Quality across the service divide

Dr Martin Bardsley considers whether we can afford quality in a period of financial constraint.

Blog post

Published: 05/03/2014

Just one year after the last Francis – yet it seems a lot has happened in the year. Recent analysis by the Nuffield Trust indicates though ‘quality’ has been ‘on the agenda’ it also coincides with real concerns about what impact financial constraints might have on quality – can we afford it?

The QualityWatch programme was set up to help us understand what is happening to quality during the periods of financial constraint. Much of our information is sourced from performance measures used within a service – and a lot of effort is going in to looking at what’s happening to quality within organisations.

But we also need to look across services too. I think there are two areas where this is especially important.

The first is a key focus for many models of integration around the obvious pressures on A&E and urgent and emergency care. Though performance is still better than it was ten years ago – when you look across the measures you see worrying signs of cracks.

These appear as crowded A&Es with long waiting times, the trend of slightly slower emergency ambulance response times and the continued rise in emergency admissions – especially for some key groups like the frail elderly.

Moreover this latter group are also vulnerable in the face of significant and ‘unprecedented’ reductions in social care spending. As we, and many others, have observed these changes are unlikely to be due to a single factor – whether A&E staffing or GPs – but more about the broader systems of care and our ability to prevent health crises and the alternatives to hospital and A&E visits when things are going wrong.

The second area has received less attention of late and is around the public health indicators and in particular the ones linked with prevention. These basic measures of population health are generally a reflection of much more than NHS care but can be slow to change.

However there are some markers that are more sensitive and need to be watched, these include indicators around health related behaviours (teenage conceptions) or those linked with the supporting processes around health screening and promotion.

There is also the question of health inequalities – which have stubbornly persisted whilst our general health improves. As money gets tighter its vital that we watch carefully to ensure that economies do not adversely affect the quality of services and the well being of disadvantaged subgroups of the population.

Both these issues suggest the need to collate information, sometimes from providers, at a population level. Where once information like this was analysed by primary care trusts – it now resides between three new organisational types – clinical commissioning groups, commissioning support units, health and wellbeing boards and Public Health England.

However these are challenging times – especially for those charged with developing this local perspective and its important that these are supported in taking these population based views. This means making data accessible across a locality, and having the capability and tools to combine information from providers and primary and community care services serving the same population.

One example is in being able to access anonymised records, that link care episodes for a defined population capture the critical events in terms of people's health, well being and service use (as for example in the type of information that can be gleaned from initiatives such as care.data). So for example we need to know not just how well people recover from a hip fracture – but how well local preventive strategies are reducing the prevalence of hip fracture in the first place.

So yes we do have to improve the way we look at quality within organisations – and yes we do have to fill in the holes in our data sets – but we also need to invest in the understanding information that spans services. This perspective is going to be essential if the fledgling models of integrated care are to be successful – and for health and local authorities to commission better quality outcomes for the whole community.

This article was cross-posted on the Guardian Healthcare Professionals Network website.