1. What is meant by ‘quality’ in the phrase ‘quality of care’? Quality, broadly speaking, is a subjective measure of excellence and when applied to health care, ‘quality’ can be understood as systems and provisions of care said to be free from defects, deficiencies, and significant variations. Within the NHS, this encompasses the provision of high quality primary, secondary and community care in which the interests of patients are protected through a comprehensive set of nationally aligned policies. Lord Darzi defines quality of care as “clinically effective, personal and safe”. How is this achieved? Within the NHS, quality is achieved through robust regulation, inspection, standard setting, change management, community and patient advocacy, alongside continual assessment of clinical competency (Leatherman and Sunderland, 2003). Quality is about effectiveness of care, from the clinical procedure the patient receives to their quality of life after treatment. The Equity and excellence: Liberating the NHS white paper’s assertion is that ‘to achieve our ambition for world-class healthcare outcomes, the service must be focused on outcomes and quality standards that deliver them’.

Leatherman S, Sutherland K, (2003) The quest for quality in the NHS: a mid term evaluation of the ten year quality agenda. London: The Stationery Office,

2. In 2008, the Department of Health published the report High quality care for all: NHS Next Stage Review final report. 30 June 2008. (a) Please summarise the main approaches to improving quality proposed by the report (b) compare and contrast these approaches to those described in Gwyn Bevan’s editorial (quoted from above).

The Department of Health report approaches improving quality by:

High Quality Care for All proposes that all providers of NHS healthcare services should produce a Quality Account: an annual report to the public about the quality of services delivered. The Health Act 2009 places this requirement onto a statutory footing.

Stringent regulation from bodies with increased statutory powers. The Care Quality Commission will have new enforcement powers. NICE will be expanded to set and approve more independent quality standards.

New Quality Observatories will be established in every NHS region to inform local quality improvement efforts

Strategic health authorities will have a new legal duty to promote innovation. This will be twinned with a portal to share evidence-based, best practice among clinicians and other NHS staff.

Devolvement of power to ensure the involvement of clinicians in decision making at every level of the NHS.

The introduction of medical directors and quality boards feature at regional and national level

Increasing patient information and choice will be introduced in the first NHS Constitution. Patient information will include the “systematically measure and publish information about the quality of care from the frontline up”.

Individualisation will become the key to the way in which patients are handled with “a personalised care plan”. Noting that one size doesn’t fit all.

Incentivisation of care outcomes will include a new best practice tariff and the paper suggests this will make funding reflect quality of care.

Partnership will be embraced, utilising “local authorities, with the services offered personalised to meet the specific needs of their local populations”

Prevention not just treatment will be paramount with “focus on improving health as well as treating sickness”.

Bevan’s editorial evaluates the internal market systems that have been tested within the NHS according to the Audit Commission and the Health Care Commission’s paper ‘Is treatment working?’ Suggesting that despite the core intention of the internal market models to improve quality and efficiency of services for patients, as Black insists, there is little evidence to suggest that this has resulted from past models or alternatively the scrapping of the internal market when Labour came to power in 1997; i.e. formation of foundation trusts, increased commissioning autonomy, patient choice or the incentivisation of health outcomes (payment by results). The NHS internal market models aimed to keep healthcare costs low by forcing providers to compete for patients not compete on the basis of quality. A stark contrast in rhetoric is seen in the proposals that are raised in the report, where marketization is the key driver of systemic improvement in quality of care. The ‘High quality care for all: NHS Next Stage Review final report’ shows the need for a more market-orientated strategy: a patient choice-led approach to hospital funding, the removal of barriers preventing the use of private health providers to carry out NHS work, and the devolution of management and budgetary control from Whitehall to local communities. It appears reform is circular and the report bears a resemblances to pre-1991 measures where received funding was based on local populations.

