How do you ensure quality in healthcare?

Competition - whatever happened to cooperation?This is perhaps the biggest challenge, when introducing competition in health care.

It is very difficult to measure quality in health care, and even more difficult to measure it contractually and enforce it. One of the biggest challenges is that healthcare is changing so quickly, that we have to learn as we go along. So one month we measuring the level of blood clots, and the next the number of bedsores. This is practically impossible in a contract. Unfortunately, in an environment where money is paid under contract, and providers are driven by the profit motive, there are rather too many opportunities to cut quality and improve profit. It happened under Blair, and it's likely to happen this time around – especially if the comments being made to the US health provider sector, about the UK health market, are anything to go by.

Large integrated organisations, such as UK hospitals, can run extremely efficiently, delivering very expensive and highly detailed and complicated operations, and at the same time providing Accident and Emergency services. With a pool of staff, it's possible to fund the training and experience needed, by performing mundane and routine operations, so that the team is available when something more demanding comes up.

This falls apart when routine operations are taken out of the system and given to an independent provider. That's not to say that a bit of specialisation went improve quality – it often does – but it's incumbent on those planning and making strategy to recognise these challenges.

Keeping track of improving quality

Unfortunately, the so much variety in health care, the maybe very small numbers of each individual type of activity. With small numbers, one complication can completely distort the hospital's ranking, and give a false perception of quality. Because of the small numbers, numbers are aggregated over many years, which means that by the time action is taken against a poorly performing doctor, the figures will take years to recover. An organisation may be unfairly penalised, when they took the action they should have.

Who is capable of enforcing minimum standards?

The Health Secretary has made a big thing of ensuring that the experience gained by the PCTs is retained in the system. In order to commission services, and to enforce the contract, you need a set of skills:

  • understanding the reports that come in from your provider
  • understanding what they mean in context (taken account of small numbers, and the services in the round)
  • the diplomatic skills to raise a query without resorting to the letter of the contract
  • the legal right to demand that the contract being forced
  • the teeth, or financial muscle, to enforce a contract, if this becomes necessary

I don't believe that units based on the size of the GP commissioning groups (effectively, in many cases, the size of the pre-2006 PCT's or smaller) will have any of these. If they're supported by "commissioning support" teams, made up of staff from the old PCT, then they may be able to understand the numbers. But it takes a director or chief executive to have the diplomatic skills; it takes an organisation the size of the new PCT's to have the economic muscle; not only do the hospitals have all of the information, this time round, in many cases, they also employ the community team, so the GPs have nothing to fall back on. For example, if the GPs want to set up a new heart failure pathway, then they will need trained nursing staff; the nursing staff are now employed by the hospital trust, who can easily say "there are no staff available", which prevents the GPs from setting up a new pathway, and means the hospital keeps the old pathway that they favour – and their income.

With teeth?Who is the Regulator, and who is the Commissioner?

Part of the debate has been on the role of Monitor – the foundation trust regulator. Monitors ended up in a ping-pong match – will they be there to encourage competition? In which case, they're not in a position to demand a minimum standards, would withdraw licensed to provide services from someone in an area where there is little competition. Will they be there to encourage cooperation? In which case, what does cooperation mean in an environment driven by profit motive?

Will they be able to enforce minimum standards, then there are also required to encourage AWP (Any Willing Provider), or AQP (Any Qualified Provider)? Given the amount of political interference going on at the moment, will they be able to enforce anything without interference?

The best solution would be local enforcement. Quality, and improving quality, driven by the people for the people.

This doesn't mean elected members on GP consortium boards, because imposing someone on a board that it is designed to make GPs responsible. With resentment and end up being manipulated. This means separating the task of referring from the task of commissioning.

Commissioner should be the local authority, which has a lot of experience of commissioning, and has frameworks in place. Specific health experience can be gained by retaining the best of the commissioners from the PCT's, but as they join the local authority, they will John endowment where the commissioning framework is tried and tested, and well understood.

GPs can get on with doing what they do best; diagnosing, referring patients, and designing new pathways. To be no more conflict between "Commissioner" and "provider", as GPs are responsible for a flowing, and an independent body is responsible for ensuring probity.

And because the local authorities are accountable to the people in their areas, services will be appropriate to local needs, and we'll no longer have to dance to the Department of Health tune.

 

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