Refine reforms, report urges

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The multitude of reforms to which the NHS in England has been subjected in recent years means it is impossible to say precisely which of them have had what effect, according to a co-author of the Nuffield Trust’s study.

From targets and choice to national service frameworks, new inspectorates and private sector involvement, the NHS’s decade-long drive to improve quality of care had been “the most ambitious and wide-ranging” in the world, said Professor Sheila Leatherman, an adviser to the US National Forum on Quality Improvement in healthcare. But it had become fragmented and needed refocusing, she added.

The elimination of long waiting times reflects the impact of the huge extra investment the NHS has seen. But few of the broad measures of quality show any signs of a sharp improvement as a result of the extra cash, staffing and targets. Measures of death rates for conditions amenable to healthcare, for example, and some of the cancer figures have continued on the same broadly downward trajectory they were on before the cash injections.

It was also clear, the trust’s report said, that “a large proportion of the extra money flowing into the NHS since 2002 has been absorbed by cost increases rather than an expansion or improvement in services”.

Nonetheless, the creation of the National Institute for Clinical Excellence, clinical governance and the introduction of national service frameworks have helped raise quality. “Nice has been highly successful in securing improvement in quality” in several areas, the report says.

The current reforms need to be refined, not rejected, its authors conclude. What is needed now, they said, is a national quality policy, using data collected independently of the Department of Health to measure success and failure. “Many of the building blocks are in place but they are not yet properly aligned and integrated,” the report says. The report suggests a national quality steering group be created to see such a programme through.

“People say, ‘But surely quality is what the new Care Quality Commission [due to replace the existing health and social care inspectorates] will do’,” Prof Leatherman said. “But that is a fundamental flaw in understanding. You don’t get quality by inspecting it and handing responsibility for it over to an external regulator. You have to institutionalise it as a core part of what the NHS does day to day.”

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