In the Chair:

Sir Liam Donaldson - Chief Medical Officer

In attendance:

Lord Ara Darzi - Parliamentary Under-Secretary of State to the House of Lords

Sir Bruce Keogh - NHS Medical Director

Peter Carter - President, Royal College of Nursing

Derek Butler - MRSA Action UK

Sir Ian Carruthers - Chief Executive, Southwest SHA

Ken Smart - British Airways

Michael Neeb - HCA

Professor Sabaratnam Arulkumaran - President, RCOG

Mike Richards - National Clinical Director, Cancer

Sir Ian Kennedy - Chair, the Healthcare Commission

Professor Herre Kingma - Medisch Spectrum Twente

Duncan Selbie - Chief Executive, Brighton Hospitals NHS Acute Trust

Professor Anthony Sheehan - Chief Executive, Leicestershire Partnership NHS Trust

Apologies:

The Rt Hon Dawn Primarolo MP, Minister of State for Public Health

Christine Beasely, Chief Nursing Officer

Jonathan Perlin, HCA

Karen Straughair, Chief Executive, Sunderland PCT

Aidan Halligan Chief Operating Officer, Elision Health

Also in attendance:

Pauline Philip - World Alliance for Patient Safety

Paul Macnaught - DH

Dr Claire Lemer - DH

Rachel Davies - St Mary's NHS Trust

James Ewing (note) - DH

Sir Liam welcomed everyone to the first meeting of the national Quality Improvement Working Group for the NHS Next Stage Review and invited Lord Darzi to introduce the scope of the whole Review.

Lord Darzi explained that many people he had spoken to had asked him why there was yet another Review of the NHS and that there had been so many of them in the recent past. There had been a major review of the NHS in 2000 that resulted in the NHS Plan which resulted in the biggest investment in the NHS since 1949.

Lord Darzi remarked that David Nicholson quotes that since the 1990s the NHS has grown by a third yet despite this quantitative increase the perspective of staff and users of the system is that we haven't achieved the aims of the plan.

The 2000 review was all about systems reform: how do you reform the NHS, make it more transparent and what are the business lessons. Yet we missed the key thing: quality of care.

The CMO has been banging on about quality and safety but staff on the shop floor have to think about payment by results and private finance initiatives not quality.

Now we need to concentrate on our product. The NHS needs to be reactive in nature and evidence based in practice. The question is: even with the National Institute for health and Clinical Effectiveness, is clinical effectiveness being implemented in everyday clinical practice?

Lord Darzi said that we needed to make the case for change. What is the outcome we want, how do we define it and how do we measure it? And once we have done that we must make sure resources are properly used.

That said where are we now? In cancer we have come a long way. 5-year mortality is much better but we are still behind the EU average. In Inequalities in London for stop you go east on the Jubilee line life expectance drops by a year for each stop. There is still variation in care - you can see from areas with less General Practitioners there are less good health outcomes and less good care.

Lord Darzi said that quality can also change quickly. If you look at stroke - care used to be about rehabilitation and now it is far more interventional. But few places are meeting best practice.

There is also the problem of defining quality from a patient perspective:

Lord Darzi showed an animation describing a patient's journey during the course of an illness. Firstly a patient goes to their GP and is then referred to a specialist at a hospital. The specialist refer them for a scan and so the patient gets another appointment to have the scan goes home and then comes back to the hospital to collect the scan and make another appointment with the specialist and go home again. Post surgery the patient ends up seeing their GP to sort it out, return home and then go to the hospital for the final appointment before receiving treatment on yet another visit and potentially having to make several visits to a pharmacist as well. Lord Darzi commented that if a supermarket did business this way they would quickly go out of business.

Services had to be fair, personalised, effective and safe.

Lord Darzi outlined the work of the in each of the Strategic Health Authorities on the eight clinical pathways looking at what care is being provided now, what the evidence base means and where it needs to go next.

Lord Darzi also outlined the national themes in addition to Quality Improvement including: innovation; leadership; primary care; workforce, education and training and the NHS Constitution.

Lord Darzi concluded by saying that the Quality Improvement Working Group was the most important group within the Review.

The CMO began with a presentation on the history of quality within the NHS beginning in 1949 where Quality was largely implicit with the professionalism of staff being expected to underpin the quality of care rather than explicit standards.

In 1998 the present Government published a White Paper with a companion document on Quality. There was to be a clear model with national standards and a framework for quality with a Chris Woodhead type figure ensuring quality. There would be in health standards, inspection and a local focus on standards and quality implementation. There was also to be a 'duty of quality' however this was never really operationalised.

From the late 1990s onwards we've had a series of organisations dedicated to quality: the Commission for Health Improvement becoming the Healthcare Commission which is now in turn to morph into the Care Quality Commission. Yet at the same time system reform measures focussing on efficiency and the tariff. And in Primary Care we have not quite yet got to the bottom of what the role of quality is.

