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Rapid Responses: Rapid Responses published:
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The quest for quality
- Yoav Tzabar (8 July 2005)
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Re: The quest for quality in the NHS: still searching?
- Sheila Leatherman, Kim Sutherland, Senior Research Associate, Judge Institute, University of Cambridge (11 July 2005)
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The search for the Holy Grail of Quality in the new NHS
- David P Kernick (15 July 2005)
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Yoav Tzabar, Doctor Carlisle
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"It must be incontestable that patients want the highest possible quality of health care" Is it? I contest it. I reckon most people want health care that is "good enough" for their needs. Very few people want the best possible car, or the best possible house but one that meets their needs most of the time. And so it is with health care. Competing interests: None declared |
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Sheila Leatherman, Research Professor University of North Carolina School of Public Health; Judge Institute, University of Cambridge, Kim Sutherland, Senior Research Associate, Judge Institute, University of Cambridge
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EDITOR – John Appleby has provided a critique (1) of our recently released book, The Quest for Quality in the NHS: a chartbook on quality of care in the UK (2). We agree that quality is a kaleidoscopic concept – an inevitable consequence of the vast number of stakeholders in healthcare and the diversity of their values, priorities, perceptions and judgements. The chartbook sought to tackle some of the difficulties of defining and measuring quality in healthcare – putting together a wide-ranging and accessible compendium of data. Our approach drew on experience in the US where a series of chartbooks on quality of care (3), (4), (5) have been widely acclaimed and instrumental in highlighting quality deficiencies and catalysing action to tackle them. What Appleby describes as a “desultory” set of statistics, past experience suggests may be seen by less specialist readers as a useful overview of a complex and multifaceted subject. We wholeheartedly agree with Appleby’s call for the linking of quality data with economic and productivity data. We also acknowledge that there are inherent difficulties in releasing quality data in book form, because of space constraints and inevitable time lags associated with traditional publishing. He is right to say that the chartbook is only the “first step in a long and arduous process of really answering the somewhat simple question of what we get for our healthcare investment”. We are now preparing to take our second step - in the form of a £2.5m five -year research initiative, funded by The Health Foundation, to be known as QQuIP (Quest for Quality and Improved Performance). QQuIP will independently collect, collate, analyse and report on a wide range of data on quality of healthcare. It will also provide coherent and accessible information on where healthcare resources are currently being spent, whether they provide value for money and how interventions in the UK and around the world have been used to improve quality. QQuIP’s analyses and reports will be made publicly available in the form of a searchable website. The information will be continuously updated as new data become available and will be designed to show trends over time. Appleby criticises the chartbook for using a considerable amount of official government data. Official data do figure prominently, but only because there is too little in the way of alternative sources for many indicators of quality. In producing the chartbook, we conducted wide- ranging searches for robust and relevant data and included datasets from numerous non-governmental sources including peer reviewed journals and organisations such as the Commonwealth Fund, the Royal College of Physicians, the Royal College of Obstetricians and Gynaecologists, and Diabetes UK, to name a few. It is however a concern that so much of the UK’s quality and performance data emanates from government sources, either directly or indirectly. This concern is founded on the difficulties in establishing the cogency and veracity of the data, with no independent audit or validation of official statistics; and on the fundamental conflict of interest when government acts as the provider, financier and evaluator of performance. The compilation, and subsequent tracking, of a broad set of indicators concerned with quality across the NHS has several potential benefits. Firstly, directing attention and marshalling resources to tackle areas of suboptimal performance; secondly, identifying successes and motivating continued improvement and; thirdly, increasing the value and credence of data. In publishing the chartbook and establishing QQuIP, we seek to facilitate the reaping of such benefits across the NHS. Sheila Leatherman Kim Sutherland References 1. Appleby J. The quest for quality in the NHS: still searching? BMJ 2005;331:63-64 (9 July). 2. Leatherman S, Sutherland K. The quest for quality in the NHS: A chartbook on quality of care in the UK. Oxford: Radcliffe Publishing, 2005. 3. Leatherman S, McCarthy D. Quality of healthcare in the United States: a chartbook. New York: The Commonwealth Fund, 2002. 4. Leatherman S, McCarthy D. Quality of healthcare for children and adolescents: a chartbook. New York: The Commonwealth Fund, 2004. 5. Leatherman S, McCarthy D. Quality of healthcare for medicare beneficiaries: a chartbook. New York: The Commonwealth Fund, 2005. Competing interests: None declared |
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David P Kernick, General Practitioner St Thomas Health Centre, Exeter, EX4 1HJ
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Appleby and his academic colleagues (Appleby J, BMJ 2005;331:63-4.) continue on their heroic quest for quality in the NHS - a confident assumption that all we need is a greater level of analytical detail to engineer the system towards policy objectives. However, the reality begs to differ and the limited application of evidence based health care and health economics alerts us to the danger of misleading rhetoric. Economic facts never compel simple responses but invariably leave room for alternative accounts that draw upon literary persuasion or rhetoric.(1) Faced with the contradictions of applying a rational framework that sees a simple relationship between cause and effect to the complex environment of health care, health economists invoke the metaphorical rhetoric of quality and value for money to maintain the internal coherence of the discipline however unrealistic it may seem. In turn, the assumptions of the rhetoric become self-fulfilling as they induce the very behaviour they purport to predict and explain. Thus economic rhetoric dictates the way in which modernisation practices are conceived, implemented and legitimised while defining the quality frameworks of target acquisition on which success is based. Unfortunately, this has a number of dysfunctional consequences that place strain upon the coherence of the system as a whole. Firstly, the focus on measurement and control may create a range of unintended and potentially dysfunctional consequences (2) and can undermine the intrinsic motivation of the workforce(3). Secondly, emergence of alternative dialogues about the meaning and ownership of value is inhibited. For example, value may be generated from the relationship between the patient and health care professional, a variable overlooked in the current economic calculus. Perhaps the reason we are still searching for quality in the NHS is that we are inveigled by economic frameworks that take us in the wrong direction? References 1. McClosky D. The rhetoric of economics. Journal of economic literature. 1983:21(2);481-517. 2. Mannion R, Davies H, Marshall M. Impact of star performance ratings in English acute hospital trusts. Journal of Health Service Research & Policy 2005;10(1):18-24. 3. Deci E, Ryan R, Koestner R. A meta analysis review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychological Bulletin 1999;125:627-668. Competing interests: None declared |
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