Promoting quality in the NHS

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

Since the publication of the Darzi review, the Government has emphasised quality improvement as perhaps the single biggest issue regarding current and future NHS policy development. As such, the Government has announced several initiatives over the past few months that it hopes will improve quality in the NHS. Most of the initiatives build on existing policies, although a few form components of a new Health Bill. This report will outline chronologically the recent quality improvement proposals.

Recent developments

In October 2008, the Government announced that it was setting up a public consultation exercise that it hoped would lead to improvements in the Quality and Outcomes Framework (QOF - the quality incentive scheme that applies to general practitioners). QOF rewards GPs for good performance relating to diabetes and cardiac care, for improving health within their populations, for good organisation of their practices, and for the quality of their child and maternity services, among other things.

NICE to review QOF indicators

The purpose of the public consultation exercise was to solicit views from clinicians, patient organisations, NHS commissioners and the public on whether the National Institute for Health and Clinical Excellence (NICE) should be involved in the annual process of reviewing the QOF clinical indicators, principally for the purpose of developing an independent, transparent process that includes input from patients, carers and primary care professionals. NICE's main role would be to recommend clinical indicators that are most likely to lead to genuine patient benefit, and that serve as a stimulus for delivering cost-effective care, but the final choice of which indicators to include would still be decided by negotiation between the NHS and the British Medical Association, who would base their decisions on the NICE advice. 

The public consultation ran for thirteen weeks, and sought views on how best to review existing QOF indicators and select new indicators that would do most to improve quality and outcomes, how to involve patients, carers and doctors in the indicator selection process, how to convene a panel of independent experts to prioritise clinical areas for developing new indicators, and how to pilot new indicators with GPs. In March 2009, the outcome of the consultation exercise was released, and it was announced that from April 1st 2009 NICE will indeed oversee the annual process of reviewing the QOF indicators. Based on what is outlined above, it has therefore been decided that NICE will from now on lead an independent, transparent process in selecting QOF clinical indicators that are most likely to lead to patient benefits and cost effective care (in theory). 

More quality improving initiatives planned

In January 2009, the Government announced a number of (what it hopes will be) quality improving initiatives as part of the Health Bill, which is currently being considered by the House of Lords. These initiatives include plans to pilot patient budgets to (apparently) give them greater choice and and control over their care, to place a duty on all organisations that provide NHS services to have regard to the new NHS Constitution (see The NHS constitution (13) 2009), to introduce prizes for enterprise and innovation in the NHS, and to tighten tobacco control to protect children and young people, among other things. We will have to wait and see which of these initiatives survive the legislative process, although Lord Darzi has stated that he believes that the (controversial) healthcare budgets and the innovation prizes would lead to important improvements in quality.

The Government's patient choice direction is also (they think) intimately tied into their quality improvement drive. In February 2009, the results of the latest National Patient Choice Survey (undertaken in September 2008) were published, and showed that 46% of patients were being offered a choice of hospital for first outpatient appointment, compared to 30% in June 2006 (incidentally, patient reports on whether their GP offers them a choice of hospital is a QOF indicator). Moreover, 67% of patients were able to go to a hospital of their choice, compared to 23% with no preference and 8% whose preferences were thwarted, and 77% of patients were satisfied with how long they had to wait for first outpatient appointment. The results therefore give a reasonable picture of quality in this choice domain, although there is clearly still room for improvement (if one erroneously believes that patient choice is necessarily a good idea).

Patient reported outcome measures

Finally, in February 2009, the Government published new guidance on recording pre and post-operative self-reported patient experiences. Proposals to record what are known as Patient Reported Outcome Measures (PROMs) had also been set out by Lord Darzi. From April 2009, patients undergoing hip replacements, knee replacements, groin hernia surgery and varicose vein surgery will be invited to record their self-reported health, both pre and post-operatively, on a PROMs questionnaire. The idea is to ascertain whether the surgery has been a success, not from the perspective of the clinical team (which will also remain important through other measures), but from the perspective of the patient. The Government  maintains that the PROMs initiative is the first of its types in the world, will lead to genuine improvements in quality, and will provide a useful source of data for commissioners and patients when having to decide were to purchase/receive surgery in a number of  clinical areas.      

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

I don't have a problem with NICE being involved in the QOF criteria. That sounds quite sensible to me. I am worried about giving patients their own budgets to choose their health care. I think this may work for educated, young individuals with minor health problems, but I can't see it being of much help (and may be of considerable harm) for the old, the seriously ill, the impoverished, the uneducated, and/or the confused. 

I am against the patient choice agenda, because I think it could in theory ultimately undermine the core NHS principle of equal access for equal need, as I have argued in previous HealthPolicyMonitor reports, but I am not unduly worried, as I think there are limits to the extent to which patient choice will be accepted (by doctors and patients) in the NHS. The collection of the PROMs data also seems sensible to me, and if done well, could provide a useful supplementary measure of health outcome.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government

• Parliament: The Health Bill is being considered by Parliament - I don't know what aspects of it they will support

• Providers: Some providers will be supportive of such things as patient choice and PROMs, some will be against it. GPs seem to have accepted the role of NICE in the QOF

• Patients, Consumers: On the whole, I don't think patients are that engaged with Government NHS policy

• Scientific Community: Some scientists and opinion leaders are for QOF, choice, personal budgets, PROMS etc., and some are against

Stakeholder positions

The Central Government, probably the strongest player, is clearly very supportive of its own initiatives. I don't suspect there is huge resistance from anywhere to NICE being involved in making the selection of the QOF criteria more independent and transparent. The BMA may have been to some extent perturbed by the idea, but its influence in choosing the criteria remains in tact, which I suspect has somewhat blunted the resistance some may have felt.

