“Stroke care was woeful,” said Dame Ruth Carnall, former chief executive of NHS London, in her sobering account of efforts to change the system. Less than 1% of patients had thrombolysis, less than 50% were treated in specialist stroke units, and standards were low across a whole range of indicators. Poor care, low standards, and it looked as if it was getting worse. Resource was geographically misplaced too—more strokes occurred in the peripheral population, but the hospitals were central.

It needed radical change. Ruth’s team focused on key priorities based on high quality modelling. They aimed for direct admission to eight stroke specialist centres and they needed to reduce journey time, facilitate repatriation to a centre close to home, and create good local access to TIA clinics. Of course there was resistance, and the doomsayers who said it would never happen. There was bitter opposition to the loss of local services—with communities very concerned about the downgrading of their local hospital. And, they needed buy in from the doctors—particularly as some physicians had to support the downgrading of their own good unit to help build up a relatively poorer one elsewhere. It was successful but, clearly, not without pain. Change was slow and compromised by political interference, and the two year delay in implementation meant unnecessary death and disability. Reflecting on the difficulties in seeing this reorganisation through, Ruth worried about the challenge of future service redesign as, following recent NHS changes there would now be 74 organisations dealing with healthcare in London and no one in charge.

Caring for older people was a major theme this year—Adrian Hopper and Mark Kinirons told us about the Amber care bundle, a pathway to improve the care of frail elderly people. Alex Wu showed how integrated care, as explained by the PACE model, helped reduce admissions, increase discharges, and led to shortened hospital stays from 9.4 days to 7.9 days, and reduced bed days from 45k to 38k per annum. Warren Wong told us about the Kaiser Permanente approach—refreshingly different from the UK. They segmented older people into five major groups and while, like many healthcare systems, they struggled in dealing with the frail and dying, they invested considerable resources in those with multiple chronic illness. Most strikingly different, however, was the focus on the robust fit older adult for whom they were particularly keen to provide fast and efficient care. This group provided the revenue base that helped offset the higher cost groups. It was especially important to look after them well.

Warren Wong gave a further interesting insight into the relationship between health economics and quality improvement at Kaiser Permanante. Their overall aim is to spread best practice (they have excellent metrics for comparison) and reduce unwarranted variation (in diagnostics, hospitalisation, and ICU care in particular). They expect their older population to increase by 20% and the cost per cast needs to reduce by 20%. But, even if they optimise care and do everything right they estimate a cost saving of just 5%. As Warren said, it is not enough to do the same but better—they need to do things differently.

In my introduction to Lucy Savitz and Kathy Luther, I teased them that they were attempting the impossible—improving quality and saving money. I enjoyed their reflection that clinicians often suspect that management have all the money and hold on to their resources. The solution was in creating the right kind of mindset. Not all clinicians can think holistically and appreciate that management needs to look at the overall picture. In improving quality while saving money, their aim was to, “extract the waste out of the system,” but, not all clinicians like to think of their clinical work as waste!

Domhnall MacAuley is primary care editor, BMJ.