Can quality and productivity improve in a financially poorer NHS?

BMJ 2009; 339 doi: (Published 16 November 2009) Cite this as: BMJ 2009;339:b4638
  1. Bernard Crump, chief executive,
  2. Mahmood Adil, fellow
  1. 1NHS Institute for Innovation and Improvement, University of Warwick Campus, Warwick, CV4 7AL
  1. Correspondence to: B Crump bernard.crump{at}

    NHS finances have been in a healthy state for a while, but the situation is set to become more challenging. Bernard Crump and Mahmood Adil argue that there is nothing inevitable about loss of quality or productivity in a “flat budget” environment

    Health services across Europe and around the world will come under increasing pressure in the wake of the recent financial crisis. There is a serious risk that the quality and productivity of health care will fall as countries make inevitable cuts to their health budgets to deal with the imminent financial gap.

    After a decade of unprecedented growth in resources, England’s healthcare services must now begin to plan for a much tougher financial future. Although growth in spending is set to continue at the planned rate of 5.5% a year until the end of March 2011, the outlook for the coming years is for a period of static resources.

    The King’s Fund and the Institute for Fiscal Studies recently speculated about the funding and resource prospects for the NHS using progressively harsh funding scenarios for the next six years that they describe as tepid, cold, and arctic.1 Even the most optimistic of these scenarios (annual real increases of 2% for the first three years, increasing to 3% for the final three years) represents a much more straitened financial outlook for a service that has been experiencing growth at an average of 6.6% a year.

    Recent growth has been following fairly closely that suggested by Derek Wanless in his 2002 report,2 which also used three possible scenarios to assess the resources required to provide high quality healthcare services in the future. His fully engaged scenario, the most optimistic and the one adopted by the government, assumed improved health related behaviours and a 2-3% annual improvement in NHS …

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