High quality healthcareMay 2012
Advances in medical science, technology and clinical best practice are making healthcare safer, more precise and effective. However, despite these advances poor quality persists. As the Institute of Medicine found in its report To Err is Human: “healthcare is a decade or more behind other high-risk industries in its attention to ensuring basic safety”.
The need to improve quality and root out poor performance is not new to the NHS – Ara Darzi’s work in the last Parliament stands out. But now with the NHS needing to deliver better quality at lower cost, the challenge has intensified. The publication of the Francis Inquiry on Mid Staffordshire Hospital later this year will further concentrate the minds of policy makers to the issues of quality, failure and regulation.
The solutions many people offer for these problems involve increases in inputs. To maintain and improve quality and access many still argue the NHS needs more doctors, more nurses and more regulation. The Francis Inquiry has revived demands for minimum nursing ratios in hospital wards, while professional associations advocate “consultant provided care” to ensure patients are treated by the most expensive experts. Statutory regulation of healthcare assistants and managers are also on the agenda. The Prime Minister has signalled that he wants nurses to dedicate more of their time to patients and has championed “old-fashioned nursing”. However the answer is not more staff or more regulation. Now that the money has run out the NHS needs new ways to deliver better for less.
Real choice has the potential to improve quality. The most powerful form of choice is for patients to take their business to another provider. If a provider has a monopoly on the supply of a service, it can ignore the complaints of its users with relative impunity. Only if it knows that the dissatisfied can go elsewhere does it really have an incentive to improve. Choice requires alternative providers and, as in consumer markets, it also calls for relevant and accessible information about clinical outcomes. People should be able to learn about anything that effects their lives; systematically measuring and publishing information about performance leads to improvements in performance. We need a transformation in transparency and accountability.
Aligning clinical and financial decision making is the core principle behind the Government’s reforms to the NHS. But for doctors and nurses responsibility must accompany power and the new clinical leaders must be held accountable for quality and cost. Clinicians as leaders can start to champion new ways of delivering quality care for less and make clinically led service redesign a reality. The test of leadership will also be for clinicians to challenge professional assumptions of “who can do what” and look to innovative new models of care that are less trapped in the old professional boundaries.
Some have argued that the NHS will not be able to improve or even maintain quality while delivering £20 billion of productivity savings during this Parliament. Yet better care should cost less – and does, as high performing healthcare organisations around the world demonstrate. The case that hospital reconfiguration can save lives and save money has been well made. The NHS now needs to focus on value as the quality of outcomes achieved for patients over total cost of a full cycle of care, not just discrete, episodic interventions. This calls for fundamental change to the measurement of performance within the traditional care delivery models. Without addressing hospitals that are not financially or clinically sustainable the NHS will not be able to deliver the promise of value.
While the Government looks for quick fixes to improve value and quality in the NHS, the financial pressures facing the health service will only increase in the years ahead, with the potential for real terms spending cuts during the next Spending Review. As money gets tight the NHS will need to transform to meet the long term need to make quality healthcare sustainable. Only by reforms to front line services and rethinking how, where and by whom is care provided can the NHS deliver its long stated ambition of high quality care for all.