Intended for healthcare professionals


Does improving quality of care save money?

BMJ 2009; 339 doi: (Published 11 September 2009) Cite this as: BMJ 2009;339:b3678
  1. John Appleby, chief economist
  1. 1The King’s Fund, London
  1. j.appleby{at}

    Higher quality is mainly driven by professional reasons, which does not necessarily lower costs

    As the NHS enters a period of little or no real growth in funding but incessant demand and cost pressures,1 the idea that improving the quality of services, treatment, and care could actually save money is an attractive proposition. But although there is plenty of evidence that poor quality health care and adverse events are costly both for the NHS in financial terms and for patients in terms of health consequences, there is, as a new report reveals, a dearth of evidence of the reverse relation: that improving quality leads to lower costs.2

    In a wide ranging literature review for the Health Foundation, John Øvretveit unearths just eight reasonably robust and well researched examples—mainly from the US—where service or clinical change has led to identifiable savings. These include annual savings of $0.7 million from reducing deep surgical wound infection rates and $0.3 million from earlier patient discharge and reductions in delays in dealing with pathology specimens.3 4

    The poor standard of much of the evidence on quality improvement and cost will be disappointing news for those at the Department of Health pushing to extract a silver lining from the approaching financial cloud. But as Øvretveit also points out, there are numerous reports of the avoidable costs of error, adverse events, and poor quality. For example, the Department of Health has estimated that the cost of longer lengths of stay in hospital arising from various avoidable adverse clinical events is around £2 billion a year,5 and 4-10% of patients admitted to UK hospitals develop pressure ulcers, which likewise increases length of stay and treatment costs.6

    And there are also, on paper at least, obvious examples where changing clinical practice or improving the way patients move from one part of a health system to another can enhance quality of care for patients and also save money. For example, estimates suggest that around 15-30% of the 100 000 or so cases of hospital acquired infections each year in England could possibly be prevented, saving the NHS between £15 million and £30 million a year.7 Past attempts to get the NHS to focus on improving quality and either saving cash or freeing up resources include the now defunct Modernisation Agency’s “Ten High Impact Changes” report, which suggested measures such as reducing variations in length of stay; treating day surgery rather than inpatient surgery as the norm; optimising patient flow through the system; and managing variation in patient admission processes.8

    There have been improvements in the NHS in many of these areas—for example, the average patient having a hip replacement in 2008 spent 30% less time in hospital than a patient in 1998.9 However, Øvretveit notes that although identifying the cost consequences of poor care and the potential savings of getting things right is one thing, actually doing something about them is another.

    Apart from detailing the lack of hard evidence on what works and what doesn’t, the review also notes the cultural, financial, budgetary, and managerial barriers to improving quality with an eye to costs. The NHS, for example, is not unique among health systems in having budgetary and purchasing arrangements that can give rise to the perverse situation where providers are rewarded for poor quality of care and treatment. Without robust action by purchasers—whether insurers in the US or primary care trusts in the UK—the costs—for example, of readmissions arising from initially poor treatment—are borne by the purchasers not the providers.

    The review also rightly points out that saving money is not a prime motivating factor for clinicians, and that professional and ethical reasons for improving the quality of care do not seem to have been sufficient in producing the win-win situation of high quality at low cost.

    What’s needed, the review argues, is better evidence that any change will actually produce the quality and cost improvements claimed for it. This in turn requires more research and evidence of the true costs of change. In addition, the review suggests that the incentive and financial systems for providers should be redesigned so that providers can kick start change by tackling poor quality and directing support for upfront investment where it is needed.


    Cite this as: BMJ 2009;339:b3678


    • Competing interests: None declared.

    • Provenance and peer review: Commissioned, not externally peer reviewed