How should the NHS prioritise quality?

Comments: 5

20 Sep 2012

With the Francis Inquiry report due in the autumn, Dr Anna Dixon, Director of Policy at The King's Fund, discusses the role of the regulator and looks at how care quality can be improved.

Leaders of NHS organisations are currently in the midst of a massive reorganisation precipitated by the Health and Social Care Act 2012.  Many of the organisations that were identified as having key roles and responsibilities for quality of care, and for preventing serious failures in care, no longer exist (eg, the National Patient Safety Agency) or are in the process of being abolished (strategic health authorities and primary care trusts). The NHS and partners in social care are facing huge financial pressures. In such an environment how can the NHS put quality first?

In our paper, Preparing for the Francis report: How to assure quality in the NHS, we argued that there are three lines of defence against poor quality care: frontline staff; Boards and senior leaders of providers; and the external structures and systems, including regulators. All staff who deal directly with patients and carers have a duty of care and must speak up to prevent failings in care. Ultimately the leaders of organisations are accountable when things go wrong, and must be able to effectively monitor quality of care and create a culture of openness. National regulators also have a part to play, assuring the public that providers are meeting certain quality standards and taking action when local organisations fail to resolve issues.

The tragic events at Mid Staffordshire NHS Foundation Trust are already well known from previous reports and the hearings and seminars that took place as part of the Mid Staffs Inquiry. It is important that they are not dismissed as historical events, but that the voices of patients and the families who suffered – and of staff who worked there – continue to be heard. Putting these voices alongside routine data and information from inspections allows the regulator to build up a more rounded picture of the quality of care. The Care Quality Commission scans patient websites and forums to pick up 'intelligence' about emerging problems; its inspectors speak to users during inspections, and increasingly they are involving users in the inspection teams. But there are limits to what the regulators can discover about the quality of care from the outside, and so whatever the external processes, those in charge of providing services must be able to demonstrate that they are confident in the quality of care they provide.

This requires good governance and effective leadership. Boards of high-performing organisations go beyond the measures required for external reporting. Measurement is used for internal purposes first and foremost. More challenging is how Boards in charge of large and complex businesses over multiple sites assure themselves that those at the next level down are listening and responding to the experience of users.

Both clinical and managerial staff must take the time to listen to the experience of patients and find ways to connect with the emotional and human aspects of the care experience, as well as being competent in delivering the technical and clinical aspects. Our Point of Care team have been supporting local teams to improve the experience of patients. The use of patient shadowing has provided powerful insights and acted as a catalyst for change and the introduction of Schwartz Center Rounds® allows staff from across the hospital to meet regularly and discuss difficult emotional aspects of care.

There is a risk that the response to the Francis Inquiry will focus on national regulators and will single out particular organisations for attention, not least the Care Quality Commission. This would be a missed opportunity. Instead regulators and providers of care must commit to moving away from a culture that encourages complicity with poor care. In preparing for the Francis Report it is now more important than ever that quality is first on everybody's agenda.


#2549 Hugh McIntyre
Consultant Physician
East Sussex Healhcare Trust

Surely there can be no other option but that a bottom up approach through accountable clinical teams lies at heart of the quality agenda. If the current system does clearly support a clincially-led patient-centered approach to care can real quality improvement occur? Is this an oportunity for Colleges to embrace the centrality of quality improvement as the core of good practice.

#2554 Donal O'Donoghue
National Clinical Director for Kidney Care
Salford Royal Foundation Trust and Dept of Health

I agrre with Hugh McIntryre that individual clinical encounters are where value is added , or not , to patient care . Quality is in the eyes of the beholder . We need to ensure active listening is a fundamental part of training , acreditation and revalidation . Respect for patient and carer opinion ; and involvement of patients in service design , governance and quality improvement are fundamental to high quality care . Supporting patient leadership must be part of the response to the insights the Mid Staffordshire mirror is revealing . The seven dimensions of quality - safe, timely , efficient , effective , equitable , patient centred and sustainaable - are each measurable . Measuring quality at team level , sharing the informatiom with patients and using the knowledge that brings not just for external regulator or internal organisational purposes but primarily to improve individual patients care is needed across the system . In his first report Robert Francis eloquently made the point that behind every statistic there are individual patient stories . Volume 2 remains required reading .

#2717 Andrew Moody

I would take serious issue with the use of the term 'tragic events' in describing what happened at Mid Staffs. A tragedy is what happens when an unforseen or randon event results in suffering or loss to people who did not deserve such a fate. What happened at Mid Staffs was the result of negligence and failure in a basic duty of care on a massive scale from top to bottom in at least four significant organisations. It is to be hoped that lessons are learned and that, as well as justice for the people who were so badly let down, there is a genuine attempt to re-focus on the values and ethics which should be at the core of a public funded and run healthcare system, starting with the premise that hospitals should do no harm.

#3042 James Bunt
Gordian Management

From my experience we face a cultural issue. Anna's report is right to pinpoint the need for boards to exercise oversight internally however the mindset of those on the board must be correct. The NHS is configured so that it is too easy to prioritise the needs of the organisation and ones place within it. Individual and organisational ambition need to be tempered with a commitment to, if necessary, act in opposition to the organisational status quo to protect patients.

#40356 David Hughes
University Professor (Health Policy)
Swansea University

Surely Anna is jumping the gun in her final comment that we risk focusing too much on the national regulators. Arguably we have never really researched the impact of the arms-length regulation model (essentially the regulated market of the privatised utilities as applied to the NHS) and that is something that urgently needs investigation. Presumably the influence of voices like Anna's lie behind the NIHR's decision to exclude regulation at the national level from its recent call for research proposals on governance post-Francis. I'm afraid that I believe that this emphasis is premature and may have an ideological component - i.e. it suggests a preference for discussing micro-level cultural issues as opposed to issues of system design.

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