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Improving the Quality of Health Care in the United Kingdom and the United States: A Framework for Change

Health systems throughout the world are searching for better ways of delivering cost-effective care. With their enhanced focus on improving the quality and outcomes of medical care, both the United States and the United Kingdom have opportunities to narrow wide variations in health care delivery and outcomes and potentially save money, too.

Health policy analysts Ewan B. Ferlie of the Imperial College Management School University of London, and Stephen M. Shortell of the University of California Berkeley, caution, however, that quality-improvement strategies afoot in both countries are doomed to fail in the absence of a comprehensive, multilevel approach to change. In "Improving the Quality of Health Care in the United Kingdom and the United States: A Framework for Change" (Milbank Quarterly, June 2001) the authors provide a conceptual framework for policymakers and practitioners to consider in order to maximize the probability of success in improving quality in each nation's health care system.

A number of initiatives to improve quality have been undertaken recently in the United Kingdom and United States in response to high rates of medical errors. Most efforts to improve quality to date have relied on relatively narrow, “single-level” program changes that the researchers say have proved largely unsuccessful. To achieve a successful transformation, policymakers and practitioners must focus on four levels of change:

  1. The individual—a physician or health care professional.
  2. The team—a small group of individuals within a hospital or provider organization that can muster the human, financial, and technological resources to do its work.
  3. The overall organization—for example, hospitals or physician groups.
  4. The larger system or environment in which the individuals or organizations are rooted.

Regardless of the approaches each country takes to improve quality of care and outcomes—whether top-down or bottom-up, incremental or radical—it is essential that such policies be considered within the context of all four levels of change, and not in isolation of any one. The chances of success are enhanced when a change aimed primarily at one level is considered within the context of the other three levels. This would mean, for example, that proposed changes in the larger political economy of financing, payment, and regulatory policy would be aligned with and supportive of the goals and objectives of health care organizations to deliver better care. Simultaneously, organizations would focus on promoting, not inhibiting, the work of groups or teams—the point at which care is provided. Groups trying to implement new changes would, in turn, need to consider the varying needs, skills, and predilections of individual members and build on each person's comparative advantage. Anticipating barriers to change at different levels, and implementing strategies for dealing with resistance, becomes paramount. To achieve successful quality-improvement work, this multilevel approach must recognize the importance of the following four essential core properties:
  1. Leadership at all levels. Both the United States and the United Kingdom need leadership development programs that focus on quality improvement. The authors suggest an effective approach to leadership training would include groups of physicians, nurses, managers, and board members from participating institutions, not separate programs.
  2. Organizational culture that supports learning throughout the care process. The challenge is getting physicians and other health professionals to adopt a truly patient-centered, quality improvement focus that seeks to eliminate unnecessary variation in clinical practice and that constantly identifies new practices that improve care and patient outcomes. New research shows that a group-oriented culture emphasizing affiliation, teamwork, coordination, and participation is associated with greater implementation of continuous quality improvement practices.
  3. Emphasis on the development of effective teams. The ability of health professionals to work in teams is essential for improving quality. This effort is complicated, however, by a number of factors: the reallocation of tasks and responsibilities as a result of new technology and treatment techniques, new modes of payment, and other changes are challenging traditional roles and responsibilities among different care providers and managers.
  4. Greater use of information technologies for continuous improvement work and external accountability. The health care sector lags behind other industries in the use of information technology. Information technology, though, holds the ability to improve patient care and quality, while providing accountability to purchasers and others.

The United Kingdom and the United States each approach the transformation process to a quality-focused system differently, and each will have to choose between different trade-offs. The United Kingdom must balance its traditional centralized approach to health care financing and delivery with an approach that invites input of physicians and others at the local level. In contrast, the health care system—based on decentralized, pluralistic approaches to financing, delivery, and quality improvement—is in need of national standards, measures, and accountability as it moves forward. Each country can benefit from careful scrutiny of the other's effort.

Facts and Figures

  • Research shows that 45 percent of U.K. general practitioners and 49 percent of U.K. specialists believe that the quality of care provided has deteriorated over the last five years.
  • In the United States, 56 percent of generalists feel quality of care has deteriorated in the last five years, while 60 percent of specialists do.

Publication Details



"Improving the Quality of Health Care in the United Kingdom and the United States: A Framework for Change," Ewan B. Ferlie, Jerilyn W. Heinold, and Stephen M. Shortell, Milbank Quarterly 79, 2 (February 2002)