Measuring quality of health care in the NHS Giving a voice to the patients

The high-profile role that the NHS played in Brexit and recent general election campaigns demonstrates that the health care system remains foremost in the minds of all political parties when considering how to present their policies.

These campaigns put a spotlight on the sustainability of the health care system, but may have also fuelled a fear over deteriorating health system performance. In 2017, the NHS was recently ranked by the Commonwealth Fund as the best performing health care system out of 11 countries, including Germany, Australia and the United States. However, 82% of the general public expressed concerns about the future of the NHS in a survey following the 2017 General Election, with quality of care identified as one reason for dissatisfaction previously. Arguably, this disparity may be the result of intense media coverage of the human and financial pressures on the NHS, which could have shaped public perception to some extent. However, it might also point to a deeper disparity: a disconnect between the general assessment of measurable health system performance versus the quality of care perceived by patients when accessing the NHS.

One reason for this relates to the difficulty in measuring quality of health care at the system level. Quality in the context of health care is a multi-dimensional framework that captures six domains:

• Effectiveness
• Efficiency
• Equity
• Safety
• Timeliness
• Patient-centredness

There are only a few universally accepted quality metrics, and often policy makers and researchers are restricted to the use of indicators that are directly derivable from administrative data sources. They either reflect on a particular dimension of the quality of care framework, or allow measurement of quality of care at a particular point in the patient pathway (eg quality at the initial hospital stay). Despite this limitation, past improvement efforts in the NHS were guided by existing quality metrics, such as the increasing national focus since 2010 on reducing readmission rates to improve quality. While targeted initiatives may yield transparent effects for triggering quality improvements, the direct impact on patient wellbeing is often not known, but assumed to correlate strongly with the target metric.

Since 2009, the NHS has been systematically collecting information on patient reported outcomes (PROMs) for patients undergoing hip and knee replacement, hernia repair, or varicose vein surgery. This was initially designed to improve patient choice and transparency, but tapping into this rich database allows measuring an additional dimension to quality of care – the patient’s perspective.

In a recent research paper published in Medical Care, members of the Data Analytics team at the Health Foundation, in collaboration with researchers from Yale University, investigated the association between readmission rates and certain PROMs for patients undergoing hip and knee replacement surgery in the NHS. The researchers looked at outcomes for over 270,000 hip and knee replacement patients between 2010 and 2013, and found that hospitals reporting largest reductions in readmissions also showed greatest improvements in PROMs.

The estimated associations between readmission rates and PROMs were only modest, indicating that each metric may measure different aspects of quality within a health care system. More importantly, the findings provide evidence that policy makers cannot rely on improving patients’ self-reported sense of wellbeing by focussing on the reduction of readmissions alone. (Yet more needs to be done to make clinically significant improvements that can be felt by the patients.)

While these findings specifically relate to hip and knee replacements, the study is an example of how researchers could use information that is collected along the patient pathway. More needs to be done to use the large amount of clinical and organisational information that is collected across NHS organisations – too often this potential remains untapped and valuable health system insights stay in the dark.

Establishing relationships between the different factors affecting quality along the patient pathway will not only inform decision-making processes in targeting interventions. Most importantly, it will also help to sustain the high level of quality of care provided to patients in the NHS for the future.

Rocco Friebel (@r_friebel) is a Data Analyst for the Health Foundation