What does the future hold for quality in the NHS? We’ve certainly become accustomed to the quality of health care rising steadily in England. As recently as 2007, only half of those waiting for elective treatment were seen within 18 weeks, compared to over 90% today. In those seven years, MRSA infections have reduced by 79%. However, given the financial challenge the NHS is facing, whether quality is even able to stand still is now being called into question.

This is because of the scale and the urgency of the NHS money troubles. In 2021, the bill for meeting the cost of the NHS will be around £30bn more than it is today. This is partly due to good news (we’re living longer) and bad (due to factors such as obesity, we’re generally a bit less healthy). To keep up with that would require NHS spending growing by 4% per year in real terms – unlikely given the current financial context. If instead spending remained ‘protected’ (only growing in line with inflation) the NHS budget in real terms goes up by zero. As such, we’re left with a gap, and a large one: £30bn.

£30bn is a colossal number. It’s four-fifths of what we currently spend on defence annually, and represents £1,140 for every household in England (check out our nifty infographic which examines this vast amount of money in a little more detail). More than anything, it is so big that ‘do nothing’ is simply not an option.

We are not alone in having to face such a challenge, as Jonathan Bamber discusses in his blog, and is the subject of our International responses to austerity evidence scan. Other countries have responded to similar challenges with drastic, sometimes brutal, changes. Ireland, for example, saw real term health spending per capita fall by almost 9% between 2008 and 2012. Starting salaries for nurses were cut by 20%, and 30% for consultants. The number of full time equivalent nursing posts was cut by by 1,600. For two thirds of the population, costs of attending A&E rose from €60 to €100.

We discussed with a number of NHS and foundation trust senior leaders how they would respond to continued austerity. As Chris Streather has described, while participants approached our hypothetical scenarios with great energy, the sheer difficulty of trying to save money while not impacting on patient care was clear to see. Options such as the need to reduce staff numbers and allow waiting times to lengthen were seen as hard to avoid.

So far, so gloomy. Is this what lies in store for the NHS? As we set out in our More than Money report, it is almost certain that additional money will be required for the NHS to maintain the current quality and breadth of services. The acknowledgement by Ed Miliband in his Labour conference speech that more money is needed is welcome (even though an extra £2.5bn a year is unlikely to be sufficient to close the gap beyond 2015/16). However, money alone is not the answer. If – and this is an extraordinarily expensive ‘if’ – the entirety of the £30bn gap was filled through new money, it would risk simply perpetuating how care is delivered now.

We know that quality of care is far from perfect, with too much variation between and even within organisations. We know too that quality is starting to fray around the edges, with areas such as waiting times and mental health services particularly under pressure. Our forthcoming QualityWatch annual statement, jointly with the Nuffield Trust, will explore these issues further. In addition, the NHS has not, and by a large margin, exhausted the wide range of productivity opportunities available to it, estimated at £10.6–18bn by 2020, representing up to 60% of the financial gap.

Such opportunities for improvement are writ large in the eight case studies of improvement projects we have profiled. All of these case studies show that improving quality and productivity can be achieved. None of these are anywhere near being implemented systematically across the NHS. This is why we are calling for more support to help providers to be able to make changes such as these.

Part of this is through dedicated money, a ‘transformation’ fund, to enable new services to be developed and existing ones improved. But it is also more support for the spreading of the skills which we know are critical to making improvement work. What sort of skills are these? Our event report Building capability to improve safety provides an excellent overview, profiling skills such as how to analyse data, creativity and innovation, and rapid improvement cycles. This needs to be backed up by political candour as to the gravity of the challenge we are facing, and support for change which may not always be easy.

Money is part of the answer to quality getting better not worse. But the decision as to NHS funding is a political one, sitting outside the control of those working in the NHS itself. Rather, the implication of the financial challenge for everyone working in the NHS is to look at how their ward, GP practice, service or hospital could improve. Our three questions to check your organisation's approach to improvement might be a useful place to start.

To close the gap between the quality of care the NHS should provide, compared to what it does provide, requires improvement at a hitherto unseen scale. Improvers of the NHS, your time is now.

Richard is Director of Policy at the Health Foundation,www.twitter.com/RichardTaunt

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