Response to British Medical Association health policy consultation

Introduction

1.1. The Health Foundation is an independent charitable foundation working to improve the quality of healthcare across the UK. Our endowment enables us to spend at least £20 million each year to make UK healthcare the best it can be. Our programmes include leadership development, demonstration projects in healthcare organisations involving clinicians, managers and patients, commissioned research, and evaluation studies.

1.2. We welcome the opportunity to respond to the British Medical Association’s discussion paper outlining its approach to health reform. Given our expertise to date, our response focuses on clinical engagement and the following recommendations:

• Recommendation 8 – Greater autonomy is needed for health professionals and managers to shape local services. This must include mechanisms to enable professionals to work together across boundaries so as to achieve coordinated development and effective delivery of services
• Recommendation 9 - National clinical standards for quality must underpin local management and provision of services.
• Recommendation 12 - The provision of high quality undergraduate and post graduate medical education across all healthcare sectors should be a central part of mature commissioning and the provision of services.
• Recommendation 23 – There is an urgent priority to develop effective clinical information systems. As part of supporting clinical networks, mangers should ensure that health professionals have the information they require to assess the services they commission and provide this information should be relevant to the breadth and scope of clinical networks.
• Recommendation 24 – Clinical governance needs to be renewed and refocused so that it spans the pathway of care and generates high-quality information that enables clinicians and management to assess and amend practice.

2. Recommendation 8 and 12: More autonomy for health professionals and managers and high quality undergraduate and post graduate medical education

2.1. We agree with the BMA that staff locally should be given the freedom to decide how to deliver improvements to health care services. However, research funded by The Health Foundation has found that clinicians do not always have the skills and experience they need to take forward quality improvement work. Clinicians have reported barriers to involvement in quality improvement such as not having access to the support they need to make change happen and lack of expertise or advice. Problems within organisations can also make change difficult to achieve1. This research is backed by our experience of supporting clinicians to undertake quality improvement work. We have found that many healthcare managers and health professionals have inadequate skills and training in how to improve quality and safety and require support on how to improve. For example, often hospitals do not have people with skills to measure key aspects of care or people do not have skills in systems thinking, leadership and implementation.

2.2. When clinicians and managers do have these skills we have seen significant improvements in healthcare quality, including improvements in safety, reorganisation of services to better reflect patients’ needs and more appropriate commissioning. But, at present there is no apparent national infrastructure for supporting providers to develop quality improvement skills. This is clearly a gap which the BMA’s proposals could seek to address.

2.3. To achieve sustainable improvements in the NHS, clinical leaders for the future need to be developed. Clearly, high quality education and training is central to this and we agree with the BMA that these should be activities which are valued across the health system. However, we think that consideration should also be given to how clinical leaders are developed and how clinicians will develop skills in quality improvement. NHS Tayside, one of the hospitals involved in our Safer Patients Initiative at NHS Tayside has successfully done this by including safety and improvement skills in undergraduate doctors training. Such initiatives should be replicated.

2.4. We also think that the BMA should support the Government’s plans for the regulation of healthcare professionals, set out in the White Paper, Trust Assurance and Safety - The Regulation of Health Professionals in the 21st Century. This contains important developments that support quality improvement. For example, the proposals to require healthcare professionals to revalidate their license to practice during their careers and for re-accreditation of specialists will help to ensure that professionals stay up to date with best practice. Using revalidation as a vehicle for quality improvement would help prevent it becoming a burdensome bureaucratic exercise.

3. Recommendation 9 - National clinical standards for quality must underpin local management and provision of services

3.1. We agree with the BMA that national standards for quality and safety are set at a national level. These are required to ensure equity of provision and access across the country. They should also assure patients and the public that clinicians follow national best practice in treating and caring for patients.

3.2. In our view, the role of the regulator should be assess whether healthcare providers have systems in place to monitor and act on key patient safety and quality indicators such as standardised mortality rates. Local healthcare providers would not be told how to achieve these standards, but be supported by access to tools and people who can help them improve. This would make nationally set standards meaningful and effective for improving quality.

