This briefing began by asking whether public anxiety about the quality of health care in the future was justified based on the experience of the past few years.

If quality was solely about getting speedy access to treatment, then there is reason to be concerned. We have shown in this briefing that the NHS in England has treated more people each year but struggled to meet key waiting time targets for a range of services in the past two years, including ambulance response times, treatment in hospital A&E departments, and the time from GP referral to consultant treatment for planned conditions, including suspected cancer.

This is concerning on two levels. For the person left in pain because their operation is delayed or they are waiting on a trolley, knowing that they are in a minority and that most other people are still treated quickly is cold comfort. But it is concerning on another level. If deteriorating waiting times are a symptom of a shortfall in funding colliding with rising needs, does it mean that other dimensions of quality are deteriorating too?

In this briefing we attempted to assess some of the other dimensions of quality in addition to waiting times. We chose to look at aspects of care for a selection of common acute and chronic serious illnesses, including heart attack, stroke and diabetes, where the data allowed for comparison across time. The picture here is more mixed. There have been real achievements. For example, in the past decade there have been strong improvements in the quality of care for heart attack and stroke, progress that has been recognised internationally. For breast and bowel cancer, and diabetes, there has also been improvement, but for these cancers the NHS is still lagging behind some comparable countries in terms of survival rates.

The one dimension of mental health we looked at, the IAPT programme, shows progress is possible, but it is still only a small step in bridging the gap between mental health needs and the services available.

It has proved difficult to know what has happened to quality more generally. This is partly a scale and complexity problem: we have looked at national averages, but there are persistent inequalities between areas and different groups. But it is also a time-period problem. Assessing whether the improvements we have seen have continued or tailed off, for even a limited set of quality indicators for a limited set of conditions, has proved to be like a book missing its last chapter. Many of the data reports have a time-lag, in some cases by two to three years.

In March 2017, the CQC found that there were examples of high quality care in many hospitals across England, but that all hospitals were facing ‘steadily increasing demand for their services at a time when they are also expected to make unprecedented efficiency savings’. It pointed out a correlation between hospital trust deficits and the ratings of the quality of care: trusts with larger deficits tended to have lower ratings.

The CQC is careful not to make a causal link between deficits and quality of care. But it is difficult to see how the intense financial pressures on all NHS and social care services will not threaten the quality of care in the near future if nothing changes. As OECD analyses have shown, the UK’s performance on quality is middling when compared with other OECD countries, but then so are our funding levels .

The improvements that we have described in the quality of care for conditions such as stroke, come from a combination of sources, including national guidance, resources to invest in infrastructure and data collection. But, above all, these improvements come from the capacity of clinicians and managers to re-design and improve care at the same time as delivering routine care. It’s important to note that such improvements have taken years of investment and effort.

The current plans developed by the NHS in England to improve care require this sort of effort on a much larger scale: for cancer and mental health services, and in general practice, as well as the models of care being implemented across the country.

What should the next government do?

Ensure the NHS has the time and resources to continually improve care, and that the health and social care system is adequately funded and staffed. To do this, the government needs to:

  • Address the immediate social care funding gap – for the NHS in England, as a minimum, spending per person must not fall between now and 2020, and must increase in line with GDP growth beyond 2020.
  • Develop a national workforce strategy to ensure that enough staff are trained, adequately rewarded and have the right skills to meet the needs of patients now and in the future.

Support the consensus forged by the NHS Five Year Forward View around the clinical strategies for cancer, mental health and primary care, but ensure the NHS:

  • Goes further and faster in developing more comprehensive and transparent ways to track quality, at national, regional and local level, alongside the existing waiting time targets.
  • Engages with patients, the public and staff to develop a fuller national strategy to maintain quality as the organising principle of the NHS. And as part of this, coordinate plans and policy initiatives to support the health service to maximise the quality of care within available resources.
  • Addresses the substantial gaps in data about the quality of primary care, mental health and community services, and achieves a step change in linking data to help scrutinise quality and improve care across clinical pathways.