- Date published
- September 2006
- Pages
- 6
- Download publication [151kb PDF]
Overview
What impact are national clinical measurement schemes having on the NHS?
Our healthcare system cannot improve unless we know how patients are treated, and if that treatment has worked. However, the only way this can happen is if we keep measuring healthcare processes and outcomes. National clinical measurement has already proven its worth and needs to be at the heart of any system to improve healthcare quality.
This briefing provides an overview of The Health Foundation’s Engaging with Quality initiative, including an in-depth case study of a project looking at improving prescribing practice for mental health. It also considers emerging policy findings from the scheme.
Introduction
Our healthcare system cannot improve unless we know how patients are treated, and if that treatment has worked. However, the only way this can happen is if we keep measuring healthcare processes and outcomes. National clinical measurement has already proven its worth and needs to be at the heart of any system to improve healthcare quality. For example, five years ago national measurement of treatment for heart disease found that less than half of eligible patients arriving at a hospital received essential treatment within 30 minutes. This finding led to changes in how patients were treated, and 83 per cent of eligible patients now get this treatment in time.
Questions and answers
In measuring healthcare processes and outcomes, the right questions need to be asked regularly. They are:
- What proportion of patients are receiving care in line with current best practice?
- How does the healthcare service need to change to reflect best practice?
- Do healthcare professionals and managers have the skills and support to make the necessary changes?
To answer these questions, healthcare practice needs to be measured and compared against explicit standards. Such standards have been established in a large number of clinical areas and are set out, for example, in National Service Frameworks, in National Institute for Health and Clinical Excellence (NICE) clinical guidelines for England and by the Royal Colleges and specialist societies of the clinical professions.
As well as measuring outcomes, clinicians should be supported to enable them to make changes safely. In his latest annual report, Chief Medical Officer for England Professor Sir Liam Donaldson said that one of the reasons for different standards of care is that, although healthcare professionals know what best practice is, they do not always know how to improve their own practice.
Closing the gap
Through its £4.5 million Engaging with Quality Initiative, The Health Foundation is supporting clinicians across the UK in nine areas of secondary care to benchmark healthcare and close the gaps between current and best practice. Working through Royal Colleges and other professional organisations, the initiative is supporting eight multidisciplinary teams, including patients or their representatives. These teams have set up and run systems for measuring the quality of clinical care and are developing ways to support local services to make changes as a result.
The teams receive leadership training and shared online resources. Teams learn from each other, as well as from national and international experts.
Projects overview - part one
The Health Foundation’s Engaging with Quality Initiative supports clinical quality improvement projects in the following areas:
Improving the quality of care for patients who self harm
Around 50 per cent of people who attend an emergency department following an act of self harm are either not offered, or do not wait for, a psychosocial assessment. This leaves them more likely to self harm again. This project compares the provision of care in acute, general and mental health services with NICE standards. The results will be fed back to participating clinicians, organisations and local groups and will provide regional education and training to help them improve.
Lead organisation: Royal College of Psychiatrists
Partners: Intercollegiate Faculty of Accident and Emergency Medicine, Mind, Royal College of Nursing, Royal College of Psychiatrists Faculty of Liaison Psychiatry
Contact: Lucy Palmer, palmer@cru.rcpsych.ac.uk
Improving the care of adult patients undergoing elective surgery
Royal Colleges of Nursing and Anaesthetists (RCN and RCA) guidance says that patients can drink water up to two hours before elective surgery. However many are still 'nil by mouth' for many hours before surgery, which is uncomfortable for patient and may delay recovery. Evidence also shows that the effectiveness of guideline implementation strategies needs testing. This project has developed three quality measurement systems for fasting before and after elective surgery. These system will be tested in 10 per cent of acute hospitals in the UK. They include standard dissemination, a web based educational package championed by an opinion leader and a quality improvement approach.
Lead organisation: Royal College of Nursing.
Partners: Royal College of Anaesthetists, Virtual Institute for Research in Health Care Practice Peri-operative Fasting Guideline Development Group
Contact: Jo Rycroft-Malone, j.rycroft-malone@bangor.ac.uk
Improving the quality of prescribing for serious mental illness
People with mental health problems who take antipsychotic drugs for long periods can experience harmful side effects and even reduced life expectancy. Better monitoring and management of medication can help combat this. This project has developed an observatory to improve the prescribing of anti-psychotic medicines in relation to best practice. The results will be fed back to lead clinicians and local patient organisations. Regional collaboratives will be set up to enable staff teams and service users to learn from each other. See the case study on page 4 for more information.
Lead organisation: Royal College of Psychiatrists
Partners: British Association for Psychopharmacology, College of Mental Health Pharmacists and UK Psychiatric Pharmacists Group, Rethink, Royal College of Nursing, Royal Pharmaceutical Society of Great Britain.
