As the NHS intensifies its drive for efficiency amid historic financial pressures, one principle is gaining significant prominence: cost savings must not compromise care quality. Central to safeguarding this balance is the Quality Impact Assessment (QIA), now mandated for all material financial decisions and service changes across the NHS.

This blog offers a tactical leadership guide for NHS system and provider leaders on embedding QIAs effectively within financial and operational decision-making. From boardrooms to clinical wards, QIAs are fast becoming an indispensable governance mechanism.

 

What is a Quality Impact Assessment (QIA)?

A Quality Impact Assessment is a structured process designed to:

• Evaluate the potential risks that cost-saving measures or service changes might pose to patient safety, clinical outcomes, access, and experience.
• Identify mitigations to address those risks before implementation.
• Provide a clear, auditable trail of clinical and executive oversight.

Since 2025, NHS England requires that all high-risk financial or transformational initiatives undergo QIA, with formal sign-off from:

• The Chief Medical Officer (CMO).
• The Chief Nursing Officer (CNO).
• The Trust or ICS Board, where applicable.

Strategic Takeaway: QIA is not optional governance; it is a formal safeguard ensuring that financial prudence does not equate to clinical compromise.

 

Why QIA is Now Essential

1. Financial Pressures Intensified

With a 7.1% national efficiency target, alongside workforce reduction mandates and agency cost controls, systems face pressure to deliver cost reductions at pace.

2. Workforce and Service Fragility: The True Price of a Life

Cost-cutting in staffing, services, or infrastructure is never neutral. NHS Digital data shows that over 170,000 NHS staff resigned in the year to September 2023, with the NMC recording over 27,000 nurses leaving the register in the same period. This is not mere turnover, it is the erosion of expertise, continuity, and clinical confidence.

Every lost nurse, doctor, or allied health professional widens the gap between demand and safe care delivery. The Health Foundation and The King’s Fund have evidenced how staffing shortfalls directly correlate with patient harm: increased mortality rates, delayed cancer diagnoses, longer A&E waits, and failed discharges leading to readmissions.

When workforce cuts are made without a clinical lens, the NHS is not just saving pounds, it is risking lives. Skill mix dilution leads to more avoidable harm, less supervision for junior staff, and fractures in the clinical chain of care, all factors driving the NHS’s liability exposure, now at £58.2 billion in set-aside negligence provisions under the NHS Negligence Bill. Every gap in clinical supervision or expertise erodes patient trust, escalates the likelihood of harm, legal action, and most critically, lives lost.

At stake is more than the budget. It is the price paid in human cost, systemic credibility, and billions in lost resources. If workforce integrity is not placed first, then what are we really paying for?

The uncomfortable question every Board must ask is this: what is the price of a life? And can we afford to pay it with short-term savings?

Strategic Takeaway: Financial savings achieved at the expense of workforce integrity are a false economy. They trade temporary budgetary gains for long-term clinical deficits, patient harm, and reputational risk.

3. Board-Level Accountability

NHS Boards are now explicitly accountable for ensuring that financial decisions are clinically safe. Regulators expect Boards to demonstrate that QIA processes are embedded and effective.

Strategic Takeaway: Without robust QIA governance, cost-saving programmes risk being derailed by quality failures, reputational damage, and regulatory intervention.

 

How to Embed QIA: A Tactical Guide for Leaders

1. Integrate QIA Early in Decision Pathways

• Embed QIA at the planning stage, not as a retrospective assurance step.
• Require QIA completion before final business case approval.

2. Establish Clear Governance and Sign-Off Protocols

• Define thresholds for when QIA is mandatory (e.g. workforce changes, service redesigns, bed reductions).
• Assign named executive sponsors for each QIA.

3. Ensure Multidisciplinary Involvement

• Involve clinicians, nurses, allied health professionals, and patient representatives in QIA development.
• Include finance and operational leads to align cost and quality perspectives.

4. Develop Standardised Templates and Risk Metrics

• Use consistent templates that assess impact across six core domains:
  • Patient Safety
  • Clinical Outcomes
  • Access to Care
  • Patient Experience
  • Workforce Impact
  • Health Inequalities

5. Monitor and Review Post-Implementation

• Build in checkpoints post-implementation to assess if anticipated mitigations are effective.
• Escalate any unintended consequences via clinical governance structures.

6. Train Board Members and Executives

• Deliver tailored training to ensure all leaders understand how to interpret QIAs and challenge assumptions.

Strategic Takeaway: QIA is most effective when it is a living process, integrated into continuous improvement and risk management, rather than a compliance exercise.

 

The Role of Boards: From Approval to Oversight

Boards should:

• Demand visibility of QIA outputs for all major programmes.
• Regularly review cumulative QIA risks via quality committees.
• Link QIA insights to wider Board Assurance Frameworks (BAF) and risk registers.

Effective Boards make QIA a cultural expectation, not just a procedural one.

 

Final Word from Altin Biba, MBA, AMBA Chief Executive of ProMedical

The NHS must walk a narrow path: achieving financial recovery without sacrificing the very standards that define public trust and professional pride. Quality Impact Assessments are not just governance tools, they are the clinical conscience of financial decision-making. They represent the pivotal question every leader must ask: how will this decision echo at the bedside?

At ProMedical, we are committed to helping system leaders navigate this balance, ensuring that financial sustainability and care excellence are not mutually exclusive. When patient care hangs in the balance, the right decision cannot wait.

References

• NHS England Guidance on Quality Impact Assessments, 2025
• NHS Financial Performance Update, July 2025
• NHS England Board Meeting Minutes, July 2025
• Care Quality Commission (CQC) – Risk and Quality Governance Insights
• The King’s Fund – Board Leadership and Quality Improvement
• Health Foundation – Quality and Cost in Healthcare
• NHS Digital – NHS Workforce Statistics, 2023
• NMC Annual Data Report, 2023
• GMC State of Medical Education and Practice, 2024