1) There are concerns that financial pressure from austerity measures may negatively impact healthcare quality, though more data is needed to establish clear relationships. 2) Multiple organizations currently monitor various quality indicators, but coverage is uneven across different settings and dimensions of quality. 3) Developing a comprehensive and standardized set of quality indicators that can be tracked over time across different care settings is an important goal, but collecting useful data, especially from patients and independent sectors, remains challenging.

1. Quality In Austerity - Indicators of
Quality
Martin Bardsley
Director of Research, Nuffield Trust
March 2013
© Nuffield Trust
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
© Nuffield Trust

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

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.
© Nuffield Trust

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

6. Topic: Trends in Ambulatory Care Sensitive Admissions
ACS admissions have increase by 40%
in the last 10 years – will they continue to
grow?
300,000
Emergency admissions
250,000
200,000
150,000
100,000
50,000
0
Age-standardised rates of admission for ear,
nose and throat infections, 2011/12
© Nuffield Trust

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

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 Secondary / tertiary provision
Population /
community General and Mental Social care commissioner Total
provision acute health provision level
Effectiveness 147 274 26 13 82 542
Access and
timeliness 46 75 41 13 9 184
Capacity 35 47 24 30 1 137
Safety 66 160 82 11 7 326
Patient
centeredness 27 159 77 18 5 286
Equity 7 10 10 0 1 28
Total 328 725 260 85 105 1503 © Nuffield Trust

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
© Nuffield Trust

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

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

12. In an ideal world, quality indicators would be built from…
1. The information we need to understand
Social Health
clinical quality at organisational level and Hospital
care
GP
status
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”)
© Nuffield Trust

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 © Nuffield Trust

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