financial pressure and maintain high quality healthcare in the UK, good practice and learnings from the Jönköping model, as well as others that already operate in the UK, should be considered. The question is, can the NHS act fast enough, or will the concerns raised in the Nuffield survey come home to roost?


The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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