The CMO explained that he had commissioned three organisations to report on international best practice in the four areas vital to quality: Standards, Data Collection, Inspection and Support. As well as this we will be doing our own investigation into excellence within the NHS which we will discuss in a little more detail later.

In discussion the following points were made:

Ian Carruthers said that so much as been done but we have not got to the top of the thought process. There are Trusts out there that can hit any target you can set and yet there seems to be little coordination between services. Targets will not achieve what we want - we need to shift into things that really matter.

Mike Richards said we need to identify what is important. Is it door to needle time? What is it that has worked. We need to pick out the successes and work out the whys.

Duncan Selbie said that he has an organisation that does some things well and other things badly because the system can act as a barrier. We do however not want to set any more targets.

Ken Smart said that he assumed each Trust had a business plan - should they not also have a safety plan? Had their been any cultural audits? BP has been doing audits in the wake of recent safety incidents. Audits were differing in different parts of the organisation and focus on the bad rather than the good.

Herre Kingma said that in the Netherlands the services was moving towards thinking about product. The National Health Service should move towards National Health delivery system. We need to identify the enablers and the barriers and then stimulate competition for Quality through awards of payments, budgets, grants and honours. Creating centres of excellence at every level. The outcomes are important - not process and structure. Its a focus on value not cost. Care coordination is the most important element - system of care should be a continuum from intensive care to the home. For technical barriers you improve the technology and professional responsibility. The objective is to send the patient home as soon as possible.

Ian Kennedy commented that in the NHS the patient seemed to bounce between services apparently randomly. What we need is a virtuous cycle of regulation. If clinicians don't own the standards they will be ignored. We need to design a system that makes sense.

WORK IN PROGRESS

Pauline Philip outlined work that was already in progress. Three international reports on best practice had commissioned to look at standards, inspection and the support mechanism in place to deliver quality services. RAND, the Joint Commission International and IHI respectively had been commissioned to undertake these reports.

Terms of reference for the international commissions

Commission to examine standard setting in clinical practice worldwide

In order to assess the quality of an organisation baseline standards are required.  Standards can be set internationally, nationally, regionally or locally.  How these translate and influence processes and outcomes of care is variable within the UK.  However, when present and functioning they permit both quality improvement driven internally within an organisation, and external assessment and benchmarking. The development of these standards is therefore of paramount importance.

In the UK, the programme of work carried out by NICE, Healthcare Commission and other bodies to develop guidelines is an example of successful collaborative standard setting. There is widespread clinical acceptance that these standards are rigorous and evidence based. However there is limited assessment against these standards to assess uptake and effect on the quality of healthcare provided. There is therefore considerable work to be done, even by this successful organisation. Furthermore the breadth of guideline development is limited, by time and resources and to date has focused more on secondary than primary care. 

The UK currently lacks a unified process for collecting routine clinical data to enable extensive national overview of performance in processes and outcomes of care.  Data collection is intrinsically linked to the application of appropriate standards.  RAND have experience in routine and clinical data collection, and have an extensive history of evaluation of healthcare programmes and are therefore well placed to undertake this commission.

To ensure that efforts by NICE, the Healthcare Commission and others are productive we invite the commissioned agency to provide a focused briefing paper identifying current international best practice and translatable lessons for standard setting in quality and data collection.

Terms of Reference:

1.                  To systematically review the scientific literature in the area of standard setting

2.                  To outline the current barriers facing UK healthcare organisations in receiving, translating, applying and implementing national standards, such as those developed by NICE, the Healthcare Commission and others. 

3.                  To carry out a further review of existing standard setting bodies in the UK and assess their relevance to UK healthcare organisations. 

4.                  To compare the UK's current model to other countries with models that facilitate more sophisticated standard setting and application to healthcare providers. 

5.                  To conceptualise how the UK could learn specific lessons from international best practice

6.                  To apply points 3-4 identify the barriers that would prevent the UK following an improved international model. 

7.                  To report on how the UK should communicate standards to each healthcare provider. 

8.                  To assess the current ability of healthcare organisations in the UK to collect routine clinical data on processes and outcomes of care. 

9.                  To assess how this data collection is collected, stored and communicated locally and nationally. 

10.             To report on international models of best practice that facilitate better data collection. 

11.             To apply how models of international best practice can be applied within the UK. 

Commission to examine inspection of quality in healthcare

Improving the quality of healthcare provided to patients in all settings necessitates assessment of standards. Various mechanisms have been adopted internationally, from accreditation to regulation. The review of the current regulatory system for Health and Social Care provides an opportunity in the UK to reassess how best to measure and inspect standards of quality in the twenty-first century.

By examining international models and identifying their strengths and weaknesses information can be gathered which will help to define this process and ensure that the UK has the most rigorous and effective mechanisms of quality assurance.

Terms of Reference:

1.                  To systematically review the scientific literature in the area of inspection of healthcare quality.

2.                  To review the current inspection available to UK healthcare organisations and the history of previous initiatives. 

