UK: The Dalton Review – A lost opportunity for the NHS?



The Dalton Review was charged with how to enable "the best leaders and organisations in the National Health Service to expand their reach and deliver more for patients" and concluded that a key part of that will be a credentialing system. However, it has failed to understand that by coupling the credentialing system it advocates with Social Franchising it could deliver more for patients, create a social entrepreneurial culture in the NHS and generate new external sources of income for the NHS.

This article explains how the proposed  credentialing system, used together with Social Franchising can be used to make a powerful and positive impact on the NHS.

What is Social Franchising ?

Social Franchising offers a new organisational architecture that engenders a spirit of social entrepreneurism through the use of tried and tested commercial techniques. It involves delivering a "tool box" with which organisations can themselves implement a proven and successful model. It presents to the NHS Trusts a blue print for success that enables it to improve its own performance, rather than rely upon a third party. Social franchising applies a commercial architecture to social services and focuses more on the social benefits it delivers rather than upon the generation of profit.

Of particular relevance to the NHS is the fact that is also used by a variety of health service providers including medical practitioners such as the Appletree Medical Group in Canada, Doctors Express in the USA and Apollo Hospitals in India.

Social Franchising in the NHS could be founded on the credentialing system advocated by Dalton.

The Credentialing System

Dalton concludes that "A new credentialing system should be developed that would 'kitemark' the most successful organisations, based upon the current oversight and assessment frameworks of the CQC and Monitor. CQC assessment remains the most important measure of quality, but for organisations interested in expanding their offer it is right that their ability to do this is also tested. Credentialing would be open to all providers of NHS care, irrespective of speciality or sector. It would "identify those organisations capable of disseminating best practice and excellence more systematically throughout the NHS".

It will go further than just providing public recognition for a provider’s high standards; it should enable an organisation to benefit from its track record of high achievement and share that benefit with those other organisations in the NHS that use the same high standards.

What Dalton  fails to recognise is that the passing on of this credentialed excellence can be best achieved by Social Franchising.

How Can Social Franchising be Used in the NHS?

Social franchising can be  used to ensure that medical services are managed and delivered in the most efficient, cost effective and patient service oriented manner possible.

As recognised by Dalton, such excellence, "would encourage high performing providers to assess their operating model and consider their strategic capability to extend their systems and culture into other areas" Social Franchising is possible in he NHS without a credentialing system, however, credentialing system would help to identify those organisations with formats that objectively deliver greatest value. Social Franchising could be used to allow challenged organisations to themselves achieve faster solutions than are currently possible, without the need for expensive external organisations doing it for them. It would mean that regulators and national bodies could have confidence that, locally determined transformational change by the franchisees of credentialed organisations will involve lower risk so that the maximum patient benefit can be delivered in the shortest time.

Once an organisation has been certified, it would offer other trusts access to its format and use of its NHS "kitemark" in return for an on-going fee and submitting to periodic quality audits.This will develop a free market in healthcare management within the NHS that sits comfortably with the NHS's internal market and encourage trusts to "monetise" their credentials.

Credentialed organisations would go to the internal NHS market and attract franchisees which wish to take advantage of their know-how, rather than use their own uncredentialed format. This will achieve substantial efficiencies and hence cost savings whilst at the same time improving the provision of patient care.

Some organisations may will become both franchisors and franchisees, franchising out their own credentialed formats, whilst at the same time becoming franchisees of those organisations with other credentialed systems. The result will be a race to the top. Funding will be channelled to credentialed organisations. The more successful the internal NHS market judges a credentialed format to be, the more funding it will attract.

Social Franchising and the  credentialing system advocated by the Dalton Review could together generate new income streams for the NHS, on the international front


The Dalton Review identifies the need for and merits of a credentialing system, but has failed to recognise how this can best be used to deliver benefits to patients and help create a new social entrepreneurial culture in the NHS Social Franchising. However, it is not too late and stakeholders in the NHS can embrace the proposed credentialing system and use it as the foundation of a Social Franchising strategy. However, they do not need to wait for the credentialing system to enjoy the benefits offered by Social Franchising.