As a junior doctor back in 2005, I remember the sadness of caring for someone who had suffered a stroke: the irreversible, sudden and devastating impairments the patient had to cope with; the weeks of waiting in a hospital bed for adaptive equipment funding or nursing home availability; the frustrations of family meetings in the face of these delays.

For stroke patients, that picture is changing. Big advances have been made in stroke care. Decades of research have helped put in place best practice, including the miracle of emergency thrombolysis. There have been coordinated investment and policy interventions, new staff roles created, and a set of clear gold standards from NICE. The stroke audit is enabling improvement, and public awareness campaigns have also contributed. All of these advances mean that, today, family meetings with stroke patients feel more inspiring, collaborative and productive.

So from my perspective, the improvements noted in our report Quality of care in the English NHS: In the balance felt real, but also fragile because of the pressures the NHS is now facing. Demand for NHS care is increasing year on year, and outstripping the funding and human resources available, with a number of consequences.

At the front line, staff are stretched. Rota gaps are increasingly common, putting extra pressure on clinicians who are already struggling to meet the rising demand.

Many of those who choose to remain in the NHS are burning out – for example, more than a quarter of consultant physicians are planning to retire early. These pressures and staffing shortages are symptomatic not only of the funding squeeze, which has seen pay increases frozen at 1% a year for nine years, but also endemic levels of stress. The latest NHS staff survey reports that in 2016, the proportion of staff who reported feeling unwell due to work related stress is 37% – this is at its lowest level since 2012. Moreover, around 20% of NHS staff report bullying by other staff, and just under 30% report psychological distress caused by bullying. Within this environment, it is not surprising that the NHS is struggling to recruit and retain staff.

But the important question is: are these pressures having a detrimental effect on the quality of care patients receive?

In the balance draws together information from a range of sources including NHS waiting time targets, national clinical audits, patient surveys and international comparisons. So far as possible, we looked at trends over the last five to 10 years.

For access to key services such as treatment in A&E (see chart below) and consultant referrals, we broadly found a levelling off in 2013/14, but deterioration in recent years. Though the absolute number of patients treated within the target time is rising, the numbers who are not seen within the target time are rising too. This means that, on record, performance is worse than ever before.

A&E waiting times in England from 2003/04 to 2016/17

For many other quality indicators, like care processes and outcomes for diabetes and colon cancer, we found impressive levels of improvement until 2010, then a levelling off in 2013 to 2015. For some indicators, such as heart attack, there was a slight down turn in in 2014/15 – but it’s impossible to say whether this is a normal year-on-year variation, or a true down turn until we have more data.

So the quality indicators look like they are holding up at present, despite the pressures. However, these data on quality indicators are generally two years behind the access data. So if quality follows the trajectory of access, they are at serious risk of worsening. It would be surprising if the current strain on the NHS was not reflected in future data on other quality indicators.

Staff are still motivated. We want to provide world class care. However we need the skills, time and headspace to not only maintain the quality of care, but improve it. The reasons for maintaining and improving quality are clear and the desire for it universal, but how to make time for it can seem less clear for busy clinicians. I can recall many occasions where brilliant leaders have tried to squeeze out some innovation from their already stretched diaries.

Similarly, junior doctors are dedicated, enthusiastic and talented, but as itinerants, it is difficult to tap in to their potential. They don’t have offices, computers, or even lockers. They don’t belong to any one organization: they rotate every few months. Every ward and every team do things slightly differently. (Making improvements when each resus trolley is laid out differently is a challenge, but it is possible.)

Local dedication needs to be supported by a national, coordinated approach to build capacity, and measure how we are doing to learn and improve. To ensure improvement is not lost when clinicians move on, we need to have  meaningful patient and clinician engagement. This approach should be evidence-based and pragmatic; coupled with funding, real-time measurement and feedback to let us know how we are doing.

Measures like this, alongside the untiring dedication of the staff, will ensure we can continue to deliver the best quality of care.

Dr Aoife Molloy is a Policy Associate in the Data Analytics team at the Health Foundation

The full version of this blog was originally published in the Clinical Services Journal.

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