Post-Blair Labour health “reforms” overemphasised a centrist, target driven culture that tended to distort how care might best be delivered. It marginalised clinical staff, leaving them often to adopt a stance of disgruntled passivity.
The desired distribution of outcomes graph
The current NHS white paper embraces clinical outcomes as a truer means of assessing the quality of NHS care, and an information revolution that promises to put this clinical data into the public domain. Provision of locally, nationally and internationally benchmarked clinical information will allow us to compare the efficacy of local care pathways.
For example, if you moved to a new area and had a diabetic child, you would be able to select the GP practice/hospital that offers best outcomes for diabetes, increasing competition between healthcare providers. Furthermore, peer pressure and professional pride will mandate that clinicians respond to improve performance which has been shown, publicly, to be sub-optimal.
Providing information to citizens about the clinical outcomes that return most health gain, in an accessible format, will create a health atlas plotting the major diseases - think of an Ordnance Survey map, contoured by health rather than height above sea level. If we overlay this atlas with programme budgeting information, then we have a tool which must be integral to commissioning consortia to ensure cost-effective care.
Several factors can lead to different clinical outcomes. Addressing heterogeneity due to the biology of disease, case mix, deprivation, etc are long term public health aims. Unwarranted variation, however, depends on disparities in clinical knowledge, allocation of resources, organisational culture and access to appropriate care, all of which are tackled in the white paper.
Concerted local action to align care pathways, implementation of nationally agreed treatment guidelines and devising financial incentives which reward excellence and improve education all feature. Making the clinical outcome data public will allow patients and their families to monitor improvements in their own health community, or choose alternative healthcare providers.
The means of presenting this data will need consideration and consultation, to make sure that we engage with patients as widely as possible, weaving traditional communication tools (local newspapers and other printed materials) with modern web based elements.
On top of this we must not be obsessed solely with objective measurements of the quality of care, but should aim to generate subjective evaluation of the service by patients and carers. See iwantgreatcare.com for an excellent example of how this might be done.
Part of the challenge will be explaining the pattern of these clinical measurements to our patients and their families. They will not split into good or bad, but rather will be continuous. This means we need to explain the concept of an average and its distribution and why there will always be an element of random variation in clinical measurements that depend on factors which we cannot easily manage.
The analogy might be height, in which there is obviously a range from short to tall and a national average, which has been creeping up since the 1940s, possibly due to better nutrition.
One can imagine a political pledge, “no one deserves to be below average”, perhaps not grasping the concept of a distributed mean. The challenge we face is to shift from a broad, flat curve to a taller, narrower distribution, with better average outcomes and reduced unwarranted variation (see graph).
This is at the heart of the quality revolution promised by the white paper, and although we cannot eradicate all variation in health outcomes, just as we cannot all be 5’10”, we believe the philosophy it is predicated on, coupled with necessary structural reform, will deliver a devolved NHS that is much more responsive to communities.