While the Report is indicative of the need for a tripartite arrangement for achieving quality, with stakeholders as informants and agents for change, Bevan argues that the internal market model proposed, although attractive, relies on the assumptions that “purchasers can be effective commissioners and that failing providers will be removed from the market”. The centrepiece of the White Paper reforms and Operating Framework is the handing over of decisions on care, treatments and commissioning solely to GPs, ultimately creating a stable internal model where there will be a ‘quality equilibrium’. GPs will be burdened with the challenge of acting as a middleman between the patient and provider, ultimately as a gateway to funding and care. They with fundamentally be dismantling the current monopoly of care provision. Their decision making will be accountable to local communities and a board. This ‘new buyer’ position is thought to remove duplication of population care commissioning and streamline decision making to where the Government foresees a natural place to put this responsibility. Propper et al, (2003) noted that in 1991, the Conservatives “created a set of buyers, funded by central government, who were free to purchase health care for their populations from both public and private sector suppliers. Public sector suppliers were therefore not given direct funding, but were set to compete with each other, alongside a small private sector, for contracts from these public buyers.” The autonomy of Foundation Trusts as buyers, in Bevan’s opinion, has led to a free market of care with little standardisation, with the private sector benefitting from the poor levels of governance most.

Bevans’s editorial suggests this may have benefit to the population because so much healthcare cost is driven by decisions that GPs make and should not be guided by ministerial change. Unviable providers will be pushed out of the market by new entrants, creating a self-regulated, internal market. The White Paper suggests there is evidence that health systems work better where budgets and spending power are moved as close to patients as possible. Providers will be paid according to their performance. Furthermore, that a bottleneck on the road to driving the quality agenda is linked to ministerial involvement in the day-to-day running of the NHS. This “new public management” gives GPs greater autonomy, placed them at arm’s length from the government, interlinks purchasing and providing functions, and increases competition with quality in mind. GPs will be responsible for all aspects of performance; acting as bureaucratic gatekeepers for all care needs their patients, and potential scapegoats for ministerial politicking. As it stands, effectiveness of this system is being hindered by hierarchical bureaucracy and political micromanagement on both a local and national level, including politically driven reforms with each new government.

The report suggests the forced autonomy of GP Consortia, comparatively to Bevan whom notes the “earned autonomy” system, in which, the independent health care inspectorate awarded each NHS provider an annual “star rating” of zero to three stars. Providers that scored well on the star ratings gain small financial bonuses but win much greater operational freedom, and the ability to apply to become an independent not-for-profit “NHS foundation trust” status. Autonomy was the incentive as this gave managers more choice. At the other end of the spectrum, providers that score zero stars are placed on “special measures,” and if progress is not soon forthcoming, their management is replaced. Bevan suggests that measures of ‘Provider’ performance (cost, equity of access, outcomes, patient satisfaction etc.) have proved difficult to progress forward and that only patients acting as ‘consumers’ has left a marked change on the system. I think it is questionable whether in the short term, GP buying powers will drive quality in a market in which there are few providers.

The 2008 DH report takes note of such and relays the importance of an individualised service in which patient information to inform choice will breed quality. Patient choice and measures of satisfaction will simultaneously puts more pressure on providers to increase performance of measured care outcomes, which in turn become incentivised by cash rewards. They foresee GP consortia, evaluating Services considered to be sub-standard and withdrawing them from service if patient satisfaction and quality care outcomes are not met.

Propper, C., Burgess, S., and Gossage, D. (2003).Competition and quality: Evidence from the NHS

internal market 1991-1999. Unpublished paper, University of Bristol.

3. As one of the accompanying papers to the White Paper Liberating the NHS, the DH has recently published ‘Transparency in outcomes – a framework for the NHS.’http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_117583 Please summarise the main approaches to improving quality proposed by this consultation.

The NHS Operating Frame is an accountability framework which should, if followed, ensure that the NHS Commissioning Board works to deliver better healthcare outcomes. This will be through measures that are valid, reliable and sensitive to change, notably evidence-based outcome measures, not process targets. The outcomes and incentives emerging from the frameworks will be organised around 5 national outcome goals /domains that cover all treatment activity for which the NHS is responsible. Outcomes appear to be related to feasibility, cost of improvements and pre-existing data sets. ‘Quality of care’ as advocated by Lord Darzi in realised in three of the domains; patient experience, safety and effectiveness. The domains fail to include outcomes of access/equity, expediency in service or efficiency, which seems to underlie previous national reforms imposed by the Labour Government in 1997. The Operating Framework fails to identify purposeful ways of addressing deficiencies and poor outcome performance. Incentives and regulation are suggested but may not be drivers.

