Introduction

Quality and safety are defined and measured in different ways by academics, commentators and agencies, while the relationship between them are viewed in different ways (Leatherman and Sutherland, 2003; 2008; Raleigh and Foot, 2010; Vincent et al, 2013). The US Institute of Medicine (IoM, 2001) provides a ‘long list’ that healthcare is high quality if it is safe, effective, timely, person-centred, equitable and efficient (Raleigh and Foot, 2010; Gardner, 2015), but this has often been reduced to a ‘short list’ of three dimensions. Raleigh and Foot (2010) write that while the definitions of quality vary in different settings, some themes – safety, effectiveness and patient experience – are common to most quality frameworks (for example, IoM, 2001; DH, 2008; NQB, 2013), and are regarded as the three pillars of quality in healthcare (Doyle et al, 2013; NQB, 2013; Swinglehurst et al, 2015).

As Donaldson and Darzi (2012) put it, however, in the first 50 years of the NHS, quality was implied but not made explicit (but see Thorlby and Maybin, 2010), perhaps assumed not to be an issue due to the ‘best in the world’ mantra (see Chapters 3 and 17). Issues of quality and safety in healthcare became more central about the turn of the twenty-first century, with important reports in the UK and the USA (Kohn et al, 1999; IoM, 2001; DH, 2000b).

This chapter examines the three pillars of safety, effectiveness and patient experience (compare DH, 2008). After a brief review of earlier periods, it focuses on reforms in England under the Coalition government. It then explores the impact of reforms on quality and safety, providing a wider comparative perspective.

Historical background: quality in the NHS 1948–97

Although rarely explicitly addressed, there were occasional concerns over quality in the early NHS. Vincent et al(2013) provide a chronology of events related to patient safety in England in the twentieth century including the Confidential Enquiry into Maternal Deaths (1952), the Safety in Drugs Committee (1963), and inquiries into failures at Alder Hey Hospital; Ashworth Secure Hospital, and enquiries into doctors – Rodney Ledward and Harold Shipman (1990s).

Evaluating the state of the NHS in its seventh decade is the subject of this book. It specifically addresses the programme of reforms undertaken by the Coalition government (2010–2015) in England. Our particular focus is from a policy perspective. This book adds to the growing body of knowledge about the design and implementation of major health service reforms in the UK (for example, Greener et al, 2014). Although it takes as its specific focus the five year period of the Coalition government (between the Conservatives and the Liberal Democrats; 2010–2015), it sets these reforms within a wider social, political, financial and organisational context of reforms to the NHS over the previous 25 years.

When a major reform of the National Health Service is announced, it is often claimed to be the most significant, the most far-reaching, the most consequential re-organisation that has taken place since its inception in 1948 (for example, Margaret Thatcher's foreword to Working for Patients, Secretaries of State, 1989). Indeed this may be so. Yet the reforms of the Coalition government, whose apogee was the 2012 Health and Social Care Act, can truly meet this oft-quoted claim. In a speech in November 2010, David Nicholson, the then NHS Chief Executive, referred to these reforms as ‘such a big change management, you could probably see it from space’ (quoted in Greer et al, 2014, 3). Moreover, not only were they major health policy reforms in their own right, but they built on a series of successive pro-market reforms which date back to the mid-1980s.

Yet the scale of re-organisation was not mentioned in the Conservative party's manifesto (for the 2010 general election); instead, its emphasis was on decentralisation of power to clinical staff (including GPs) and enhancing autonomy for NHS providers. For example: ‘We will decentralise power, so that patients have a real choice. We will make doctors and nurses accountable to patients, not to endless layers of bureaucracy and management’ (Conservative Party, 2010, 45).

Nor did the Coalition partner, the Liberal Democrats mention largescale NHS reform in their 2010 election manifesto. For example: ‘We all know that too much precious NHS money is wasted on bureaucracy, and doctors and nurses spend too much time trying to meet government targets’ (Liberal Democrats, 2010, 40).

During the 2000s there was a great deal of rhetoric about evidencebased policy and evidence-based policy-making (Davies et al, 2000; Perkins et al, 2010). However, policy and policy-making often appear to be rather more based on the existing ideas (or even prejudices or ideologies) of those in positions of power rather than on research evidence. And there are several reasons for this.

Policy-makers may believe they already know what needs to be done, and so do not need to examine what research says. Equally, those in positions of power may find research inaccessible in terms of its place of publication, or that it is written in dense, academic language they find difficult to understand. They may also find research to be too equivocal, too concerned with trying to consider both sides of a problem than coming to a conclusion or solution that they can get on with turning into a workable policy. Policy-makers may also have strong views about what needs to be done by government, regardless of what researchers are telling them, often seeming to put their own political goals ahead of research, and their ideology ahead of evidence.

When looking back at NHS reorganisations, it does seems to be the case that since the 1980s policy-makers have been unable to resist changing organisational structures, not even waiting to see if the last changes they attempted to put into place had worked or hadn’t. Secretaries of State for Health have sometimes seemed as if they are intent on leaving their own impression on the NHS organisation without considering whether what they are planning to change has any real chance of working.

From the perspective of academics and researchers, on the other hand, policy-makers and politicians often appear to have short attention spans and do not want to engage with the complexities of the area they are trying to change. Politicians can sometimes look as if they have decided what needs to be done without looking at lessons from the past or from other countries.