Contact: Mary-Rose Cavanagh, mcavanagh@cru.rcpsych.ac.uk
Improving the assessment and management of perineal trauma
Torn tissue during childbirth can cause persistent pain, affecting women’s physical and psychological health. This is one of the most commonly reported postnatal problems but pain can be reduced by following best practice guidance on tissue repair. This project has set up a national survey of students, qualified midwives and education providers to review current practice and training provision in the repair of tissue trauma sustained during childbirth. Audits will also be developed and carried out in 20 maternity units and repeated at appropriate intervals. The outcomes of the surveys and audits will support the development of educational packages and training sessions.
Lead organisation: Royal College of Midwives
Partners: Royal College of Obstetricians and Gynaecologists, National Childbirth Trust, Thames Valley University, University of Keele Medical School, University Hospital of North Staffordshire NHS Trust
Contact: Sue Macdonald, sue.macdonald@rcm.org.uk
Projects overview - part two
Improving the quality and effectiveness of hospital care for people with chronic obstructive pulmonary disease
There is wide variation in mortality rates from chronic obstructive pulmonary disease, with small hospitals having mortality rates up to 60 per cent higher than large hospitals. This project uses the results from the Royal College of Physicians’ 2003 national audit and other information to compare the care of patients in acute hospitals with British Thoracic Society guidelines. Participating organisations will visit each other to compare ways of changing services to improve quality. A repeat national audit will be carried out following the visits.
Lead organisation: Royal College of Physicians
Partners: British Thoracic Society, British Lung Foundation
Contact: Rhona Buckingham, rhona.buckingham@rcplondon.ac.uk
Improving the quality of care and outcomes from treatment for cancer of the bowel
Mortality rates from bowel cancer are higher in the UK than in other developed countries. There are several established national standards for the management of bowel cancer which are not being met consistently, for instance on the accuracy of diagnosis using colonoscopy. This project is measuring six aspects of performance in the management of colorectal cancer and comparing actual practice to NICE guidelines. Online feedback and specific advice about how to secure improvement will be provided to participating teams. The audit results will also be shared with NHS trust chief executives, patients and the Healthcare Commission.
Lead organisation: Imperial College London, Association of Coloproctology of Great Britain and Ireland
Partners: Bowel Cancer Campaign
Contact: Paris Tekkis, p.tekkis@imperial.ac.uk
Assessing and improving the quality and management of care for patients with epilepsy and for those with communityacquired pneumonia
There are an estimated 1,000 deaths per year in the UK due to epilepsy, many of which could have been prevented by long term seizure control. For people with community-acquired pneumonia, meanwhile, inappropriate prescribing and incomplete case records have led to significant gaps in the quality of care. These are two web-based audits which compare current practice with Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the diagnosis and treatment of epilepsy in adults and SIGN and British Thoracic Society guidance on the management of community-acquired pneumonia. The epilepsy project focuses on a chronic condition in which clinical management is largely community and outpatient based and for which NHS Scotland is developing managed clinical networks. The community-acquired pneumonia audit is focusing on management of the disease in acute hospitals.
Lead organisation: Royal College of Physicians, Edinburgh
Partners: Royal College of Physicians and Surgeons of Glasgow, Epilepsy Scotland; Information Services, NHS Scotland
Contact: Stephen Leonard, s.leonard@rcpe.ac.uk
Assessing and improving the quality of services for patients with inflammatory bowel disease
The management of inflammatory bowel disease is complex and there are many opportunities for errors, such as inappropriate steroid therapy, which can result in increased long term illness or even death. This project has set up the first national clinical audit of inflammatory bowel diseases, including the development of national standards with which to compare current practice. The results will be fed back to participating clinicians. Multi-disciplinary regional meetings will be held to help clinical teams improve.
Lead organisation: Royal College of Physicians
Partners: British Society of Gastroenterology, Inflammatory Bowel Disease section, Association of Coloproctology of Great Britain and Ireland, National Association for Colitis and Crohn’s Disease
Contact: Calvin Down, calvin.down@rcplondon.ac.uk
Case study: Improving mental health prescribing
The Prescribing Observatory for Mental Health
Royal College of Psychiatrists
One in four people in the UK will experience a mental health problem at some point in their lives and each year more than 250,000 people are admitted to psychiatric hospitals.
Many people receiving care from specialist mental health services are prescribed one or more psychotropic drugs. There is good evidence for the effectiveness of these drugs and a body of authoritative guidance about their use. However, prescribing practice varies greatly and frequently departs from best practice.
If patients are not prescribed medication in line with best practice, they may not obtain the full benefits of the medication, may be less likely to follow the correct course of medication, experience more avoidable side effects and their condition may be more difficult for a doctor to assess. In extreme cases, this situation can lead to more cases of severe, long term illness and even death.
The Prescribing Observatory for Mental Health (POMH-UK) was set up in March 2005 to help mental health services monitor and improve their prescribing of psychotropic medicines in relation to known best practice, such as Healthcare Commission Standards for Better Health and National Institute for Health and Clinical Excellence (NICE) guidance.
