National Quality Improvement Working Group
Third Meeting
26th February 2008



Sir Liam Donaldson introduced the meeting.  The group would be looking at proposals and work that the review has looked at so far.  They would look in more detail at the work of the international commissions, and report back on the visits to the high performing facilities around the country.


Sir Liam set out the aims of strands of work set out in more detail.  The main purpose of the work is to try and mainstream quality and safety throughout the NHS, ensuring it's there in the refining and design of services, and to look at the management of services and how they are assessed and how they are funded.


There was acknowledgement that there are a number of services around the world that we are aware of that have demonstrated systematic quality improvement and the review has drawn on those in the analysis by the international commission.


The quality working group has engaged in assessing various work, including Didier Pittet in Switzerland who has implemented his programmes in a very systematic way.  In the UK, James Cook University Hospital, a Cardiac Service in Middlesborough, they have over time in a very deprived area of the country developed an excellent cardiac service that is now rolling out angioplasty to the catchment area of that hospital, giving bronchiatic therapy to people with disease, approaching all of these services, Sir Liam's team went out and it wasn't a formal piece of research, but an in-depth discussion.


Visits to St Thomas's Stroke Service, and a service in a semi rural part of Dorset, which has a superb integration with the local population and has lots of very good initiatives including lists of volunteers who help the practice with prescriptions for elderly patients, who ferry people to hospital and willingly step forward to help the practice with any new developments.  The Bristol Children's Cancer Service outcome findings are comparable to Seattle which are the best in the world.


There was a visit to a mental health outreach team characterised by involvement in the planning and running of services. 


There were stakeholder engagement events in London and Somerset, with NHS staff to get their reaction and feedback.  This was a trigger to some of the issues we wished to discuss in the Stakeholder event.  Two videos were shown to the meeting:


The reason for the success in stroke services is we are able to provide responsive care right from the very start with acute care and through the patient journey into the community.  It's very important that you have a pathway of care that is joined up.  We are trusted to do the things that are right, this is important.  The team of nurses, therapists and doctors developed quality improvement over time.  Leadership is key, having people in units who can bring along everybody else.  They look at data and are critical in assessing the service, and frank about quality and the people they are working with in a constructive way, creating an environment without a blame culture. 


Mother who is involved as a patient representative from the Children's Cancer Service in Bristol, Trust invited her to be involved.  She believes we shouldn't be scared of the patient input.  The patient perspective can be quite different from the medical perspective.


The Rt Hon Dawn Primarolo joined the meeting at this point.


There were two key messages that had evolved from the visits and engagement events:

-        The need to try an replicate high performing clinical teams across the whole NHS and

-        Genuinely involving patients in the planning, design and delivery of services


At the stakeholder event someone used a phrase "islands of excellence in a sea of mediocrity" and one of the nurses stood up at the meeting at Bridgwater and said "there are islands of excellence but there aren't any bridges or ferries to help people across"


Two key characteristics of high quality clinicians had emerged


-        Ownership of the management agenda clinically


Business managers are not saying these are the things you have to deliver, waiting times are too long, length of stay is too long, not seeing enough patients on each operating list and we want you to put more patients through.  They are not having those sorts of discussions, they themselves understand the goals and performance of the Trusts and their own in particular, and they are managing that challenge themselves and more than that, when they communicate they are communicating the benefits in clinical terms, so if we are shortening the length of stay then we are shortening it because we are improving the clinical outcomes for our patients.  It's very, very striking.


The second striking characteristic


-        The extent to which data are used in terms of performance


There was a genuine curiosity to see how well they were performing, and data was being used in what is being described as a scientific way, so rather than using the routinely available data that we have, they were enhancing the data with specially collected data to throw light on how their services were performing, and in all the services when you walked around, there were wall charts with trends and comparisons, and clearly the data were being used not just to assure quality but to look for opportunities for quality improvement.

