How healthy is quality in the NHS?

The experts:

What is the state of quality in the NHS?

Tim: It depends on how quality is defined. If we examine quality through the experience of patients, then the state of quality can best be described as variable. This is true from primary care through to secondary care and beyond. It is evident that practitioners want to deliver a quality experience to their patients but the system, poor communications and capacity issues are causing problems. In the recent survey by the CQI and the Health Service Journal, the perception of quality was depressingly low amongst the clinicians.

John: Quality in our health service is perceived to be generally high compared with some international standards but we have no systematic way to measure it and no universal agreement on a quality framework. There is a sense of quality slipping, both through the reforms, lower demand, staff frustration and the strain on partnerships, which are all occurring at the same time as increasing patient expectations because the younger cohort are less tolerant of poor customer service and bureaucracy.

Philip: I think the present state of quality in the NHS is patchy. There are some individual quality enthusiasts, such as Dr Kate Silvester (an ophthalmologist who left medicine and learned quality improvement from aerospace), Richard Steyn (a thoracic surgeon), Professor Matthew Cooke (an emergency department consultant) and Dr Helen Bevan. There are also some enthusiast-led organisations, such as Bolton Hospital NHS Foundation Trust, whose former CEO David Fillingham introduced a Lean training programme throughout the entire organisation. The Health Foundation and the NHS Institute for Innovation and Improvement (NHSI) have contributed to an increased awareness of quality improvement, but the uptake and benefits from their programmes are harder to quantify.

Another issue is that we are no longer dealing with the NHS per se. NHS England has a different ethos to Scotland (where a quality improvement strategy has been in place for some years) or Wales (where the ‘1,000 Lives’ campaign has helped significantly). Questions remain around the ability of the Care Quality Commission to perform its function, and quality in general, throughout the service (we will see the final report into Mid Staffordshire Hospitals later in the year).

How do you measure quality in the NHS?

Tim: There are literally hundreds of measures of quality, from waiting times on the full range of pathways, A&E statistics, infection rates, quality indicators, length of stay, patient experience, waste and staff satisfaction. It is not the absence of measures that is the issue. It is more that not all clinicians associate the measures with delivering quality care. There are sensitivities about the measures being founded on political rather than clinical motives.

If we look at waiting times as a measure, they have undoubtedly reduced. Infection rates, particularly for MRSA, seem to be under control. Some measures have made the improvements that everyone wants to see. Others, particularly around A&E performance, have had less impact.

Philip: Part of the problem is that there is no generally accepted definition. A commonly used definition is that of the US Institute of Medicine, from 1990: ‘Quality consists of safety, effectiveness, patient-centred care, timeliness, efficiency and equity.’ In the NHS’s Next Stage Review, quality was described as being: ‘as safe and effective as possible, with patients treated with compassion, dignity and respect [and] care that is personal to each individual.’ I think these are reasonable insofar as they go. However, there is no reference to an external standard for patient outcomes (and often there is none), nor any commitment to quality improvement.

John: There are lots of numbers, but again there is little agreement on quality in the round. The tendency has been to break quality down into safety, patient experience, an absence of hospital-acquired harm etc, but with no real way of putting the ‘apples and pears’ back together. There have been some useful attempts at using maturity matrices with statements of achievement and satisfaction rather than numbers, but the focus has been on inputs, process and some outputs, rather than all of these joined together to enable better outcomes.

What have been the challenges and problems for quality in the NHS and what caused these?

Tim: The fact that management has been under pressure to drive costs down has often brought them into conflict with their clinicians. A failure to deal with under-performers due to concerns about being accused of bullying has allowed poor care or a failure to meet standards to continue unnecessarily. Inadequate IT processes mean that staff are inputting the same data over and over again and that an army of people push paper around hospitals every day.

There is increasing demand from a population that requires a level of service that the country cannot afford. For example, avoidable attendances at A&E will continue to place pressures on a fragile system.

We cannot keep using our hospitals for primary care; hopefully the introduction of Clinical Commissioning Groups will have some success in making this transformation in patient thinking.

Philip: To use Deming’s ‘deadly diseases’, I think the main challenges have been: lack of constancy of purpose; focus on short-term profit; mobility of senior and junior management (not least through frequent restructuring); and running the service on visible figures alone (such as number of operations performed), ignoring the less easily measurable ones. While lip-service is paid to quality and patient safety, on the ground the impression given all too often is that expressed by a CEO I heard say: ‘The main purpose of this organisation is to make money.’ There is also fear: of saying the wrong thing, of rocking the boat and of being disciplined for it. In addition, we have a bad habit of thinking that ‘our problems are different’ and that we have nothing to learn from anyone outside healthcare.

