Life on Marsland says it’s time to mind the quality
The NHS is suddenly determined to improve quality. But what does this mean? And where is the information to do it going to come from? wonders Iain Marsland.
Some time ago I was faced with a consultant surgeon who was politely incredulous about my suggestion that IT could improve the care his team provided to patients. “But Iain, don’t you think that I provide the best possible care now?” he asked.
Thankfully, I had prepared for this question and was able to divert his attention to the wonders of the electronic patient record in ‘normalising’ the decisions and care provided by his more junior team members, as well as in sorting out some of the administration horrors of modern hospital practice.
I have since been careful in using terms such as ‘improving patient care’, ‘better patient care’, ‘effective and efficient patient care’, especially in the company of clinicians. However, the current metamorphosis of the term – ‘quality care’ - appears to have gained a strong footing in the NHS.
“Underpinning the Quality Framework is the need for new data standards, the currency of quality measurements.”
Quality has become synonymous with Lord Darzi’s Next Stage Review and has been used to badge its final report, High Quality Care for All, which set out the medium-term strategy for the health service. Since it was published, quality has become the byword for change and improvement. If you want something changed or improved, then call it a quality initiative.
Quality Framework
So, if quality is in danger of becoming an over-used word in the NHS, what is the pursuit of it really going to mean? Well, the NHS is about to go through a major step-change in the type of data it collects and the use it makes of it.
Once, we had Korner activity statistics. Then we had contract data in support of the internal market (and now Payment by Results). The Quality Framework will be founded on a plethora of clinical data, which will require a significant change in systems and processes, both for clinicians and for the technologists who support them.
The chief executive of the NHS, David Nicholson, has defined six quality elements that describe how he expects the NHS to implement High Quality Care for All. These can be summarised broadly as setting standards, measuring performance and fostering innovation.
Underpinning the Quality Framework is the need for new data standards, the currency of quality measurements. These are being defined by the National Institute for Health and Clinical Excellence, advised by the new National Quality Board – equivalent boards can be expected to appear at strategic health authority (SHA) and local levels of the NHS.
“The quality of NHS data needs to improve if it is to meet the demands being placed upon it.”
Lord Darzi noted that all high performing clinical teams measured and evaluated their practice. Clinical teams will now be encouraged to collect, evaluate and benchmark their quality performance metrics, such as outcomes. Further measures will be required by commissioners, regulators and others. The process and data will then build into Quality Observatories, overseen by SHAs.
All NHS organisations will be mandated to provide quality accounts (equivalent to the statutory financial accounts) that describe their performance in terms of quality care. This requires a change in the NHS legal framework that is scheduled for this current parliamentary term.
NHS providers are also being encouraged to improve quality of care through innovation. Commissioners are holding specific funds for quality and innovation schemes.
The Care Quality Commission
On 1 April, the Healthcare Commission, Commission for Social Care Inspection, and Mental Health Act Commission merged to form the Care Quality Commission (CQC). The CQC is the independent regulator of all health and adult social care in England. From 2010-11, its remit will also include General Practitioners and dentists.
CQC’s role is to ensure high quality care which will encompass patient safety, improving outcomes, managing the patient experience, promotion of preventative care, service availability and value for money (they couldn’t leave that last one out).
In terms of modus operandii, CQC’s new chief executive Cynthia Bower, has said that whereas the Healthcare Commission had taken a "big brain" approach to regulation, using intelligence systems to identify risks in the NHS, the CQC approach will be more about "running the finger around the toilet bowl".
We assume (and certainly hope) that by this Ms Bower means her inspectorate will be casting a matronly eye across individual implementations of practices, processes and technologies.
The data challenge
The drive for quality standards, measurements, benchmarking, commissioning and now regulation will result in a new NHS-wide stratum of quality data which must be supported by systems and processes for collection, processing and reporting. The IT requirements should not be underestimated.
On 9 April, the Audit Commission published Figures you can trust: A briefing on data quality in the NHS. The briefing’s main point was that the quality of NHS data needs to improve if it is to meet the demands being placed upon it.
The key to unlocking this black box of data is of course the NHS Care Records Service, with its wealth of clinical and patient data. Again, IT may be faced with an expectation that cannot be met without the need to resort to interim solutions. Hopefully the industry is listening and have solutions to meet our, as yet undefined, needs.
About the author: Iain Marsland has been in the NHS for 34 years, most recently as chief information officer for Essex Strategic Health Authority and previously as director of IM&T for acute trusts in Brighton, Sussex and Bristol. He is now an independent consultant.