Some of the other points were very relevant; there was stability and continuity of senior staff. The jobs that people were doing on the units were interesting jobs they weren't putting their nose down and seeing patients, some of the nurses were attending conference to show how they were delivering their service and achieving change, roles were being extended, leadership responsibilities were being divided out. 


So it was a place with people with a very positive culture, this was common to all the units.  There appeared to be more of equilibrium in workload terms compared to other services areas that do not perform so well.  The workloads were not overwhelming in absolute terms, the workloads were very high but teams had found a way of managing them.  Teams that are not performing well have been characterised by being totally swamped and overwhelmed with workload, and they can't think about the quality of their service because they are too busy shifting the patients.


One of the proposals for change will be to try and put in place mechanisms to spread this pattern of working amongst clinical teams and not doing it by the modernisation agency spreading good practice route, which would take 15-20 years, but to try to build in some much more concrete mechanisms to attempt to make this the norm of clinical working rather than something is just a centre of good practice that we highlight and hope that everybody takes account of.


Where doctors are creating microcosms, they can help in the design of solutions to deal with very high levels of work, and that is the clue, that is the system that does the hard work for you in the management process, and spending much less time dealing with the consequences of badly designed services.  The paradox here is that many people are doing more work but feeling less stressed, the skills and time to design the system seems to be really important.  So it's worth stopping the clock and looking back and doing a redesign.  The design of the system the use of feedback and curiosity, give people the skills to actually do that and give them the time and the space.


The definition of teams and how you define teams is vitally important, how teams inter-relate and particularly in terms of primary and secondary care. There does seem to be very good inter-relations in diabetes care.  Joined up thinking is needed particularly in the care of the elderly.  Working in silos in your own team prevents you from working with other teams, which is crucial if you are going to have joined up patient care.


In attempting to replicate excellence around the country there is clearly a managerial element that needs to be considered to put the infrastructure in place, but there is also a clinical drive as well. 


We've always had a small number of champions and they will work to whatever system there is.  What we want to get is the much more average clinician seeing that they can take ownership of this, and a lot of this is that we need to develop them.  In the leadership programme that's being run for endoscope services it's not just focused on the clinician, it's the lead clinician, the lead nurse and the lead manager jointly going on the leadership development programme.  The managerial imperative called 18 weeks has had some influence on developing the service. However the clinicians wanted to deliver colorectal screening, but we said no you can't do that until you achieve a certain level of quality, and because they wanted to achieve that cancer screening, they wanted to participate and they have really revolutionised the service, this is a service where we have started to join up the islands around the country.


Derek - just an observation from someone who doesn't work in the medical profession, there is a big gulf between what's the best and what's the worst. A fortnight ago I visited a Stroke Unit in St Thomas' that I was very impressed with, five days later I received a phone call that broke my heart from a lady who wanted to know what our Charity could do to help an old lady she lived next door to who had been taken into a hospital, she didn't know whether she had had a stroke or a heart attack, the doctor his attitude in broad terms stank, what he said was he wasn't going to give this lady food or water, he wasn't even going to put a saline drip in. He would put her on a morphine drip because it was her time to die. Now there's a big gulf between what's the best and what's the worst, and what you've got to do in to try and bring them both together, because you do have to work as a team in the NHS, one unit, it's a national institution. And bringing that team together to improve the standard is going to be difficult, but that attitude of that doctor does not help the image that the NHS gets.


We need to monitor the attitudes of doctors; there are doctors that need a bit more pressure and correction.  There are pioneers that can work with other hospitals.


Most people picture revalidation and regulation as judgments about individual doctors treating individual patients, by the decisions they make, and that the data is aggregated to look at their outcomes of care.  If we consider the position of the Head of an Intensive Care Unit, they are not the Medical Director, they are not the Clinical Director, they probably haven't even got a formal management title, but people wouldn't think of them as a manager.  They may treat some patients individually themselves, maybe not a huge number but their role is to ensure that the practices and running an intensive care unit are such that they give the patients chances of maximum survival and reduce the avoidable risks of healthcare, so do we ignore that whenever we look at them for purposes of how well they are practising? Do we ignore them because they are not a clinical manager or it's difficult to sort out which patients they are treating individually or collectively?


