New design rules for driving innovation in access to secondary care in the NHS

BMJ 2008; 337 doi: (Published 15 December 2008) Cite this as: BMJ 2008;337:a2321
  1. Hugh Rogers, senior associate, service transformation1,
  2. Lynne Maher, head of innovation practice1,
  3. Paul E Plsek, consultant on innovation and complex systems2
  1. 1NHS Institute for Innovation and Improvement, Coventry CV4 7AL
  2. 2Paul E Plsek and Associates, 1005 Allenbrook Lane, Roswell, GA 30075, USA
  1. Correspondence to:
    H Rogers{at}
  • Accepted 4 October 2008

Although access to secondary care in the UK has improved, more still needs to be done. Hugh Rogers, Lynne Maher, and Paul Plsek describe how understanding the unwritten rules could help us move towards more radical redesigns

Delays in access to health service have been one of the public’s top concerns and the focus of major political reform in the United Kingdom for many years.1 2 Waiting can have an important clinical impact; for example, delays in access to diagnosis and treatment can increase the likelihood of preventable complications, creating unnecessary risks for patients.3

Progress towards meeting national targets has been substantial but has been achieved largely through incremental change and expanding capacity. The most recent review of the NHS notes the need to accelerate change, in view of factors such as the rising expectations of the public and the development of our information society, to provide what patients want—personalised care.4

The US Institute of Medicine’s Committee On Quality And Safety In Healthcare recommended the use of frameworks based on simple rules to guide the complex changes that are needed to transform health systems.5 Simple rules have also been successfully used to guide major improvement initiatives in England (box 1).6 7

Box 1 “Simple rules” developed in the Cancer Services Improvement Partnership6 and Improvement Foundation/NHS Institute for Innovation and Improvement7

High level change principles for cancer services
  • Redesign the system of delivering care to improve experience and outcomes for patients

  • Ensure that patients and carers remain at the centre of the redesign process

  • Enable their views to form the basis of service improvement

  • Focus on the patient and carer experience across the whole patient journey

High impact changes for practice teams
  • Promote self care and self management of patients

  • Improve management of patients with long term conditions

  • Improve access for patients

  • Improve care for patients by redesigning roles in general practice

  • Use data and information to drive improvement

  • Improve care through systematic review of patient …

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