On top of all this is the recently passed Health and Social Care Act. The concern remains that its main thrust is the marketisation or privatisation of the NHS, with the very real possibility that it will discourage integrated care. The Act also abolishes the National Patient Safety Agency (NPSA), the NHS Institute for Innovation and Improvement (NHSI) and the Health Protection Agency (HPA); the functions of the NPSA and HPA are being transferred to other organisations; the NHSI is going to try to function as an independent company. It is unclear what effects this will have on their work and influence.

John: There have been too many short-lived initiatives rather than sustained long-term commitments – a sense of this year’s flavour rather than building on improvements. There are also too many institutional and too few individual ‘owners’ of quality – we have commitments to quality and excellence but not ‘commitment to improve’. The so-called ‘agenda for change’ missed an opportunity to embed quality improvement in job specifications. There is no requirement for a qualification in quality to work in the NHS, nor surprisingly for regulators to show they have competence to judge quality. This means that training is haphazard and quality knowledge is assumed.

How can quality help achieve savings in the NHS?

Philip: If primary, secondary, tertiary and community care are allowed to work together, with a clear view of what is to be achieved, then we may begin to realise the potential that systematic quality improvement can bring to the NHS. The CQI is barely known among the main ‘quality players’ in the NHS, although the institute has much to offer. I think Dr Paul Batalden’s adaptation of Deming’s 14 points is a good beginning: despite being written in the mid-1980s, it sounds surprisingly current.

Tim: Focus on prevention, bring appraisal costs to reasonable levels and drive out the main cost of poor quality – waste. Standardisation of end-to-end processes through standard operating procedures and effective quality systems audits will drive out wasteful variation. Analysis of data and effective preventive and corrective action will reduce errors. Aligning quality and associating core behaviours and values with performance management will ensure that the right measures drive the right behaviours. For clinicians to be effective, quality practitioners they need to learn how to apply ‘symptom-cause-remedy’ to their process problems as well as their patients.

John: The focus has been on savings mitigated to protect safety rather than using quality to reduce reworking and additional costs. The boards of both providers and commissioners have an important role to play in getting this right and also in applying best value criteria for finding alternative providers if the service is poor and there is no appetite or capacity to improve.

Which quality initiatives have worked and which haven’t?

Tim: QIPP, the Quality, Innovation, Productivity and Prevention programme, (introduced by the NHS as a large scale transformational programme), has not given the impact on quality that had been hoped – with many managers feeling pressure to deliver the productivity element as a priority. Attempts to engage staff have lacked the capacity to create the time for them to become involved in quality improvement activities and the productive series has not been fully deployed in the hospitals or community environments. There are pockets of success with Lean but there are sustainability issues and the longevity of such successes has been compromised by changes in management or priorities. In hospitals, a focus on reducing bed sores and infection rates seems to have worked well. Some initiatives to reduce smoking and promote a healthy life style may have success for the next generation, more so than the current one.

Philip: There are a number of initiatives that have been tried. The Health Foundation and Commonwealth Fund sponsor fellowships to the Institute for Healthcare Improvement in the USA, to train individuals to a higher standard. On their return, some of the lessons learned have been heeded and ideas have been used to good effect; some have not. The Health Foundation and NHSI have funded projects such as Safer Care and the Productive Ward. These have been variably successful, depending on the degree to which their underlying principles have been understood. The majority of hospitals have made some effort at quality improvement, some specialities being better at it or finding it easier than others. Getting senior management to focus on quality rather than money can prove tricky, as can asking them to regard quality improvement as essential, rather than as an optional extra.

John: Some sustained, targeted initiatives which are followed-up have worked, such as the drives to cut waiting times, reduce hospital-acquired infections or campaigns like ‘1,000 Lives’. Boards also have to hold themselves to account if achievements are to be made and sustained.

What are the main risks for the NHS and how should the NHS approach risk?

Tim: Risk is something the NHS is very good at managing. If anything, there is a tendency to be risk averse. Fear of litigation will only increase this anxiety in the years ahead. A growing risk will be the failure to match capacity with demand. Outdated IT will mean that labour-intensive processes will consume finances and lack of investment in IT enablement will continue to erode efficiency. In the community, failure to integrate teams and locating them in fewer and fewer buildings will mean continued breakdowns in communications and relationships.

