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At the heart of general practice since 1960

Is your hospital delivering quality care?

Rebecca Norris gets top tips from GPs and other experts to assist CCGs as they move further into their role as overseers of the level of quality being provided in hospitals

http://www.pulsetoday.co.uk/practical-commissioningl

1. Seize the role of quality custodian

Quality has to be the top priority for any CCG, says Dr Shane Gordon, national co-lead of the NHS Alliance's GP commissioning federation and CCG lead for NHS East of England: ‘It's for CCGs to move into the role that PCTs had as the custodians of the local health system.

‘It's absolutely vital they have a good picture of the quality of not just services in hospital, but in all their services.

‘Quality is the thing patients regard as the most important in the health service – not the finances. Although funding issues are really important and challenging, if we get the quality wrong, our patients won't forgive us for that. That is the most important thing to attend to on their behalf.'

He says the first step for CCGs is to seek clarity on what the PCT already collates.

Dr Gordon says: ‘If they're not already doing it, CCGs should very quickly have a conversation with their PCT cluster quality leads and understand the sort of information that is available to them to assess quality, and to get a grip on how important the PCT sees the quality agenda for the future.'

CCGs also need data to be collated into quick-read, easily understood summaries, he says: ‘I think a good arrangement would be for a CCG to have someone who routinely collates the data and finds areas that are not within expected boundaries. This allows the CCG to concentrate its efforts on investigating the areas that are potentially cause for concern.'

2. Look at a broad mix of quality indicators

There is a consensus among GPs, academics and other experts that no single indicator can define a hospital's quality of care.

Dr Gordon says: ‘You need to have a broad range of indicators against which to assess the performance of your providers, and they've got to cover clinical outcomes, clinical care, patient safety and patient experience.'

He believes mortality and infection rates ‘are really critical', while indicators like cancer treatment waits give an indication of how efficient processes are within a hospital.

The hospital standardised mortality ratio is available monthly and can be broken down by specialty if CCGs want, for example, to look at issues such as cardiovascular deaths.

The new, and less frequently reported, summary hospital-level mortality indicator (SHMI) could be helpful in showing how joined up care is across the NHS, he adds, as it measures not only in-hospital deaths but those in the 30 days post-discharge.

Dr Gordon also highlights the annual national inpatient surveys as a useful measure of patient experience, and suggests CCGs ask hospitals for data on any internal patient surveys they carry out.

3. Review quality data regularly

CCGs need to hold regular reviews of quality data, says Dr Gordon: ‘We review quality data monthly. We receive a summary report covering a large number of indicators and patient experience.

‘If there's anything that appears not to be going right, there's a number of mechanisms to address that – such as the regular quality meeting with the local hospital.

‘We also have meetings with the clinical directors on a regular basis where we raise particular issues.'

4. Know the limitations of quality indicators

CCGs need to treat quality indicators as a contribution to the overall picture of quality rather than as the solution, advises Dr Mark Davies, executive medical director at the NHS's in-house statistics library, the NHS Information Centre for health and social care, and a GP in Hebden Bridge, west Yorkshire.

‘I often liken [indicators] to an oil warning light going on in your car,' he says. ‘They're not telling you what the problem is, they're just telling you to stop and have a look and see if something's wrong. There might be a series of things going on that will explain it.

‘The mistake people make sometimes is they view clinical indicators a bit like the speedometer, something that's precise. They aren't and they never will be. They're about giving you a warning and saying this is something we'd like to delve into in detail.'

However, he adds that CCGs should be reassured that many national indicators use a standard methodology of measuring, to allow for comparisons with other units, and have a degree of professional reassurance attached because associations of specialist doctors have backed them.

Dr Davies adds: ‘I think it's really important that the underlying workings of those measurements are freely available and open to peer review and challenge.'

5. Use experts to analyse and interpret quality indicators

CCGs – or agencies on their behalf – may be able to easily get hold of quality indicator data, but given the wide variety of sources and measurements, they are likely to need assistance to untangle and interpret figures. Public health observatories and their close cousins, the new quality observatories, are recommended by GPs and academics as an excellent source of help.

Dr Bobbie Jacobson, director of the London Health Observatory, explains: ‘The observatories are in the business of making sense of routine information that is endlessly submitted but not really analysed, interpreted or easily understood. You can lie with statistics, inadvertently. You can get the whole picture wrong.'

The consequences of this could be the removal of funding from services mistakenly seen as underperforming, Dr Jacobson adds.

‘We recognise that a lot of "talk" about hospital quality is not really intelligent. It might show great variation in intervention rates or outcomes, but that itself doesn't tell you about the difference in quality between one provider and another – because each provider is meeting the needs of a different population, or there might be historical commissioning practice that needs to be taken into account,' she says.

‘Take diabetes. In London, we know there's a high level of need in Newham, and it is lower in Sutton and Merton.

‘You can't just generate an indicator and say there's a seven-fold difference in hospital admissions for diabetes patients between the two, you need to understand what it means.

‘The observatories are good at this and we've done a lot of work to adjust indicators for population need.'

6. Develop a mature conversation with trusts over quality issues

CCGs should put in the groundwork with trusts to start a ‘mature' conversation about quality, says Dr Davies.

‘I think looking at "a hospital" is pretty unhelpful, actually,' he says. ‘The really important thing is the conversation that occurs between a commissioner and individual service.'

Dr Davies adds: ‘I think the original Darzi definition around quality stands true – a focus on patient safety, a focus on patient experience and a focus on quality indicators.

‘So the NHS Information Centre for health and social care has a library of indicators CCGs will be able to go to and use, as well as tools such as HES data or comparator data, to build a picture.

‘But that will be augmented by local conversations between commissioners and people who run the services, and asking: "What are the things that we jointly agree make sense?"'

7. Keep an eye out for new quality indicators

CCGs need to start thinking now how they will respond to the NHS Outcomes Framework, the new way of holding the NHS to account, through 60 indicators split over five domains:

i Preventing people from dying prematurely

ii Enhancing quality of life for people with long-term conditions

iii Helping people to recover from episodes of ill health or injury

iv Ensuring people have a positive experience of care

v Treating and caring for people in a safe environment and protecting them from avoidable harm.

A quick-glance guide to the 2012/13 framework is on the Department of Health website.

Dr Davies says: ‘It will take time to develop all the indicators we need. Developing methodologies can be time-consuming and difficult, but we are at the beginning of a process of getting increasingly rich indicators over time that in the future will contribute very significantly to the picture we paint of the quality of an individual service.'

Rebecca Norris is a freelance journalist

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