Quality In Austerity - Indicators of
Quality
Martin Bardsley
Director of Research, Nuffield Trust
March 2013
Twitter: #NTSummit
© Nuffield Trust
Why is HF/NT investing in work on quality?
There is no inevitable inverse relationship between finance and
quality but....
•
Financial pressure may divert attention from quality
•
Search for transformational changes in delivery may have
unintended consequences (good/bad) on quality
•
Historically success in areas like waiting times and HAI linked
with significant investment
•
Efficiencies likely to be sought in staffing
•
New organisational structures everywhere
•
Implications of austerity on health needs
© Nuffield Trust
There a whole lotta monitoring going on
Public Health England
support to the
commissioners
Department of Health
NHS Outcomes Framework.
Monitor
Performance
against
objectives
NHS CB
National Quality Dashboard
and corporate intelligence
CCGs
NHS TDA
Performance
against plan
third party information
Care Quality
Commission
Experience
Self
Contract
Data
Inspection
monitoring
monitoring
monitoring
Data (eg QRP s) and
inspection / investigation
Information from
people using services
HealthWatch
NHS Ombudsman
CSUs
Data
Contract management
Data
Commercial analysts
Provider
Continuous
monitoring of
quality
Quality of education
Individual competence
Professional
regulators
Engagement
Patients
Complaints
Experience
User-generated content
organisations
© Nuffield Trust
What can Health Foundation and Nuffield Trust add?
Provides an independent overview of how quality of care is
changing over time.
Offers a view across different dimensions of quality that is
not linked to any one provider or sectors.
Enable flexible analysis of important quality issues as they
arise, and uses a range of methodologies.
Develops the methods used to measure quality, including
innovative analyses across linked data sets at person-level.
Looks across the care system and where possible include
international comparators.
© Nuffield Trust
Quality in Austerity Programme
•
5 year, multi-stranded programme
•
Compliment existing initiatives looking at quality
Developing sets of indicators…
…to measure changes in the
quality of care over time across
care settings.
Deeper analyses on ‘hot
topics’…
…building on our capacity to use
complex information to create
new approaches and new
perspectives on how the quality
of care is changing within the
NHS.
© Nuffield Trust
Topic: Trends in Ambulatory Care Sensitive Admissions
ACS admissions have increase by 40%
in the last 10 years – will they continue
to grow?
Emergency admissions
300,000
250,000
200,000
150,000
100,000
50,000
0
Age-standardised rates of admission for ear,
nose and throat infections, 2011/12
© Nuffield Trust
Individual indicators
Effectiveness
Access and
timeliness
Capacity
Safety
Patient
centeredness
Equity
© Nuffield Trust
An explosion of indicators…
…but some areas better covered than others
Outcomes Frameworks, NICE, QRP, QIPP, QOF, Quality Accounts, Dashboards, Thermometers, Atlases…
Primary and
community
provision
General and
acute
Mental
health
Social care
provision
Population /
commissioner
level
Total
Effectiveness
147
274
26
13
82
542
Access and
timeliness
46
75
41
13
9
184
Capacity
35
47
24
30
1
137
Safety
66
160
82
11
7
326
Patient
centeredness
27
159
77
18
5
286
Equity
7
10
10
0
1
28
328
725
260
85
105
1503
Total
Secondary / tertiary provision
© Nuffield Trust
Even more limited outside acute trusts
Some areas better populated than others
Hospital admin systems - strong on activity and coverage but limited detail
General Practice – massive data sets with untapped potential
Acute care specialist and clinical systems – hugely variable
Social Care – tend to be local, not shared. Major problem re self funders
Community Care – very variable
Independent Sector Care – very limited
© Nuffield Trust
And an external body can only see so much in a complex
organisation
Corporate
Clinical
Visibility of
performance
(quality)
Though good data
exists in places we
still rely too much
on HES based
Community
© Nuffield Trust
Failures in quality: the holy histogram theory
COMMISSIONING
(contracting, choice, competition…)
‘IMPROVEMENT’
BODIES
‘IMPROVEMENT’ BODIES
Number of organisations
REGULATOR or COMMISSIONING
(enforcement)
(contracting)
Non compliant
Basket
Weak
OK
Good
Excellent
Quality
© Nuffield Trust
In an ideal world, quality indicators would be built from…
1. The information we need to understand
clinical quality at organisational level and
above should flow from information collected in
the course of people doing their jobs
Hospital
Social
care
GP
Health
status
Including... Patients views, PREMS and PROMS
2. Data linkage between these encounters /
events / episodes at patient level is important:
a. To make the most of what data we have
b. To measure outcome
(“change in patient health status that can be attributed to
antecedent health care”)
© Nuffield Trust
Some of the most critical areas are the most challenging
eg Information from care users
Care Users – Surveys, F&F, Complaints, Individual reports/stories
Patient reported outcome measures
Staff perceptions
Quality of medical treatments – limited information
Patient outcomes – difficult to assign causality
Capturing qualitative intelligence
Improving these will help but no guarantee of predicting
future failure
© Nuffield Trust
So what do we need to do…
A. Continue developing information from patients and staff
B. Fill the gaps for services that are lacunae – OOH,
community, independent sectors...
C. Go beyond HES into the quality of services including
clinical audits
D. Integrate the quantitative and qualitative
E. Link data to make the most of what there is and to assess
consequences /outcome
F. Link the information to subsequent action....
© Nuffield Trust