Quality In Austerity - Indicators of Quality

1. Quality In Austerity - Indicators of Quality Martin Bardsley Director of Research, Nuffield Trust March 2013 Twitter: #NTSummit

2. Why is HF/NT investing in work on quality? • There is no inevitable inverse relationship between finance and quality but.... • Financial pressure may divert attention from quality • Search for transformational changes in delivery may have unintended consequences (good/bad) on quality • Historically success in areas like waiting times and HAI linked with significant investment • Efficiencies likely to be sought in staffing • New organisational structures everywhere • Implications of austerity on health needs

3. There a whole lotta monitoring going on Data monitoring Contract monitoring Self monitoring Inspection monitoring Experience monitoring support to the commissioners Public Health England NHS CB NHS Outcomes Framework. National Quality Dashboard and corporate intelligence Monitor NHS TDA CCGs CSUs Data Performance against objectives Performance against plan Contract management third party information Provider Data Commercial analysts Data (eg QRP s) and inspection / investigation Care Quality Commission Department of Health Continuous monitoring of quality Professional regulators Information from people using services Patients Quality of education Individual competence HealthWatch Engagement User-generated content organisations Experience NHS Ombudsman Complaints

4. What can Health Foundation and Nuffield Trust add? • Provides an independent overview of how quality of care is changing over time. • Offers a view across different dimensions of quality that is not linked to any one provider or sectors. • Enable flexible analysis of important quality issues as they arise, and uses a range of methodologies. • Develops the methods used to measure quality, including innovative analyses across linked data sets at person-level. • Looks across the care system and where possible include international comparators.

5. Quality in Austerity Programme • 5 year, multi-stranded programme • Compliment existing initiatives looking at quality Deeper analyses on ‘hot topics’… …building on our capacity to use complex information to create new approaches and new perspectives on how the quality of care is changing within the NHS. Developing sets of indicators… …to measure changes in the quality of care over time across care settings.

6. Topic: Trends in Ambulatory Care Sensitive Admissions ACS admissions have increase by 40% in the last 10 years – will they continue to grow? Age-standardised rates of admission for ear, nose and throat infections, 2011/12

7. Individual indicators Effectiveness Access and timeliness Capacity Safety Patient centeredness Equity

8. An explosion of indicators… …but some areas better covered than others Outcomes Frameworks, NICE, QRP, QIPP, QOF, Quality Accounts, Dashboards, Thermometers, Atlases… Primary and community provision Secondary / tertiary provision Population / commissioner level General and acute Social care provision Mental health Total Effectiveness Access and timeliness Capacity Safety Patient centeredness Equity Total

9. Even more limited outside acute trusts Some areas better populated than others Hospital admin systems - strong on activity and coverage but limited detail General Practice – massive data sets with untapped potential Acute care specialist and clinical systems – hugely variable Social Care – tend to be local, not shared. Major problem re self funders Community Care – very variable Independent Sector Care – very limited

10. And an external body can only see so much in a complex organisation Corporate Clinical Visibility of performance (quality) Community Though good data exists in places we still rely too much on HES based

11. Failures in quality: the holy histogram theory REGULATOR or COMMISSIONING (enforcement) (contracting) ‘IMPROVEMENT’ BODIES COMMISSIONING (contracting, choice, competition…) ‘IMPROVEMENT’ BODIES Number of organisations Non compliant Basket OK Weak Good Excellent Quality

12. In an ideal world, quality indicators would be built from… • 1. The information we need to understand clinical quality at organisational level and above should flow from information collected in the course of people doing their jobs • Including... Patients views, PREMS and PROMS • 2. Data linkage between these encounters / events / episodes at patient level is important: • a. To make the most of what data we have • b. To measure outcome • (“change in patient health status that can be attributed to antecedent health care”) Social care Health status Hospital GP

13. Some of the most critical areas are the most challenging eg Information from care users • Care Users – Surveys, F&F, Complaints, Individual reports/stories • Patient reported outcome measures • Staff perceptions • Quality of medical treatments – limited information • Patient outcomes – difficult to assign causality • Capturing qualitative intelligence • Improving these will help but no guarantee of predicting future failure

14. So what do we need to do… • Continue developing information from patients and staff • Fill the gaps for services that are lacunae – OOH, community, independent sectors... • Go beyond HES into the quality of services including clinical audits • Integrate the quantitative and qualitative • Link data to make the most of what there is and to assess consequences /outcome • Link the information to subsequent action....