3.3. In addition, we think that clinical and patient reported outcome information by condition, risk-adjusted where appropriate should be published at national and local levels. This will provide an overview of healthcare quality and value nationally and enable international comparisons. This information is also essential for commissioners locally. The Department of Health is beginning to pursue this and in some surgical treatments this data is already available. We think it is crucial that relevant measures of clinical and 1 Healthcare professionals’ views on clinician engagement in quality improvement, Huw Davies, Alison Powell and Rosemary Rushmer, The Health Foundation, April 2007. patient reported outcomes are developed for medicine and long term conditions. These measures need to cross health and social care boundaries and be available to both social care and healthcare commissioners.

4. Recommendations 23 and 24 - There is an urgent priority to develop effective clinical information systems and to reinvigorate clinical governance.

4.1. We strongly support recommendation 23 and 24. Better information about the care patients receive and the outcomes of that care is critical at a number of levels:

• Nationally: Clinical outcome information is needed to provide an overview on healthcare quality, including issues relating to equity. It also allows for international comparisons. Data needs to be available by condition and risk adjusted where possible.
• Commissioners: Commissioners already use activity profiling, conversion rates and data on lengths of stay to manage demand and financial pressures with providers. This should be matched with clinical outcome information about healthcare providers to support improvement and assess and manage provider quality.
• Providers: Clinical outcome information is essential so clinicians and managers can take responsibility for their own services, make any necessary changes to improve them and for Boards to exercise their responsibilities.
• Professional responsibility: Healthcare professionals need clinical outcome information so they can assess and improve their team’s and their own performance compared to peers and national best practice. Where outcome measures concern the actions of a single healthcare professional, they are also relevant to professional regulation and revalidation.
• Patient decision-making: Patients and the public have a right to know about service quality. This information can help them make informed choices about where to go to meet their healthcare needs.

4.2. In our view, the aim should be to establish and maintain national systems for measuring clinical and patient reported outcomes for all treatments. Patient reported outcomes are already available for some surgical treatments. More work needs to be done in many areas of medicine and long term conditions. However, the experience of our ‘engaging clinicians’ programme demonstrates that healthcare professionals and patients have considerable interest in developing and using measures of clinical and patient reported outcomes for improvement.

4.3. We are pleased that the Department of Health is examining how to reinvigorate clinical audit and is increasing the funding available for audit. This is a step in the right direction, but we are keen to ensure that sustainable funding mechanisms are developed for nationally-accredited clinical measurement schemes. Funding models, such as those developed in mental health, where national clinical quality measurement systems are funded by subscription, could be an option for acute and general services. These are under pressure in the current financial climate but if national standards require organisations to report on clinical outcomes this essential activity would be funded.

4.4. In addition we are proposing that the national clinical governance infrastructure include a ‘library’ of accredited audits, for use locally, regionally and nationally. This would give clinicians easy access to accredited tools with which to carry out their own measurements. It would also avoid people reinventing audits or using ones that have not been quality assured, would enable comparison between results from different places and would help expose which areas of care need further work to develop robust measures.

4.5. Lastly, we think it is particularly important that it is particularly important that attention is given to the action part of the clinical audit cycle. There is little point in investing in very expensive national clinical measurement systems and clinical governance if this does not happen. Our experience shows that clinicians often lack the expertise about how to improve services when they have received the results of the audit. Access to support and training in quality improvement skills is essential so that sustainable change is achieved.

5. Conclusion

5.1. With these national components in place we think that substantial improvements in healthcare quality can be achieved. For example, through our Safer Patients Initiative we are supporting 24 hospitals across the UK to reduce avoidable harm to patients. This initiative has an overarching objective to reduce hospital mortality rates by 50%. It then provides the hospitals with support and training for staff to develop skills in quality improvement. Within this supportive framework, frontline staff are liberated to work on their own ideas about how to change practice. The four hospitals involved in the first phase have halved their adverse event rate in just two years.

5.2. We think that the British Medical Association’s proposed way forward for the NHS in England should incorporate a national infrastructure to support quality improvement which includes:

• Support for people working in the healthcare system to develop skills to improve healthcare quality so that the gaps between best practice and current practice can be closed.
• Clear national standards and best practice to ensure equity of provision and access across the country.
• Clinical outcome measures at the centre of the healthcare system so patients, commissioners, providers and professionals have information that identifies when patients are and are not receiving high quality care.

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