Doctors in such situations have a collective responsibility to groups of patients, as well as to the individual patients that they treat, so if we read that across to the discussion we are now having about why some services are not focused on life and death matters and others are, I mean collectively not just the treatment of individual patients, you start to see it as a professional responsibility, and obviously there are situations where the infrastructure isn't there, people can't help not being not being able to do that, but perhaps there ought to be more of an emphasis on a collective responsibility for patients coming through a service, not just the individual patients and an individual doctor. 


Michael Mead from the HCA, he came on some of our visits and he said exactly the same thing, in HCA in North America if they've got an excellent cancer service performing, they use the lead clinician from that cancer service to mentor other cancer services in those groups.  He also said, having experience of worldwide medicine that he considered the quality of clinical leadership in those groups was amongst the best that he had seen anywhere else in the world, not just in this country, so we have got it in the NHS it's the bottling and putting in crates and the lorries to drive it around the country that we haven't got.


If you asked the patients on the stoke unit, you would find that they are not actually interested in the performance of individual doctors; they are interested in the performance of that unit.  We need to define what it is that makes a good doctor; working together and taking ownership of the problems is a really big part of that.


How do we inspire clinicians with the language we use to get clinicians to aspire in being involved in achieving goals and objectives?


From some of the observations we've seen it seems that sometimes people don't realise just how good they really are, there is humility about the really excellent clinicians.  The mediocre doctors are the ones who have the arrogance.


Derek - it's a natural thing in human performance for a person to be arrogant because, forgive me for saying this, but the higher the intelligence the more arrogance the person has, the very vulnerable person can be very intelligent, something I have come across in the past, my own father has a high IQ yet he is a very arrogant man, my stepfather was a very ordinary man but was very kind and gentle with other people.  Human performance demonstrates the attitude of people in the way they work.


Can we stop people behaving like this, and the answer is yes, in some areas people will say they know better than what the evidence suggests, there are some personalities like this.  We must be the only industry in the world where we spend millions on research and developing policy and then say whether we apply it is down to you.


There has been a lack of trust amongst doctors, which what the actual motives are for some of the data we are being presented with.


Derek - when I said arrogance before I got quite a few looks, but I'll put it in another word, it's very simple it's called pride.  I asked this question to some colleagues at work, the difference between arrogance and pride, and they said pride can mean an excessively high opinion of one's ability, being self focused with pride tends to blind us to the value of what others can offer and provide, hindering teamwork.  People foolish with pride think their competence is being called into question when they are corrected about their expectations.  This is a human fallibility not competence.  It's about how you change that attitidue.


What would be that attitude and reaction of clinicians if we were to get someone to come and offer to mentor them?  In other aspects of life if someone offered you the best to help you, you'd go for it, wouldn't you?


To be able to trust the data used in performance management, you make the collection of the data completely divorced from any of the players involved, whether they be government, clinicians or anybody else, and the model of ONS demonstrates no-one can doubt the authenticity of the data, everyone becomes a customer, but you can no long argue that you don't accept that, its not one profession against another where you can have that argument, you need to get rid of the argument about its authenticity and validity.


International Commission Findings


The commission were asked to particularly look at our approach to standard setting in the NHS, and the comments they made were:

-        A plethora of standards

-        No clarity on which standards should be in use day to day

-        No clarity on what was mandatory and what was optional

-        Problems with definitions and taxonomy, different terms being used in standards, guidelines, pathways, no clarity on what those different terms meant

-        A debate about degrees of independence, with some standards set predominantly by the Department of Health, although delegated a bit, some set by independent bodies like NICE seen as working with standards set by the DoH, and then the Royal Colleges working independently


So an argument about whether we should rationalise our standards, and whether we should get more clarity and taxonomy, whether we should get more clarity on which ones had to be followed or whether, greater clarity on whether they were optional, clarity on local versus national, and independent versus in-house.


