Service improvement needs “a more empowering, bottom-up approach” says Nuffield Trust report

Blackboard with chalk writing saying "Our Priorities"

The current financial situation for health and social care is worrying, and levels of service quality are deteriorating. In this policy briefing, the Nuffield Trust presents their perspective on the main health and social care priority areas, applying both “published and forthcoming research”, while drawing on expert opinion, to provide an evidence-based analysis of the current situation in health and social care, and how it can be improved. The ten priorities are identified at the start of the document:

  1. Addressing the funding crisis
  2. Committing to a fundamental review of funding
  3. Review NHS issues with management and culture, and implement an action plan to overcome them
  4. Review the effectiveness of performance targets
  5. Reduce disparities in accessing mental health services
  6. Develop a sustainable prevention plan to improve wellbeing
  7. Ensure that service transformation initiatives are sustainable and can be adopted throughout the health service
  8. Facilitate the development of new care models throughout primary care
  9. Engage and empower the core NHS workforce
  10. Implement patient-centred workforce development and planning

This briefing groups the priorities under four key themes, suggesting ways by which they can be met:

  1. Funding and finance
  2. Quality of care
  3. New models of care
  4. Workforce
Piles of coins

The authors reflect on the financial strain that clinical commissioning groups (CCGs) are facing


In the chapter on funding and finance, the authors reflect on the financial strain that clinical commissioning groups (CCGs) are facing, and how it may lead to unpopular rationing decisions. Additional funding of £8 billion is planned, and this briefing presents a plan for how this extra amount should best be implemented. As none of the political parties tackled the issue of social care funding, a further recommendation is made for all major parties to review health and social care funding.

Ink stamp labelled quality

The Nuffield Trust and the Health Foundation run a QualityWatch programme, which looks at 300 indicators of care quality

Quality of care

The Nuffield Trust and the Health Foundation run a QualityWatch programme, which looks at 300 indicators of care quality, and provides overviews of “how the quality of patient care is changing”, comparing the UK’s performance alongside other international health systems. In 2004, they identified issues with waiting times, access to mental health services, and staff wellbeing. In their investigation, the authors have identified issues regarding current performance management systems, management cultures, and fair access to all health services, both mental and physical. One of their main suggestions is that all stakeholders, including patient groups, are brought together “to develop an action plan for improving the culture in the NHS”.

Model of a structure

New ways of working need time to integrate with the health system as a whole

New models of care

Innovation has long been encouraged in the NHS, but one of the issues is that, because of the urgent requirement for making savings, decision-makers want to see immediate improvements, and this is not always possible. New ways of working need time to integrate with the health system as a whole. The workforce and patients need to understand the reason for the proposed change to the current working model. Therefore, the Nuffield Trust are proposing that more time is given to develop new ideas, so that they can be tried and tested, before being implemented elsewhere in the NHS. This requires workforce commitment and collaboration with all the stakeholders, including patients.

Network of people surrounding a circle labelled organisation

Decision-makers need to listen to the workforce when planning service delivery


With more than 1.4 million people working for NHS England, and another 1.5 million people working in social care, decision-makers need to listen to the workforce when planning service delivery. The recommendation is that leaders need to reconnect with staff so that they feel engaged and empowered. We have recognised the expert patient, and we need to value the expert employee. More collaboration is required between the workforce, patients, and the decision-makers.


While this paper does not focus specifically on commissioning, references are made throughout about the role of commissioners and providers. It is important that you are aware of the priorities, so that you can see if and how your priorities align with the national ones. With most of these priorities, effective communication and collaboration between all stakeholders is vital. Priority 8 – “Support and encourage the development of new care models in general practice and wider primary care” – in particular, is very relevant to you because you work with all areas of health and social care delivery, including the voluntary sector and local authorities, so you already have the networks in place, and understand what will and will not work. The decisions you make will have a direct impact on demand for emergency services, and therefore, it is essential that you help develop primary care services that support the smooth transition between primary and secondary care.


Nuffield Trust. (2015) Health and social care priorities for the Government: 2015-2020. London (PDF)

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Caroline De Brún

Caroline De Brún

Caroline has been a medical librarian in a variety of NHS and academic roles since 1999, working in academic, primary and secondary care settings, service improvement, knowledge management, and on several high profile national projects. She has a PhD in Computing and currently develops resources to support evidence-based cost and quality, including QIPP @lert, a blog highlighting key reports from health care and other sectors related to service improvement and QIPP (Quality, Innovation, Productivity, Prevention). She also delivers training and resources to support evidence identification and appraisal for cost, quality, service improvement, and leadership. She is co-author of the Searching Skills Toolkit, which aims to support health professionals' searching for best quality clinical and non-clinical evidence. Her research interests are health management, commissioning, public health, consumer health information literacy, and knowledge management. She currently works as a Knowledge and Evidence Specialist for Public Health England, and works on the Commissioning Elf in her spare time.

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