Getting involved
So far, 40 mental health trusts across the UK have been recruited to take part in the programme. Its first two projects included audits and quality improvement interventions to reduce the prescribing of high-dose and combination anti-psychotic medicines and increase the screening for metabolic side-effects of anti-psychotic medicines across the UK. Data collection was web-based, allowing participants to input data online and to compare their practice against other trusts.
Mary Cavanagh is leading the project team based at the Royal College of Psychiatrists. “The Health Foundation award has given us a great opportunity,” she says. “The funding has enabled us to establish this new programme from scratch, including the vital infrastructure.”
Dr Andrew Blewett, a consultant psychiatrist in mental health at the Devon Partnership Trust, also works on the project. He says that variations in prescribing can be hard to see locally because most mental health trusts have only one pharmacist who may be under resourced to audit prescribing patterns. He adds that the project shows the potential for pharmacists to really get involved in quality improvement in mental health trusts.
The patient perspective
Patients have a key role to play in the programme: most participating trusts have recruited at least two service users to their project teams. Mo Hutchison is a service user consultant on the central project team based at the Royal College of Psychiatrists. Her role is both to ensure that the patient perspective is taken into account by the team and to liaise with other users. “It’s important for service users to be involved because they have a unique perspective, they’re on the receiving end of medication,” she says.
“In the ideal world, more care would be taken in the prescribing of mental health drugs,” she continues. “I don’t think psychiatrists take all the factors involved into account when they prescribe, or take account of the impact that medication has on people lives.”
Mo highlights the work the team is doing to make sure that patients’ physical health needs are taken into account. Some anti-psychotic medications can have adverse side effects such as stiffness. “We’re hoping to produce a small appointments card that encourages people to look after their physical health and go for checks,” she says.
Practice makes perfect
The next stage in the project is to draw out lessons for quality improvement from the data collected. At regional workshops, clinicians from participating mental health services will compare data from different wards and services, such as those in the table below. They will look at the differences between those that are and are not meeting best practice guidelines and use this information to draw lessons for improving performance, which they will then take back to their trusts and implement.
Other innovative methods the team has introduced include mechanisms for involving health professionals in the project. These include training events for pharmacists and clinicians, a slide set with speaker notes for local champions to present the audit results and posters and sticker alerts for patient case notes.
| Key learning | See also |
| |
| External sites | |
Emerging policy findings
Although in its early stages, the Engaging with Quality Initiative has already highlighted important policy issues about how to support healthcare professionals to improve quality through clinical measurement. The Health Foundation believes that we need:
1. More resources for clinical measurement
Clinicians, patients, GPs and regulators all have a need for clinical quality measurement. The overwhelming response to our Engaging with Quality Initiative demonstrates clinicians’ desire to measure clinical outcomes and compare them with best practice, in order to improve their own performance. Patients also want information about service quality, so they can make informed choices about where to go to meet their healthcare needs, and GPs need this information to advise patients accordingly. Regulators need the same types of information to assess healthcare organisations’ performance. Further down the line, healthcare professionals’ participation in national measurement schemes could feed into professional education and training. However, this cannot be done while the resources available to develop new areas of clinical measurement remain inadequate.
2. Greater participation in national schemes
We need more people to take part in nationally accredited clinical measurement schemes. At the national level, such schemes allow informed decisions to be made about where to focus resources for improvement. For organisations, participation provides essential information about their own services, allowing them to make any necessary changes. Individual healthcare professionals can only judge their own performance if they can compare themselves to their peers. However, it can be difficult to get clinicians in local hospitals to submit data to national measurement schemes. In some projects, participation rates are as low as 20 per cent. The reasons for this may include competing national priorities, such as balancing budgets or reducing waiting times, or concerns about being blamed for poor performance. National measurement schemes should be able to deal with such concerns and be of sufficient value that clinicians and organisations prioritise them.
3. More support for implementing change
Measurement is an essential building block for determining how healthcare can be improved, as it highlights discrepancies and variations. However, it is only when action is taken on the reported results that gaps in quality are addressed. In practice, this is not always straightforward. Our projects have found that the complexity of the healthcare system means that measurement is not always followed by action and that where it is, healthcare teams struggle to implement change. So more support is needed for the development of improvement methodology and leadership skills in healthcare teams.
4. A sustainable system for the future
There are a number of organisations funding national clinical quality measurement, including the Healthcare Commission, Royal Colleges and the charity sector. Some funding, such as from the charity sector, tends to be short term. The Health Foundation understands that the Healthcare Commission’s support for this important area has significantly declined over the last two years, and that there are virtually no funds for development in new areas. More sustainable funding mechanisms for nationally accredited measurement schemes need to be developed. Funding models such as those developed in mental health, where national clinical quality measurement systems are funded by subscription, could be adopted by acute and general services. Despite other budgetary pressures, this activity needs to be prioritised by boards.
Next steps
Building on the early success of this initiative, The Health Foundation now plans to make a further substantial investment through the Engaging with Quality in Primary Care scheme. This will fund projects that engage primary care clinicians in the quality improvement process and, by so doing, aims to increase the capacity for improvements in clinical quality in primary care throughout the UK.
