My job as NHS chief executive is to help transform the healthcare system from a rigid top-down monopoly to a service that is much more focused on the individual needs of patients. 

International evidence and 30 years’ managerial experience in this country have taught me we can only achieve transformation on the scale required if reforms are connected to purpose.

Incentives are needed but are not sufficient in themselves to drive transformation

It is the responsibility of the centre to ensure that we create and develop the right incentives and tools that encourage and allow staff to provide better care for patients and better value for taxpayers.

Arguing for the NHS tariff in this column this month, Paul Corrigan quoted me calling it an ideologues’ mistake to think “all you have to do is put the right incentives and penalties in place”.

I believe change does not come from incentives alone, or even, dare I say it, the guidance that often accompanies them.

The power to deliver the changes that incentives make possible lies in the interactions between frontline staff and patients: the GP helping an elderly woman to decide where best to get her hip operation; the consultant dermatologist working with managers from the primary care trust to agree how to get more services into the community; the cardiologist working with their team to understand how their outcomes compare with other units and agreeing improvements to make.

The great thing about working with former health minister Lord Darzi on the next stage review was that as a practising surgeon he was

driven by evidence. The result of his unrelenting focus on evidence to support lasting change was the seven steps for quality, which set out the levers and drivers necessary to ensure quality is at the heart of all the NHS does.

First you need to define what you are trying to do (quality standards); you put in place requirements to measure those standards (benchmarking); you require individuals/teams/organisations to publish them (quality accounts); you put in place incentives to reward success (tariff linked to quality); you safeguard against poor practice (regulation and contracts); you put in place systems to raise standards (performance management); and you ensure there are systems to encourage the service to stay ahead (innovation).

Incentives are necessary but not sufficient by themselves to drive transformation of the healthcare system. They need to be connected to a purpose - better quality care - and aligned with other levers to ensure all parts of the system work towards continual improvement. This approach sees the world not as a binary battle for power between “the centre” and “the NHS”; but as a complex and dynamic set of relationships between patients and staff. This model of change is driven by the principle of subsidiarity, so that the starting point for any discussion is “what can the individual GP and patient achieve between themselves and what support might they need from the next level, such as GP consortia”. The centre itself does have a role of course, but it must do what only it can do.

And the starting point for radical reformers should not be “are you for or against foundation trusts/choice/competition”. The real questions are “how can we give patients more clout? How can we improve access to real choice of high quality services? How can we create a revolution in information so that those choices are meaningful and available to all?”.

The role of NHS leaders is then to use the various tools and levers at their disposal to deliver benefits for patients.

In May 2009 I set out the challenges the wider economic circumstances present to the NHS. The economic climate makes it even more necessary that the NHS drives transformation to improve quality and reduce cost at a pace and scale never seen before. We need to maintain clarity and consistency of purpose; using and aligning all of the levers at our disposal to give greater power to patients.

So I stand by my earlier claim: this is no time for ideologues. Our chances of success are not guaranteed, but they can be greatly increased if our priorities are driven by what matters most to our patients, public and staff and our means for delivering them are founded on the very best evidence of what works.

Seven steps to quality

  • Bring clarity to quality
  • Measure quality
  • Publish quality performance
  • Recognise and reward quality
  • Raise standards
  • Safeguard quality
  • Stay ahead