Some of the initiatives in the Health Bill (i.e. patient budgets) and the patient choice agenda continue to divide opinion (for opinion is all it really is). I suspect that the majority of the academic health policy community (and much of the policy making community) are not supportive of this direction, but the Government continues to persist with it. Patient choice has of course been introduced, and time will tell how successful (or otherwise) this direction proves to be. The initiatives outlined in the Health Bill are currently passing through the Lords, so we will have to wait to see the extent to which they are modified by the legislative process.

The collection of the PROMs data will not meet with everyone's agreement in the health service, first because it is an extra level of administration and second because some doctors may feel that it is undermining of their opinion and judgment. But, as noted above, this initiative has been implemented, and is part of the Government's drive at putting the patient's perspective at the forefront of the service (cf. patient choice), admirable if there was an unlimited budget, but maybe at odds with equitably sharing the NHS pie between all of its (hungry) beneficiaries. That said, the PROMs exercise is, I think, less controversial than the patient choice agenda, because the former is an additional potentially useful supplementary outcome measure, whereas the latter is essentially a matter of process that has potentially grave opportunity costs (e.g. if those who are good at exercising choice benefit at the expense of those who are not).  

Actors and positions

Government
Central government	very supportive		strongly opposed
Parliament
House of Lords	very supportive		strongly opposed
Providers
Hospitals	very supportive		strongly opposed
GPs	very supportive		strongly opposed
Patients, Consumers
Patients	very supportive		strongly opposed
Scientific Community
Scientific community and opinion leaders	very supportive		strongly opposed
current    previous

Influences in policy making and legislation

Most of the initiatives that I have outlined above have been implemented. The exceptions are those outlined in the Health Bill, which will be considered by parliament (at the moment, the House of Lords) for a few months.  

Legislative outcome

n/a

Actors and influence

Government
Central government	very strong		none
Parliament
House of Lords	very strong		none
Providers
Hospitals	very strong		none
GPs	very strong		none
Patients, Consumers
Patients	very strong		none
Scientific Community
Scientific community and opinion leaders	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

As mentioned, most of the initiatives have been implemented. Those outlined in the Health Bill will be considered by parliament (at the moment, the House of Lords) for a few months.  

Actors involved in implementation

Regarding actors and stakeholders involved in the implementation process, for QOF, it is NICE, the NHS and the British Medical Association (BMA). For the Health Bill, it is currently the House of Lords. For patient choice, well, this is just an ongoing policy direction and all NHS payers and providers (and of course patients) are theoretically involved (although, as can be seen from the results of the latest National Patient Choice Survey, fewer than half of patients are being offered a choice of specialist provider by their GP). And for PROMs, all licenced providers of the stated surgical categories are subject to administrating the pre and post-operative patient report questionnaires, which, anecdotally (from Alan Maynard), has created a lot of work in the NHS.

Monitoring and evaluation

There are no results yet relating to the initiatives I've outlined in this report, other than for the offering of choice of provider, and I've already outlined those results.

Expected outcome

Not yet applicable.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

It's too early to assess the real impact of most of the measures discussed.

References

Sources of Information

Department of Health. Government outlines changes to GP quality incentive scheme. 19 March 2009. http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=395888&NewsAreaID=2&NavigatedFromDepartment=False.

Department of Health. NHS ready for PROM date. 6 February 2009. http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=392024&NewsAreaID=2&NavigatedFromDepartment=False.

Department of Health. National patient choice survey latest results. 3 February 2009. http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=391624&NewsAreaID=2&NavigatedFromDepartment=False.

Department of Health. New measures for better quality, personal health care. 16 January 2009. http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=389905&NewsAreaID=2&NavigatedFromDepartment=False.

Department of Health. Consultation on GP Quality Incentive Scheme launched. 30 October 2008. http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=382709&NewsAreaID=2&NavigatedFromDepartment=False.

Department of Health. Consultations web site. www.dh.gov.uk/en/Consultations/index.htm.

Professor the Lord Darzi of Denham KBE. High quality care for all: NHS Next Stage Review final report. 30 June 2008.  www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/DH_085825.

Department of Health. Report of the National Patient Choice Survey, England, September 2008. 3 February 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_094013.

Department of Health. The standard NHS contracts for acute hospital, mental health, community and ambulance services and supporting guidance.10 December 2008.  www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091451.

Reform formerly reported in

Promoting improved access through the GP contract Process Stages: Implementation, Evaluation, Change

Choice and responsiveness in the English NHS Process Stages: Implementation, Policy Paper, Legislation, Idea, Pilot

The new GP contract Process Stages: Implementation, Policy Paper, Legislation, Idea

Author/s and/or contributors to this survey

Oliver, Adam

Suggested citation for this online article

Oliver, Adam. "Promoting quality in the NHS". Health Policy Monitor, April 2009. Available at http://hpm.org/survey/uk/a13/3