Measuring up the NHS
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b703 (Published 25 February 2009) Cite this as: BMJ 2009;338:b703
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Nigel Hawkes focuses on the general quality of care given by
individual hospitals, teams, etc. However, his cartoon is about the care
given to an individual patient. So how can the quality of an individual’s
care be assessed as opposed to the quality provided to a population of
patients? The first step would be to provide high quality information to
the individual patient.
The basic information required to assess the individual’s quality of
care would be the abnormal findings identified, all the treatments, the
diagnostic indication for each treatment; and for each diagnosis, how it
presented, how it was confirmed and the latest markers of progress. This
would also allow the patient to participate in decisions about their care
as now expected by the GMC [1] and to show a high quality Past Medical
History to the next doctor or nurse.
If all patients were given a typed evidence-based medical history
then all patients would be empowered to assess the quality of their own
care (even if many did not bother). This information would also generate
data for a high quality audit of general care. This approach can be
taught systematically [2] and could provide the in-built review of NHS
quality sought by George Godber.
1. General Medical Council. Consent: patients and doctors making
decisions together. http://www.gmc-
uk.org/guidance/ethical_guidance/consent_guidance/part1_principles.asp
2. Llewelyn H, Ang HA, Lewis K, Abdullah A. The Oxford Handbook of
Clinical Diagnosis, 2nd edition. Oxford University Press, Oxford, 2009.
Competing interests:
None declared
Competing interests: No competing interests
This article, along with many others, implies that UK heart surgeons
are to be congratulated for reporting their mortality rates. But death is
not the only indicator and they could and should have done more to measure
quality of life after surgery. I have friends and relatives with chronic
pain and severe lung damage after surgery. While not wishing to overrate
a small sample of my acquaintances, life or death is a very crude
indicator, even for CABG, and even more so for other types of surgery.
Until I see routine PROM quality of life figures for heart surgery, I will
see the cardiologists and their stents as my first, second and third port
of call if I ever suffer from angina! Sadly, as it approaches the end of
its own life, the Healthcare Commission had still done almost nothing to
develop PROMs beyond riding on the back of the heart surgeons' mortality
reporting.
Competing interests:
Peter West is a senior research associate with York Health Economics Consortium and has worked on a wide range of studies in the NHS and the private sector. He has recently worked on clinical indicators for the NHS Institute and for the Healthcare Commisison but is not currently working on any quality studies linked to the topics in this article
Competing interests: No competing interests
No one disputes that the quality of care in the NHS varies greatly.
However, by ‘empowering’ patients with choice, all that happens is that
instead of randomising which patients receive better care we stratify this
according to how well-informed the patient is: can you really imagine an
elderly person living by themselves surfing the internet to find out which
surgeon is the best? If we want everyone to access the best, we must
address the shortcomings of our medical training and regulation systems
that create under-performers- and not fob patients off with ‘choice’.
Adam M Ali
Competing interests:
None declared
Competing interests: No competing interests
What QuOF did was to show that pre-2004 GPs were poor at recording
"quality markers", even those based on good clinical evidence, and the
change in contract inevitably pushed Practices ( not necessarily
individual GPs ) into measuring the markers with money attached.
Surprise,suprise! at least to the employers and the Treasury,
entrepreneurial, innovative, and "thinking" GPs rapidly out-performed
expectations, and have since been penalised financially for so doing and
damaging the relationships within Practice teams.
Now Lord Darzi's dash to quality in primary care shows up in the
requirement in Darzi Practice tender documents to invent 12 quality
indicators above and beyond QuOf, including proposed national or local
Quof changes for 2009/10, as a demonstration of clinical leadership and
commitment to improved quality outcomes for patients. This within a capped
bid price for a 12 hr. daily service available to registered and
unregistered patients on request, which repeats the disruption to
continuity of care found in secondary care, destroying the key
foundationstone of the longterm doctor-patient relationship upon which the
QuOf " successes" were based.
This feels like anti-professionalism on an institutional scale, being
asked to achieve more with less in an environment hostile to personal
longterm care of individual patients.
Or is it just me?
Competing interests:
I am a GP
Competing interests: No competing interests
How strongly can one object to Hawkes' characterising GPs as hitting
the "bullseye" of achievement in the Quality and Outomes Framework "with
contemptuous ease"? I would like to make it clear that it takes sustained
focus and hard work to achieve; there is nothing easy about it.
Competing interests:
I am a GP
Competing interests: No competing interests
Refused admissions for pyloric stenosis. A possible quality measure in Paediatric Surgery?
A Department of Health report(1) published in February 2007 showed a
steady increase in the number of operations performed in Specialist
centres, rather than district hospitals (fig 1). The greatest changes
occurred for cases of pyloric stenosis; in 1994 52% of pyloromyotomies
were performed in a district hospital, which fell to 17% by 2004 (fig 2).
We studied the number of pyloromyotomies performed at Birmingham
Children’s Hospital, the regional specialist centre, retrospectively
collecting data for consecutive babies operated on for pyloric stenosis
using theatre, anaesthetic and surgical records from 1993 to 2008. Data
on refused admissions was obtained prospectively between November 2007 and
April 2008. We also obtained relevant Hospital Episode Statistics (HES)
and Department of Health bed occupancy rates to inform the interpretation.
We found the number of pyloromyotomies performed increased steadily
from 12 cases per year in 1993 to 83 cases per year in 2000, as district
hospitals withdrew from managing pyloric stenosis, with no refused
admissions for pyloric stenosis during this period.
In 2001 the overall number of surgical beds at our centre was
reduced, including the loss of five neonatal surgery beds, which has
reduced our capacity to accommodate babies with surgical problems. This
is reflected by the number of babies operated on with pyloric stenosis in
our centre, which has fallen to less than 50 cases per year since 2001
(fig 3).
Between November 2007 and April 2008 34 referrals for pyloric
stenosis were made to our centre, but 21 of these cases were refused. This
equates to a 62% refusal rate. Our audit of referrals showed that these
pyloromyotomies were being performed in other specialist centres around
the UK, not in district hospitals.
The withdrawal of district hospitals from managing pyloric stenosis
has resulted in an unplanned change in service provision in our region.
This, combined with a reduction in the number of beds at our centre, has
resulted in an inadequate regional service with many babies needing to
travel long distances to receive care.
Hannah L Rhodes, ST2 Paediatric Surgery, Royal Liverpool Children’s
NHS Trust
Anthony D Lander, Consultant Paediatric Surgeon, Birmingham
Children’s Hospital
References
1. Trends in Children’s Surgery 1994-2005: Evidence from Hospital
Episode Statistics Data. Hugh Cochrane & Stuart Tanner. February 2007.
Child Health, Maternity and Women's Health, Department of Health, UK
Competing interests:
None declared
Competing interests: No competing interests