For debt-ridden trusts it may be hard to believe, but tough deficits need not be detrimental to the quality and safety of care. Alison Moore reports

With health service deficits so high up the political agenda, it is no surprise that balancing the books is the number one priority for many NHS staff. But ask any patient, and the safety and quality of services is likely to be rated a rather higher priority than trusts reaching in-year balance.

However, emphasising quality and safety need not be at the expense of the bottom line, according to Health Foundation director of programmes and policy Vin McLoughlin.

'People have to get financials right but there's a risk that this focus will distract them from the safety and quality of care,' she says. 'But a real focus on safety and quality is the way to get long-term benefits in finance.'

Coming from Australia, she was astonished by the number of major reforms being attempted simultaneously in the UK. 'There's a real risk that focusing on organisational restructuring and finance will affect the ability to improve safety,' she warns.

The think tank has been working with four NHS bodies - Luton and Dunstable Hospital foundation trust; NHS Tayside; Conway and Denbighshire trust; and Down Lisburn health and social services trust - on safety and quality, engaging everyone from chief executive down.

Senior management involvement is particularly important, she says. Chief executives walk round the hospitals listening to staff views on what needs to be done, and promising to respond within 72 hours. Successes include a drop in standardised mortality rates from 111 to 95 in one hospital, improved compliance with hand-washing and a reduction in healthcare-acquired infections.

For New Health Network chief executive Margaret Mythen, the key message at the fringe event will be to concentrate on the patient: 'It comes back to what the NHS is for and it's about getting quality care for all patients.'

This needs to be strongly reflected in commissioning, where the important issue is not who does it, but what is achieved by it.

Knowledge is power

And information flow is an important part of this - do primary care trusts know where their money is going and whether it is being spent on the most effective treatments? She points to the variation around the country in areas as diverse as artery bypass grafts, caesarean sections and grommets.

'Some people are being treated inappropriately and over-treated,' says Ms Mythen. 'There are others who are not being treated early enough or don't have access to the procedures they need. It is not just about having more procedures. It is about making certain that the people who need them get them quickly.'

She confesses to hating the words 'demand management' and their connotations of imposed rationing. What is needed to improve quality, she says, is selecting the most appropriate treatments with the money available.

She does not believe that the current financial difficulties need be detrimental to quality and safety, although she understands that keeping the long-term benefits in mind can be hard for those working in deficit-ridden organisations.

'It is not just short-term savings? but it is easy for me to say that and it is difficult for that to happen,' admits Ms Mythen. 'There is a temptation to be short-sighted, but it does not have to be that way. There is lot of money out there, it's just how it's used. The focus has to be on quality and equality.'

Dr Foster Intelligence chief executive Tim Kelsey also highlights information as critical to improving healthcare quality - and helping eliminate some of the variations in care. 'The NHS is often without the necessary information to make proper decisions,' he says. 'Information about local needs is particularly important in ensuring the healthcare offered is what is needed.'

Although this may involve short-term financial outlay, there could be savings through better targeted healthcare, he adds. Mapping local needs could also help NHS organisations argue for more cash.

'There is no way HSBC or Barclays would run a business without effective market intelligence,' he points out.

The union view

But Unison head of health Karen Jennings believes some areas integral to quality and safety are suffering because of the current financial problems; these include investment in education and training. There are concerns that funding pledged to staff development is easy for pressurised organisations to raid. 'If you want a modern NHS with a modern workforce you have to invest? but it is the first casualty when you have financial deficits,' she points out.

Opportunities for staff to move upwards - through, for example, the skills escalator - may also be reduced.

But she is also concerned about how some of the current destabilising elements in the NHS will impact on its ability to improve safety and quality. For example, reconfiguration is likely to remove much 'institutional knowledge'.

Along with other trade unions, Unison is launching a major campaign urging the government to slow down the pace of reform. 'It is so chaotic; there is so much going on,' she says. 'We need to slow it all down. We need to pilot things, to look at the direction of travel.'

The current thrust towards contestability of services also worries her, and she highlights what happened to cleaning services during an earlier drive towards market involvement: 'It's quite clear that even the in-house services that stayed have difficulty cleaning hospitals because they have had to cut costs to win the contract.'

Dr Stephanie Brown, director of education and communications at the Medical Protection Society, says: 'Choice has been the big buzz word. It's a very sexy word.'

But she argues there is another side of choice which is rarely talked about - that as well as offering patients autonomy through the right to make their own decisions, it also requires them to take responsibility for the consequences of those decisions.

And that can sometimes mean a less optimal outcome - or a lower quality of care. Patients may choose to ignore their doctor's advice and decline treatment, or choose a less effective one. In this sense, she suggests patient choice and patient safety do not always sit comfortably together.

Dr Brown points out the importance of information flow: 'The doctor has a responsibility to explain the implications of your choice. Patients won't always want to hear about this.'

She believes complaints and even litigation may arise as patients find it hard to cope with a healthcare system which cannot cure all, or where there are complications or side-effects from the course they have chosen. Unrealistic expectations may also play a key role.

The nature of their illness will also affect this. Someone choosing elective treatment or with a chronic disease will be in a very different frame of mind to someone needing emergency treatment for an acute disease or accident.

On safety, she calls for government action to tackle some of the systematic elements that affect safety. There's ample evidence that system failures and the working environment are at least as important in adverse incidents as mistakes by an individual. The government has recognised this through reports such as An Organisation with a Memoryin 2000 and the encouragement of adverse incident reporting through the National Patient Safety Agency.

But has this been taken on board? Dr Brown suggests some healthcare staff are still reluctant to admit mistakes or point out those of their colleagues because they fear disproportionate effects: 'There must be circumstances where blame is appropriate, but it is about getting it into perspective. We have not got real buy-in on this - such as funding - at a political or governmental level.'

Incorporating risk management in medical education and having core educational initiatives across the NHS 'so we have the concept of the culture change from bottom up, top down and from the side at every level' could be part of this.