This document discusses efforts to reform the UK National Health Service (NHS) to balance quality, values, money, and power. It summarizes various approaches that have been tried, including commissioning reforms, target-setting, regulation, models of care, and quality initiatives. However, these have faced challenges from a crowded policy landscape constraining innovation. Going forward, it argues for a mixed model with differentiated organizational forms and incentives for different types of care, more local discretion, redefined roles and relationships, negotiation of quality objectives, increased patient influence, use of data/IT to support innovation, and "regulation light" to provide more flexibility.

1. Tipping the balance:
quality and values versus
money and power
Dr Rebecca Rosen, Senior Fellow
The Nuffield Trust
1

2. The context for change
Financial
Technology and
Patient & Public
innovation
Slow progress
to more
efficient service
design and delivery
Policy & Regulation Professional
2

3. What have we tried to date?
NHS commissioning cycle
1: Commissioning
Commissioning reform agenda
• Clinician engagement - PBC
• Building commissioning capacity
• External support for commissioning
• World class commissioning
• New incentives and tools
• Payment by results
• Demand Mx & service redesign
• Competitive tendering
2008 Audit commission review:
• Limited clinician engagement in PBC with main focus on provision
• Mixed picture regarding commissioning capacity and effective use of new commissioning tools.
• Mis-aligned incentives restricting progress.
• Early signs of competitive tendering used to change provider landscape
• Power imbalance with providers a continuing problem.
3

4. What have we tried to date?
2: Targets
• Wide range of targets
• Some clear wins
• waiting times
• access
• QOF
• Cancer care
Well described un-desired
effects
• Tensions between managerial
and clinical goals
"The waiting time targets for new outpatient appointments at the Bristol Eye Hospital have been
achieved at the expense of cancellation and delay of follow-up appointments. At present we cancel
over 1,000 appointments per month. Some patients have waited 20 months longer than the planned
date for their appointment."
Harrad R. Evidence Submitted On Behalf Of Bristol Eye Hospital To The Health Select Committee,2004
Risk of distorted organisational and clinical priorities 4

5. What have we tried to date?
3: Regulation
• Financial - Monitor
• Assessment
• Regulation
• Development support
• Quality HCC – CQC
• Annual reviews
• Special reviews/studies
• Special investigations
• Clarity about who does what
• Nature and timing of investigation and intervention
• Regulation as an improvement process
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6. What have we tried to date?
4: Models of care
• NSFs and other national
models
• Evidence based quality
improvement for high
prevalence conditions and
key care groups
• Single diseases & all long
term conditions
• Regionalisation via Darzi
work streams
Balancing top down and bottom up initiatives to improve quality of care
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7. What have we tried to date?
5: Quality and values
•Multiple NHS initiatives :
NHS Institute
IHI
Pursuing perfection
Collaboratives
• Locally driven through clinical
champions
• Built on professional engagement By helping to develop and promote a culture of
competency, the NHS Institute is seeking to help all
and values
NHS organisations achieve the same levels of quality
and efficiency as top performing organisations.
www.institute.nhs.uk 2009
Often project based small scale and
hard to replicate
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8. What have we tried to date?
6: Money and power
NHS Turn around
•Purely financial focus
•Brute force change at high speed
•? Impact on quality
• ‘Hair-cutting’ with no attempt to
re-align incentives for the long
term
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9. What are we aiming for?
Elective care
Aligned incentives
supporting different
types of care
Primary care Long term conditions
Integration of:
• Patient care
• Prof practice
• Information
• Strategic planning 9

10. Current challenges
Crowded policy and regulatory landscape is
constraining ability to innovate
• Payment by results
• Financial regimes
• Regulatory requirements
• Choice and competition
• Information governance
10

11. Getting the physiology right:
Policy, regulation Professional Patient and public
finance and targets
• Quality: Post-Darzi • Quality: re-balancing • Quality: access,
quality improvement ‘clinical ‘quality with outcome and
other dimensions relationships
•Move away from
blanket approach • Pace – a thirst for •Choice and voice in
across all care sectors change different settings
• Balanced range of • Engagement > • Multiple ways to
national and local resistance interact with NHS
policy levers
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12. What will give us some oomph
– Mixed model of organisational and financial regimes
• Differentiation between episodic intervention and chronic care
• Freedom to develop new organisational forms
• Mixed basket of macro and micro incentives
– Within different models, local discretion and redefined
roles and relationships
– Renegotiation of objectives re quality
– More sophisticated patient influence
– Data and IT to support targeted innovation
– Air cover
• regulation light, IT innovation, reduced levels of choice etc 12

13. www.nuffieldtrust.org.uk