Each of these five areas will have:

outcome indicators

improvement areas according to evidence (collected data, patient surveying of experience, etc)

Quality standards, developed by NICE, will inform the commissioning of all NHS care and payment systems.

Measuring and reporting on outcomes will focus the attention of clinicians and managers on how well they are doing, where the gaps might be between actual performance and the high aspirations of those who use the NHS. I don’t believe all the outcomes are necessarily reliable measures of quality. In Domain 2, for example, there is a focus on functional outcomes and qualities of life for long term illness, which may lead to patients to receive care they do not want. A great deal of the outcomes will be developed through incrementalism, for example those related to compassion, dignity and respect as indicators of the quality of care. The measured outcomes should represent the overall quality of healthcare provided by the NHS, as well as being responsive to population need and demand. The outcomes should also be attributable directly to the actions of health care provided within the NHS, to enable accountability. Best practice should be identified and used as a basis for ensuring that the framework itself does not propagate practice that in itself leads, however indirectly, to inequalities.

Key to the five high level outcome/domains is the need for a whole system approach in aspiring for complete transparency, effectiveness and patients exercising appropriate choices, alongside a need to balance local priorities. Seven principles underpin the framework which are intended to improve the quality of health care, these are:

Balanced between need and demand

Accountability and transparency

Internationally comparability

Patient and clinician centred environments and service delivery.

Excellence and equality promotion

Adaptability and focus on outcomes that can be forged in partnership with other public services.

International comparability

The Health Secretary will be able to hold the new independent NHS Commissioning Board to account for securing improved health outcomes, and measuring the outcomes that are most important to patients and healthcare professionals. These will be backed up by authoritative, evidence-based quality standards that will ensure everyone understands how those outcomes can be achieved

Based on past experience, what do you think are the likelihoods of success of this latest initiative? Please ensure that you consider these in the context of the likely challenges for the NHS over the next few years. (Please cite references if referring to evidence of the impact of previous initiatives).

The attention of policymakers is always firmly fixed on the future and rarely on documented measures of progress to assess the impact of one set of reforms, before the next wave of organizational change. Political values dominate empirical evidence for reform. With such levels of political uncertainty, it is hard to evaluate if in five years’ time, a general election will lead to a change in leadership and new Health Minister. With this in mind, change often does not necessarily make best use of available resources, skills and knowledge. The direct influence of research evidence on decision making is often tempered by factors such as financial constraints, shifting timescales and decision makers’ own experiential knowledge (Elliott 1999). With devolvement of power to local government, there is need for a precise balance to be struck between strategies based on choice and competition on the one hand, and local “voice” and democratization on the other.

On its own, I don’t think the NHS reforms will create a patient-led system. It is the people, the leaders and staff of the NHS, who will make or break the change process. Central to this, is the way in which the White Paper reforms will radically change the way in with GPs work collaboratively with providers to better the health and social care of the population they serve. Reorganisation will ultimately mean GPs will have to create new organisations and learn new skills. This will take behavioural change that is likely to be unwelcomed, as there’s a shift towards increased paperwork and decreased patient time. GPs have shown considerable levels of apathy towards working reforms and changes in service delivery in the past, including contracted hours. For example, previously published opinion has indicated that the medical profession were predominantly opposed to the package of NHS reforms outlined in the Working for Patients and were especially opposed to the administration of hospitals by self-governing trusts (Lister, 1990). GP consortia will be exactly that, self-operating. As the Operating Framework enters its live consultation it will be important to gather evidence as to strength of feeling with which those opinions, either for or against various aspects of the NHS reforms are held.

Reform is costly, since managers and other NHS professionals invest a huge amount of time and effort with each re-organization. The NHS faces the need to make cost savings of £15-20 billion over the next four years. It is faced with the challenge to create better health outcomes with less resources. Moving to the new system, maintaining control of day-to-day services, and implementing these savings is going to require skilled management. This at time when the NHS is shedding much of its management workforce – and when managers have been under political attack.

Introduced in 2004 as part of the General Medical Services Contract, the QOF is a voluntary incentive scheme for GP practices in the UK, rewarding them for how well they care for patients. the higher the score, the higher the financial reward for the practice. The very suggestion that this was ‘voluntary’ implies that not everyone welcomed such change.