The IHI report concentrated on ways in which we could achieve improvement, so they made this point that we have already come to in this discussion about excellence in a sea of mediocrity.  And talked about some of the barriers to improvement, again some of which we have touched on already, on patients and families not being sufficiently involved.  The overarching definition of quality goals. 


All three commissions talked about the tensions in the system at the moment, and that was reflected in their discussions with NHS staff, the phrase culture of fear was used a lot.  There was talk about rifts between clinicians and managers.  The point made that a lot of clinicians in the NHS were very passionate about quality, the technical skills necessary for quality improvement, the understanding and use of data - those tools were not widespread, people might be motivated on how to improve quality but they actually didn't know how to do it, and if you put somebody in the position where they are motivated but they haven't got the tools they'll get bored and they'll forget about it, so that point was made very strongly by the IHI.


Their actual recommendations are quite broad based, they're about achieving clinical leadership, dual change, enhancing the skills, getting clearer accountability for quality, so fall slightly short of very concrete mechanisms for change, but are very useful.


The Joint Commission come from a different culture, in that there isn't a national health system in the United States, there are no centrally set statutory standards, and therefore they have developed their role over about 50 years, by essentially a voluntary method, encouraging organisation to be inspected and accredited by their standards.  The reality is that many healthcare organisations in the USA would do that, otherwise they can't advertise themselves to funders and patients as Joint Commission accredited.  We have a very different system and there is the need to be statutory and mandatory about some of these things. 


They have made the criticisms that standards development has been very top-down, so it has no ownership of the clinicians on the ground, they make the same point about a variety of standards, the lack of clarity between them, they point to an absence of an improvement imperative, and what all three groups said was, there is a lot of hope placed in the commissioning process.  It can take over the whole of these problems and sort them out, and they make the point that doesn't square with the current state of commissioning that was played back to them, it's seen as a relatively immature system.


The skills of people doing the commissioning are very general; they haven't got access to specific specialist skills.  For example with the diabetic service, they don't know whether it's appropriate to draw clinicians in given that they are on the provider side of the fence. 


The video conferencing event with the USA, showed that they got the impression that commissioning was about screwing the system down, by getting the highest volume of work for the least money and there was much less concern about value and quality in the process, as it currently stands.  A feeling that commissioning is the great hope for the future but how long is it going to take to get there and what do we need to do to facilitate it.


The Joint Commission's main proposal is to set up an accreditation body, which would be separate from proposals for regulation in the Health Bill.


We need some high level quality improvement goals which can operate at all levels, there are no organisations around the world in health or anywhere else that don't have a clear statement about the quality and improvement that they are trying to achieve, it doesn't mean numerical targets but it means four or five statements.


Rather than having separate statements about heart disease, diabetes, why not use a statement that relates to the quality of care for patients with chronic diseases, for example that the aim was to

-        Detect chronic diseases early

-        Organise services so as to slow their progression, reduce the rate of complications and give people with disease the highest quality of life that they can achieve if they've got the disease.


When there was a high-level leadership meeting in the region, the managers could kick around that and say well how are we doing on this?


If a diabetic service was being discussed at a much more local level, you could say well have we got anything to show that we are doing these things, this allows us to look at the big picture performance but local performance as well.


A new approach to setting standards I think we have got to sort all of this out, then the point that we've spent quite a lot of time on in the meeting so far to get this high performing clinical team concept, and make it a duty that services would try and perform in that way, and what accountability mechanisms we need to get in there. 


We have patient safety initiatives that have saved lives and if it can be done in one area we need to look at why this can't be done elsewhere.


