Systems, design and value-for-money in the NHS: mission impossible?

NHS organisations are being challenged to transform themselves sustainably in the face of increasing demands, but they have little room for error. To manage trade-offs and risks precisely, they must integrate two very different streams of expertise: systems approaches to service design and implementation, and economic evaluation of the type pioneered by the National Institute of Health and Care Excellence (NICE) for pharmaceuticals and interventions. Neither approach is fully embedded in NHS service transformation, while the combination as an integrated discipline is still some way away. We share three examples to show how design methods may be deployed within a value-for-money framework to plan operationally and in terms of clinical outcomes. They are real cases briefl y described and the unreferenced ones are anonymised. They have been selected by one of the authors (TY) during his sabbatical research because each illustrates a commonly observed challenge. To meet these challenges, we argue that the health economics cost / quality-adjusted life year (QALY) framework promulgated by NICE provides an under-appreciated lens for thinking about trade-offs and we highlight some systems tools which have also been underutilised in this context