10 October 2014
Ian Blunt, Senior Research Analyst, The Nuffield Trust - photo

Ian Blunt

Senior Research Analyst
Nuffield Trust

Recent NHS headlines will not have made happy reading for the Secretary of State for Health or the chief executive of NHS England.  It seems as though report after report has warned the NHS is teetering on the brink of an abyss. Now our own QualityWatch programme has added to those voices (though in a more measured tone), highlighting concerns about declining performance in access to care, quality in mental health services and work stress amongst care staff.

No simple answers

Is it right to be so negative whilst there are still many examples of excellent care? Well, first we must be wary of any simple answers on the question of quality. We know that quality is complex and varies across many thousands of individual services.  In any one organisation some will perform well, others less so and there is no one single measure of the quality of the NHS.

“Quality is complex. In any one organisation some will perform well, others less so and there is no one single measure of the quality of the NHS.”

Having said that, we can identify broad national trends in quality measures to guide patients, providers and policy-makers; this is the main objective of QualityWatch.  Yet even at a summary level the quality picture is complex. For example, our report highlights that the safety of care appears to continue to improve (as far as we can tell) and that patient surveys are not reporting any worse experience of care, on average. 

Falling behind on common indicators

So why the negativity? Our analysis also shows that measures of performance in many services are declining, particularly with regard to the ease with which people can access care.  Some of the most commonly used performance indicators are even falling below their target levels, such as the percentage of people spending more than four hours in major A&E or waiting more than 18 weeks for planned inpatient treatment. 

There have also been marked reductions in the numbers of people able to access some forms of publicly funded social care, for example the number of people receiving community based social care has fallen by 30% since 2009/10.  There are signs that the staff providing care are suffering too. Over one third of NHS staff report having been made ill by work stress in the last 12 months, and up to quarter of a million social care workers are paid less than the minimum wage.

The first step is good data

There are notable gaps in our information on many services and we can’t assume that quality in unmeasured services is being maintained.

Just as worrying is what we don’t know. There are notable gaps in our information on many services and, set against a background where measured performance is falling, we can’t assume that quality in unmeasured services is being maintained. For example, quality in mental health is not well recorded but what we do know suggests significant emerging problems – for example, long waiting times compared with physical health (as noted earlier this week by the Deputy Prime Minister), increased use of detention, more out-of-area placements and more young people placed on adult wards. This highlights just how important it is to understand quality of services, and the first step in understanding is to collect good data.

So what are the prospects? Clearly the NHS is high up the political agenda at the moment, and it’s easy to see a link between the negative headlines and the promises of extra health spending made at all three major party conferences. So maybe the "negativity" (that is, being open about changes in the quality of care in the NHS - good or bad) is helping the service attract the extra support it needs. However, the same does not seem to be true for social care, which looks set to experience more cuts after the election. As for the NHS, we will have to wait and see if the trend for increased health spending is maintained in the post-election comprehensive spending review.


The problem with being the only publicly funded health service in the world is that it will always be inextricably linked to the politics of the day, all political parties will promise to throw yet more money at the system. Perhaps more money shouldn't always be the default. Maybe political parties should work collaboratively for the greater good of the Service to address the really hard questions i.e. "why is demand increasing at such an insane rate?", "why can't patients with one or more long term condition more effectively manage their own health?", "why do health professionals all too often feel obliged to always 'do' something to the patient?", "why do we still measure arbitrary/meaningless things like wait times instead of outcomes?". The great thing about this report is it highlights the warning lights for mental health and social care services which if more effective could probably go a long way to addressing the current forecast £billions black hole...the NHS is unique in its structure (free at the point of delivery) providing a world leading, amazing service for our population. The general public and those working within the service need to hear this message too from time to time!!
Sally Deacon (not verified)
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