Then we have the introduction of regulation of health and social care services, and we need to understand how that helps all of the things that we are trying to do, by making quality and safety mainstream, so what do we mean by inspection, how do we look at licensing work, do we want to build in this concept of accreditation, and if so how does that fit in?


We are working on more detailed proposals to try and move some of those things forward, and we need to prepare a summary of where we have got to so far.


We need to look at the barriers to actually allowing this to happen.  There is a culture of fear and mistrust, there is the silo mentality, we need to look at quality for individual patients rather than groups of patients.  There needs to be knowledge sharing and information sharing.  People are prepared to be accountable for what they do for the individual patient.  We do need to look at the barriers otherwise we are not going to be able to do anything about it.


One of the criticisms to us was, the doctor patient accountability has moved on, there was a system of accountability.  We have never really thought about clinical accountability in those terms before.


The Bristol Report identified the challenge between the doctor perceiving his duty as being to a patient, as opposed to his duty to his patients, there is a self-delusion that my duty is only to the patient in front of me, but that isn't the case as you are making the other people wait, by making that decision.  So that means we have to think in terms of systems.


If you formalise that as a leadership role, people think about leadership and are willing to take on a bit of extra responsibility.


Derek - A leader is an individual who takes personal responsibility for their performance and that of their colleagues, and attempts to influence an improvement on the organisation that supports that improvement.  Accountability, its not about who, it's about what, it's not always about the individual when something has gone wrong, it's about what caused it that may be at fault.  On quality, forgive me Minister if I say this, but at St Thomas' one of the reasons they were so good on quality is that they had stability in that unit. This isn't just about the NHS, it's about the political scene as well, the NHS needs a political stability. Let them get on with what it wants to do, there has been too much interference in the past, and forgive me for saying it, but its true, we set this target, we set that target, we've had this we've had that, that's my interpretation from my side.  What we need to make a success is a system that's in place, it's good, robust and that is driven by the people from within the system.  That will improve quality.


There were four questions that have to be asked about standards

-        Where do they come from

-        What do they address

-        How is meeting them measured

-        And how do you build in the notion of improvement


There should be specific standards that might address pathways of care for a patient with disease.  Standards must be the product of conversations with clinicians and their patients, they must not emerge from the DoH, of course the DoH should be part of implementing the process, but if they are not recognised or if they are not understood, and the clinicians have to operate them, they are dead in the water from day one, and if they are informed by clinicians then you will build in that ambition and you will build in that sense of discipline, and they must also take account of patients, because patients are experts and they must be party to it, and if you can create that environment in which both the generic and the pathways from which they emerge then you'll ignite that ambition and build in the notion of improvement over time.


We should involve clinicians and patients, but we have to ask what is the role of the Royal Colleges?  The Royal Colleges need to work together rather than in silos on this.  I think there is no point in having a standard unless it can be measured.  If you take a holistic approach you will cut down the number of standards by 90%.  Take for example the NICE clinical guidelines, they are very good, but they absolutely cannot be measured, so we identify the 20 most important things in that guideline and we set out to measure those.


An example of some of the dilemmas that local services or local managers face, a Chief Officer in an SHA is told by one of their providers that they are intending to raise their standard on the NHSLA accreditation to CNST 3, and they've said they need another £100k, so the NHSLA have ratcheted up the standard, the Trust has said, well we had better meet this as its about safety, and as a manager in control of a budget for the local population, they are left in a position where they don't know how many patients are going to be helped by this ratcheting up of the standard, how many lives are going to be saved, and yet nobody can tell us. 


Which standards must be adopted, should be adopted.  How do managers know the cost benefits and investing in an upgrade of one area compared to another area.  We can start scratching the surface of that, but it is a practical problem.


Undoubtedly there are lots of players involved.  There must be an orchestrator of that process who is the body responsible, and everything else feeds into that.  Let's only measure what we can.


Derek Butler


MRSA Action UK

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