Measurements for Improved Quality in Healthcare
The responsibility for healthcare is devolved in the United Kingdom and is the responsibility of the individual countries, England, Wales, Northern Ireland and Scotland. The discussion in this paper concerns England only unless otherwise stated.
The English healthcare system is currently in a state of change, and as a result of the Health and Social Care Act of 2012, a number of organizational changes have been implemented. Examples include that a new executive body, NHS England, now has the main responsibility for healthcare provisions; that new mechanisms for the commissioning of services have been introduced; that the National Institute for Health and Care Excellence (NICE), which provides clinical guidance, has had its remit expanded to also include adult social care; and that a new agency for public health has been formed. Many other relevant organizational changes have also been made. The healthcare reform is to a large extent, intended to improve health outcomes, improve efficiency and meet health challenges for the future.
Quality improvement is of utmost importance and is driven forward not only by the government but also, to some extent, by interest groups and public pressure. Most of the current work on quality improvement originally stems from the 2008 report, High Quality Care For All – NHS Next State Review, led by Lord Darzi. The report discussed quality primarily in terms of effectiveness, safety and patient experiences. The NHS Outcomes Framework was later developed to define quality in outcomes and processes and to hold NHS England accountable for its quality as well as for upholding essential standards. In addition the National Quality Board has produced guidelines on quality, and a large number of other specific initiatives exist as well. Quality is sometimes coupled with monetary incentives, for instance in the Quality and Outcomes Framework (QOF) for general practitioners (GPs).
There are a number of public actors, including the regulators Monitor and the Care Quality Commission (CQC), present in the healthcare quality improvement system. While Monitor is the regulator that mostly focuses on management and efficiency, the CQC investigates clinical performance and excellence. Public Health England instead works with a more broad approach including the promotion of a healthy life style. However, the main responsibility for public health now lies with local authorities. NICE is not a regulator, a fact that often is brought forward as important, but sets quality standards, formulates guidelines and makes recommendations for indicators used for measurements. The commissioners on local, regional and national levels including the Clinical Commissioning Groups (CCGs) and NHS England are of importance to put pressure on quality improvements in the services they commission.
Measurements of healthcare performance are clearly important to increase quality and a well-organized infrastructure is in place for this. A multitude of measurements are made including audits, patient-reported outcomes measurements, surveys, measurements on procedures, drug use and outcomes, hospital episodes statistics etc. Data sources may include patients, GP practices, hospitals as well as other sources. The data is used for many purposes including research, funding decisions, regulation, to monitor safety and essential standards, to enable public choice and for policy decisions. Some anonymized data is published openly while data for research may be included in clinical quality registers or databases. Interestingly, some data for research is provided at commercial rates to companies and academic scientists.
The further development of advanced electronic data collection systems, the implementation of interoperable integrated personal electronic health records, and new devices to input data will most likely enable data collection to become qualitatively better and also more efficient in the future. It should be pointed out that while the description here is focused on national efforts, very advanced systems are used locally in some trusts.