Philip: There remains a perception that the Health and Social Care Act represents the principal risk to the NHS in England, not least because it is unclear how it is to be implemented, with views ranging from ‘it means nothing’ to ‘it means the end of the NHS in England’. As a service, I do not think we understand risk at a corporate level. We are still all too good at blaming individuals for errors or sub-optimal performance. On the whole, we remain less effective at using root cause analysis, exploring potential countermeasures and making the most of human factors research that are standard in other industries. Clinicians seem better at understanding (clinical) risk and uncertainty than most non-clinical staff; the question remains how best to reduce that risk?

John: NHS management and boards are risk adverse, whereas clinicians have greater risk appetite for service redesign but are often naive of financial regulatory and reputational risks. This has real significance for clinical commissioning as GPs’ greater appetite for risk is translated into new commissioning priorities.

How can the NHS innovate?

John: By committing to continual improvement every day in every way. I particularly like the Welsh proverb, ‘Nid da lle gellir gwell’, which means, ‘good is only good until you find better’.

Philip: The perennial problems remain of how to introduce new developments and how to persuade managers and commissioners that they should invest in new treatments and equipment because this will be a) better for the patient and b) lead to savings elsewhere. The majority of staff are able and willing to improve their work environment and simple innovations and improvements (from how to run offices to how to restructure cancer pathways) can be done at little cost, yet achieve great clinical and financial benefit. However, these changes need to be led from, and supported at, board level, with facilitation from a quality department. And no, the quality department is not solely responsible for quality!

Tim: The ‘I’ in QIPP was about innovation but this has not been fully realised. So much emphasis is on the here and now that people try to solve problems with what they know. Horizon scanning or benchmarking are not used extensively enough, either within a sector or across sectors to stimulate innovation. Problem solving has resorted, too often, to ‘tinkering around the edges’ by people who have a vested interest in the current state.

While IT can often just make bad processes do bad work faster, true IT enablement will allow clinicians to spend time eye-to-eye with patients and not buried under records. However, the ‘Choose and Book’ programme in the UK has reduced the amount of paper referrals and increased the offer of choice to patients. Some of the deployment of enhanced recovery for patients undergoing operations has reduced pre- and post- operative length of stay.

Breakthroughs in new equipment that were optimised in the private sector by the same consultants who work in the NHS as well are now being used in NHS hospitals, eg green light laser surgery. These examples of innovation have made improvements to ‘length of stay’ as well.

Finally, what can the NHS learn from health services in other countries?

Tim: There is clear evidence that internationally, hospitals and health economies are beginning to exploit IT. For example, the NHS Scotland Strategic Partnership has had breakthroughs in patient information systems and e-rostering. In France, there is a continually improving patient record system, giving rapid access to patient data across the country. Hospitals in Spain are beginning to exploit the use of mobile technology. In the USA, there are good examples of hospitals moving from intuitive to prescriptive medicine, allowing patients to be dealt with by an appropriate grade of clinician in the best environment.

John: The NHS in England can learn to: integrate health and social care, based on the experiences of colleagues in Wales, Scotland and Northern Ireland; improve quality year on year (as in Canada); focus on improvements based on patient experience (as with Dutch patient coaches); improve the handover at boundary (as seen in the EU handover project); and to engage in worldwide knowledge transfer, for example through the International Society for Quality in Health Care.

Philip: The Commonwealth Fund (2010) ranked the NHS as among the best three health systems in the world for efficiency, access, equity and quality of care. Within these, the UK scored less well on patient-centred care and timeliness of care. I think we can learn from the integrated health services in other countries, such as Jönköping County Council in Sweden and Intermountain Healthcare, a not-for-profit provider in Utah, in the US. In both instances, the boards have embraced quality improvement methodology as essential for the entire organisation and have supported clinical and non-clinical staff in developing new initiatives. As one might expect, these have been good for the financial balance of the organisation but more importantly good for patients.

Where does quality fit into the future of health?

Following the publication of the CQI’s research on quality in the NHS (2011), the CQI is establishing a Health Special Interest Group (HSIG) for members operating in the health and social care sector. If you are interested in joining, please contact Catherine Bithell by emailing cbithell@thecqi.org. For more information on the CQI’s research on quality in the NHS visit: www.thecqi.org/documents/knowledge/NHS%20research.pdf