3.                  Identify strengths and weaknesses of current UK model. 

4.                  Carry out an assessment of international best practice for inspection of standards.

5.                  Use the knowledge from the international review to suggest models for improvement. 

6.                  An exploration as to whether a model centred on accreditation, inspection, regulation or alternative approach would translate successfully in the UK.

Commission to support Quality Improvement in the UK

In the USA, the Institute for Healthcare Improvement has shown clearly the power of collaborative quality improvement to invigorate clinicians and produce real change. The UK has attempted to follow this model, first with the NHS Modernisation Agency and now with the National Institute for Improvement and Innovation. To date, whilst there are exceptional examples of quality improvement work, the concept has not yet taken off to the same extent as it has in the USA. A myriad of complex factors may be behind this. However without support for quality improvement, even the most evidence based standards and the most rigorous inspection will not produce change. The support needs to be accepted and embraced by clinicians to ensure maximal efficiency.

Underpinning this support must be attempts to ensure that clear lessons are learnt and disseminated, potentially through classical quasi-experimental study designs in addition to quality improvement methodologies.

Terms of Reference:

1.                  To systematically review the scientific literature in the area of supporting quality improvement in healthcare.

2.                  To review the current support available to UK healthcare organisations for quality improvement and the history of previous initiatives. 

3.                  Identify strengths and weaknesses of the current UK model. 

4.                  Carry out an assessment of international best practice for quality improvement.

5.                  Use the expert knowledge of quality improvement at Institute for Healthcare Improvement and from the international review to suggest models for improvement.

6.                  To report on how the UK could better communicate lessons of quality improvement to healthcare organisations.

UK Investigation into excellence

Claire Lemer outlined the six UK investigations that were being undertaken by a DH team into HCAIs, GP Access, Stroke Access, Acute myocardial infarction, Mental Health, Diabetes in Primary Care and Childhood Cancer.

The services being looked at had selected on the basis of a triangulation of information between talking to professional healthcare workers, patient groups and, where it existed, hard data. And while the services selected may not be the best services in the country we were reasonably sure that they were better than average.

The team is made up from a consultant, two specialist registrars and one of the DH clinical assistants.

In discussion the following points were raised:

Duncan Selbie said that there will always be some services who are ahead of the curve - the task is how do we make that curve move upwards across the piece.

The CMO commented that in for cardiac surgery a range of good practice had been identified so even the outliers at the bottom are still within the "good practice" bracket. Bruce Keogh picked up on this point and said that a lot of the issue was in perception. When they initially defined what a negative outcome was - 2% mortality - there was not a lot of sign-up. But when it was changed to 98% success there was a lot of buy-in. There were other factors as well such as ensuring the patient was discharged correctly and ensuring they patient received the right drugs.

Derek Butler said that one approach could be that for the different parts of quality and safety you select one champion in each area. If one service can get to 100% they can then share it but it has to be a process of daily improvement. Eventually when safety is at 100% the target is to keep it up.

Heinrich Audebert said Trusts like Guy's and St Thomas' can create a problem because they when they do achieve a good service they do not look to other parts of the country and share. The route could be for one service to support others in doing better.

Sabaratnam Arulkumaran said that each Trust can decide who is the best in maternity for example but for the people at the top no-one has established what the high standard is so that they can continue to improve.

Bruce Keogh said we also needed to align quality with emphasis on finance. Higher mortality costs more therefore there is a material benefit to improving quality.

Michael Neeb used the example that 20% of lab tests in the US have to be reordered simply because the first set was lost. Simple key indicators like that can drive up quality.

Mike Richards said that the Cancer Peer Review programme had been interesting because clinicians who were review hospitals other than their own spent a lot of time learning how services could be delivered differently. The UK investigations into so few sites seemed a bit limited and he has asked if there was the possibility of doing something bigger perhaps with a survey?

Anthony Sheehan suggested that if the methodology was freely available it could be done but for areas without tariffs it would be very difficult to know what was going on unless a local network was in place for comparison or an outside stakeholder group like the Royal College of Psychiatrists could take a view.

Herre Kingma said that we should look at bad practice as well as best practice, measuring both the lower 10% and the upper 10% if we wanted to improve quality. One example would be look at reinfarction rates after 3-months but it was very important to look at outcomes not simply processes.

Ian Kennedy said he felt it was very important that we do not focus just on hospitals but that community and primary care. There is also an issue around the mediocrity. The top performers will always be good and we can take corrective action around the bottom but for those in the middle there is the question how long do we tolerate adequate?

PATIENT SAFETY

Pauline Philip outlined the approach for the safety part of the Next Stage Review. The agenda would be taken forward through the Patient Safety Forum and would essentially consist of two parts:

1.                  Reassessing the recommendations in Safety First to identify if any of them need reframing.

2.                  Identify any additional recommendations.

At the next stakeholder group there would be an update from the Patient Safety Forum.

The CMO concluded by saying that the next meeting will be in January 2008.

For more information contact Derek Butler

Email: derek.butler@mrsaactionuk.net

Telephone: 07762 741114