Why is it so hard to measure quality in community services?

Report author Nora Cooke O'Dowd describes the challenges of measuring the quality of community-based health services.

Blog post

Published: 29/11/2017

Our Community Services briefing raises a number of issues about the complexity of measuring the quality of community health services at a national level. While we set out to gain a comprehensive overview of care in this part of the health system, we struggled to illuminate more than a small corner of the whole picture. Here, we highlight some of the main challenges we encountered.

There’s no comprehensive list of community providers

The first hurdle we faced was that there is no comprehensive list of providers. Care is delivered predominantly by NHS trusts, but also by private providers and charities. Where community services are delivered alongside acute, mental health and/or learning disability services, it is difficult to disentangle those services from the rest of the care delivered by the hospital in a given dataset.

Community services encompass a broad range of care

So we don’t know how many providers are actually delivering community services and, in the ones which are delivering community services, we can’t easily separate out that care. To ensure that we were only looking at community services, we focused in on 18 standalone community trusts. We looked on their websites and in their board papers to see what sorts of services they deliver – it’s an impressively broad range. They deliver services across the life course from children, young people and family services (e.g. new-born screening, infant feeding support) to adult services (e.g. dentistry, mental health and physiotherapy), older adult services (e.g. falls prevention) and on to specialist services such as prison health. This was reflected in the make-up of the staff detailed in our briefing: community health nurses, allied health professionals and community health visitors make up the majority of those providing care.

Broadly, community service providers aim to improve local health and wellbeing, bring care closer to home, and allow people to live independently. In a world of multi-morbidity and increased life expectancy, community services are seen as a sort of panacea for keeping people out of the hospital in an NHS under serious financial strain, popping up in key national strategy documents such as the Five Year Forward View. Community services are also the right place to deliver preventive interventions from primary prevention of disease onset with immunisation services; through secondary prevention of catching health problems early with health visiting and school nursing; to tertiary prevention of controlling and alleviating the negative consequences of an established disease e.g. diabetes management clinics.

The appropriateness of the quality measures we currently have is questionable

What’s clear from the services delivered by community providers is that the care is much more about improving quality of life rather than immediately saving life. It’s therefore quite likely that a patient would have different expectations from these types of service. There are some generic quality measures, which we looked at in this briefing, that are universally applicable: would staff and service users recommend the trust as a place to receive care; is the care safe; are staff happy in their jobs and would they recommend their trust as a place to work?

The difference lies in the expected outcomes of the care people receive. For example, a person’s expectations about the outcome of surgical care received in hospital after acute myocardial infarction are probably quite different when compared to expectations about outcomes of getting help to manage a chronic disease at home. A good outcome for a person receiving care in the community may be that the support they receive enables them to go to Bingo on a Sunday. Nationally published statistics barely even try to capture this type of experiential quality measure.

It’s challenging to take a ‘DIY’ approach

It’s hoped that the new Community Services Data Set will start to collect data about some of this, but after years of delay with starting data collection, many seem sceptical. In the absence of this data set, service providers have been doing their best to collect data and benchmark themselves against their peers. However, there are frustrations that arise when trying to “do it yourself”. When a scheme is voluntary, data quality and consistency issues may arise and it can be difficult to maintain data collection on a regular basis.

Ignorance is not bliss

When we consider that there are roughly 90 million contacts per year with community services in the NHS – a number that looks set to increase with policies shifting care out of hospitals – we see how important it is to have a coherent national picture of the quality of that care. However, this briefing highlights that much more is needed to enable this. Regularly collected, nationally benchmarked and quality assured data that translate to meaningful quality metrics are imperative to understanding quality nationally, being able to monitor changes over time and look at regional disparities in care quality and ultimately to ensuring that people receive good care.