I received some criticism for the blog Bye Bye Quality (Hello Value), as a record company might have labelled it, but most reaction was positive. Where it was not this indicated that I had not made clear enough the fact that quality improvement – doing things better –  does add value, but the issue is how much value and whether more value would have been produced by using these same resources in another way – for example simply by treating more patients at the same level of quality. This point was much better made, by coincidence, the week after my blog called Bye Bye Quality, when the BMJ published this letter from the highly experienced and respected Alan Maynard.  The letter was headlined, “Is quality of care improving? What about value for money?” and said:

“The reports of the apparent lack of success of investments in patient safety in hospitals by the National Patient Safety Agency and the Health Foundation are remarkable for their absence of economic evaluation [read editorial by Provonost et al, which the letter responded to]. Given the focus on cost effectiveness of the National Institute for Health and Clinical Excellence and public research and development programmes, the lack of consideration of value for money in these studies is reminiscent of old fashioned “effectiveness myopia.” With budget cuts and structural “redisorganisation,” the pertinent study question remains whether (and what) funding of patient safety merits shifting resources from other aspects of patient care.”

There was also a very powerful “perspective” in the New England Journal of Medicine called Cottage Industry to Postindustrial Care, which emphasised the importance of quality but gave higher status to value of the care provided, which they defined as a function of three elements; its design (the right treatment for the right patient at the right time), its execution (reliably doing it right every time to achieve the best outcome) and its cost over time.

The cost of safety improvement –  sometimes seen as part of quality improvement, sometimes as a separate topic – namely the added value of making care safer also needs to be recognised and accepted, or rejected because greater value could be obtained if the same amount of resources were invested in another service. I will report on the Case of the Nail Clipper Mountain in a future blog.

Muir Gray is visiting professor of knowledge management at the Nuffield Department of Surgery, University of Oxford.