The introduction of a free market, in which providers can tender for supplying a service as opposed to an internal market, could serve to drive efficiency savings and quality of care. However, accountability and patient choice would require considerably management and information sharing across GP consortia.

Department of Health. Payment by Results. London: DoH, 2002.

5. One of the differences in the current UK coalition government’s approach to improving quality, compared to previous governments’, is in the use of targets.

Targets are defined by the DH (DH 2004) as: ‘Targets refer to a defined level of performance that is being aimed for, often with a numerical and time dimension. The purpose of a target is to incentivise improvement in the specific area covered by the target over a particular timeframe.’ List the possible benefits of using targets to improve health/health services and then list the potential disadvantages of using targets. Use examples (either from your experience or from what you’ve heard on the media) to illustrate your points. On balance, are you for or against publication?

The benefits of health/ health services targets include:

Supports priority setting

Promotes consistency

Improves commitment and fosters accountability

Guides allocation of resources

Milestones for incremental improvements

The disadvantages of health/ health services targets include:

Priorities may be misdirected and are often politically engineered

Not always evidence based

Hard to measure/quantify

Not always related to health care outcomes

Often cost related, not need related.

Clouded by bureaucracy

Often incentive driven – ie pay to treat.

One such health target in the Labour Government’s Health Policy, the ‘four-hour target’, imposed in Accident and Emergency Departments has received mixed reviews. It was just one of a range of centrally imposed standards, most of them designed to speed up treatment. With such a target, volume of patients being treated and the expediency of their treatment is implied to be of greater importance that the quality of care or health outcomes of patients. The Guardian, (2010) reports “In opposition Lansley had been critical of the way that targets “distorted” the behaviour of doctors, saying in the case of A&E that people should be treated in relation to the “severity of their injury” not an arbitrary time limit”.

6. The current government is strengthening the role of the regulator. Please summarise the role of the Care Quality Commission (CQC). What challenges do you think the CQC will face over the next few years?

In April 2009, as the result of passing of the Health and Social Care Act 2008 (2008 Act), the outcome-based regulator, Care Quality Commission (CQC) was officially established. Their primary role is to act as an independent regulator of the quality and capacity of health and adult social care. They are responsible for registering, reviewing and inspecting health, adult social care and mental health services to judge the clinical quality of healthcare. Regulation directly relates to the quality of care experienced by people, so called ‘end users’, who use the services and align to the Coalition’s vision of a “user-centred, integrated service with a strong focus on quality” (CDC, 2010). Indeed, when services fail to meet the health and safety legal requirements of their compulsory registration, action against them is taken through strict enforcement powers.

In the next few years, as we transition from one governance model to the next, exchanging power to a local level, improvements must be closely aligned to quality and substantial, evidence-based research. Research grants are being cut and it is likely public sector research, including health research, will suffer as result of such austerity. The CDC’s broad remit to oversee NHS organisations is not limited to particular service areas or functions, like that of many of the existing regulators. They may find themselves over extending and unable to fully engage with the public in a transparent and meaningful way.

As ‘quality of care’ is embedded to offer assurance and to deliver improvements over time, there is potential for major disruption to be caused by the scale of the change management discussed within the White Paper. The CQC’s model of regulation puts user involvement and community level accountability at the core of their actions. Though this is consistent with the changes implied within both the White Paper and Operational Framework, there is still considerable ambiguity surrounded where responsibility will lie across all regulated services, especially with the introduction of GP consortia. Until this is resolved and clarity found, ambiguity will only be escalated by poor engagement of stakeholders and insufficient information dissemination through the crucial transitional points.

As patterns of service provision change, consistently identifying providers and commissioners, and then allowing for local communities to hold them to account for the services they provide may prove difficult. Once established within a professional capacity, the CDC will need to be aware of the information on outcomes and how it should be presented in a format that is accessible and meaningful to influence patient choice.

Furthermore, in their role as an advocate of patients, as a consumer champion, the CDC will also be required to ensure that people who use services understand the care choices available to them and are involved in making decisions about their own care and support. The CDC (2010) note that “Patient and public involvement in health organisation will be strengthened by the creation of HealthWatch England – a new independent consumer champion within the Care Quality Commission”. As a so called ‘consumer’ champion, this suggests end user expectations may be heightened. Questions must be asked of how HealthWatch England shall be regulated.