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The Quality Agenda

Analysing Health Policy / Contemporary Health Policy Analysis
Kate Thomson

Session overview
• How has ‘quality’ been embedded in NHS reforms
▫ What mechanisms have been used to monitor and improve quality? ▫ How has the quality agenda changed?

• Have quality mechanisms been effective? • What is the meaning of quality? • What other drivers for the NHS pose a challenge to the quality agenda?

World of acronyms:
Do you know what these abbreviations stand for? If not, find out. How does each relate to the quality agenda /performance management?

Quality – from 1997
• NICE (now)National Institute for Health and Care Excellence • NSFs National Service Frameworks • CQC (CHI  Healthcare Commission ) • Outcomes Frameworks
 Centralised regulation, standardisation  Quality, performance & accountability

Quality issues
• Regulation of medical profession
▫ Bristol case; Shipman

▫  Clinical governance

• Central monitoring & inspection • Care ‘failures’ e.g. Stafford (Francis Report) • Resources & financing

What is the relationship between quality and cost /investment?

Quality

Striking a balance in healthcare provision

Access

Cost

Performance & targets ( ~2000 )
• ‘traffic lights’; star rating systems; health checks; • ‘earned autonomy’ & Foundation status • Primary care targets • Increased number & coverage of targets
▫ From Increased central control – uniform standards – less ‘control’ from early 00s

• Payment By Results + patient choice – incentivising quality?

Targets/ performance indicators:
▫ Greener (2004): tightening of national regulation frameworks betrayed a lack of trust in professionals to act in the best interests of the health service. ▫ Stevens (2003) (cited in Klein 2006): they ‘undermine intrinsic motivation and produce a compliance culture in which only what gets measured gets done’.

• Do you agree?
• Coalition govt promised to eradicate ‘target-driven’ culture

From.. Quality Domains (CQC mid 00s)
• Safety • Clinical and cost effectiveness • Governance • Patient focus • Accessible and responsive care • Care environments and amenities • Public health

2001-13 Changing purpose of CQC (CHI)
Learning organisation

Light touch

Regulator

Inspector

To.. Care Standards (CQC) -current
“You should expect: 1. to be respected, involved in your care and support, and told what’s happening 2. care, treatment and support that meets your needs. 3. to be safe. 4. to be cared for by staff with the right skills to do their jobs properly 5. your care provider to routinely check the quality of their services.” > Intelligent Monitoring

From: DH (2010) The NHS Outcomes Framework 2011/12 (updated frameworks & docs for each available via Moodle site).

NHS Outcomes Framework

Quality emphases
• Access to services
▫ Acute care /diagnostics – waiting times ▫ Primary care– times, availability ▫ Drugs & treatments ▫ Closer to home / integrated care

• Prevention
▫ Numbers offered screening /checks

Quality emphases
• Patient safety
▫ Infection control ; ‘never events’ ▫ Staffing levels

• Choice & empowerment • Value for money • Evidence & leadership

Quality emphases: Customer satisfaction!

Button from CQC website

Friends and Family Test
'How likely are you to recommend our ward/A&E department to friends and family if they needed similar care or treatment?'

NHS England 2013:
“Our guiding principle for success is receiving positive feedback from patients and NHS staff on whether they would recommend treatment at their hospital to their friends and family.”
What do you think?

Discussion points:
1. What do the changing regimes and emphases tell us about policy directions and assumptions: • about the relationship of the service user to professionals /organisations • about the relationship of the state (or its representatives) to service providers Think about choice and autonomy

2. What is the relationship between quality monitoring /inspection, and high quality services (or quality improvements)?