Published: 22/04/2002, Volume II4, No. 5902 Page 16 17 18

Will the DoH's 'standards for better health' reflect patients'needs in the 21st century?

Next year the NHS will leave behind an era of performance management dominated by central government diktat and, instead, begin to be assessed by an independent inspector, the Healthcare Commission.

Its assessment criteria will be based on the 'standards for better health', the Department of Health's response to the requirement included in last year's Health and Social Care Act to establish new national standards for the NHS. Issued in February, the consultation period for the new standards closes on 4 May.

The DoH's 'standards for better health' are both interesting and unusual. Interesting, because they describe a vision of the requirements for a total healthcare system, and unusual in that, instead of being assessment tools, the standards establish the policy parameters of good practice in the management of a healthcare system.

These organisational standards resemble many others found around the world.However, they are unusual in their description of the elements of a healthcare system rather than simply the organisation of healthcare. They focus on the key components of safe, clinically effective, patientcentred healthcare, good governance and accessible and responsive care. Although not new in their prominence as elements of modern healthcare, the standards are the distillation of good practice recognised internationally and enshrined in recent DoH policy documents.

The existence of national standards is considered to be key to the current policy of devolved management. For local management to be freed from central diktat concerning management processes there has to be universal acceptance of the main features of good healthcare.

These standards cannot dictate the structure of, for example a good infection-control system.

This would vary according to the circumstances of individual patients and the work of individual organisations, including the nature and the structure of the buildings in which services are provided. To be truly modern, healthcare systems need to become more flexible, to allow services to meet rapidly changing needs and new developments in clinical care.

There can no longer be an assumption of a single prescription of good practice, but there are universally recognised values and assumptions about good quality in healthcare which need to be continuously restated and reinforced through external review. The standards are the vehicle for enabling this to happen.

The standards are intentionally written to reflect high-level policy, rather than management, requirements.

One view is that standards should be absolutes, based on numerical values. However, political scientist Professor Giandomenico Majone argues against this approach in 'the uncertain logic of standard setting'.

He writes: 'Regulators have traditionally sought legitimacy for their decisions by wrapping them in a cloak of scientific respectability... The scientific and conceptual basis of environmental regulation is so precarious, the empirical evidence so ambiguous, that most regulatory decisions can only be evaluated and legitimated in terms of procedural, rather than substantive, rationality - by process not by outcome.'

The alternative view therefore recognises the significance of determining the parameters of good practice, leaving the assessment processes which will underpin them open for decision by the bodies - such as the Healthcare Commission - which will undertake the assessment. It also allows for assessments to be tailored to recognise local conditions and differences between services and population, patient and user groups.

Standards can be used in two ways: to produce a consensus on the features of good quality in healthcare, or to create a framework for an inspection process in which external reviewers determine whether the standards are being met. In turn, the inspection findings can be used to generate a mechanism for licensing healthcare providers by determining whether an organisation meets the minimum requirements to operate safely.

Failure to comply with the standards may cause a healthcare facility to be closed down or refused entry into the 'market'.

Standards can also be used for certification. For example, the supply of NHS funds could be denied to an organisation which failed to achieve the necessary quality.

Finally, if standards are set at a higher level than most organisations can achieve, they can demonstrate best practice and provide something to which organisations can aspire.

The 'standards for better health' are intentionally agnostic towards these regulatory issues.

The role of the standards is solely to define what is expected of all organisations which provide healthcare to NHS patients. The standards had to be written in a way which communicates the fundamental requirements while permitting local freedoms and flexibility.

This is in order that the independence of the Healthcare Commission is not compromised when determining what information is necessary to assess whether the standards are met.

The use to which the assessments will be put will be determined by regulatory processes outside the standards-setting system.

In order to assess the nature and the content of the standards, a set of working rules were agreed by the DoH with a range of stakeholders. These provide the framework against which the topics chosen for inclusion in the standards would be assessed.

The rules stated that the standards should:

apply to all organisations and functions involved in providing care to, or commissioning care for, NHS patients or using NHS resources (public, private, voluntary and foundation trusts and independent diagnostic and treatment centres);

follow a generic formulation for the standards, ie there should be one set of standards for use by all healthcare providers;

reflect a patient or public perspective, ie what the patient or the public can expect from healthcare services;

be underpinned by a wholesystems approach;

allow local flexibility, ensuring innovation and service design and not be overly restrictive;

be more than just minimum market-entry standards, so no organisation or function can ignore them;

be comprehensive in scope, focusing on governance, clinical and public health outcomes and patient experience;

be restricted to existing policy and, therefore, not introduce any new requirements on the NHS;

where possible, enable a rationalisation of current reporting requirements, thereby reducing duplication;

be subject to continuous updates and reviews, with the content of the standards therefore developing over time;

be capable of permitting both internal and external assessment, but not rely solely on statistical data to assess their impact;

be developed with, and be acknowledged as significant features of, health services by key stakeholders, including patients, the Healthcare Commission and providers. The starting point for establishing the topics to be covered by the standards were areas considered to be fundamental to the provision of high-quality healthcare, later referred to as 'domains'.

Seven domains (see table below) were identified as significant, mapping out the cornerstones of a high-quality healthcare system.

The significance of the domain descriptions must not be underestimated. These are the current powerful policy areas which create the framework within which the standards were to be developed. As understanding of the definition of quality healthcare progresses, the standards will need to change over time to reflect developing policy concerns.

The domains combine the primary concerns for any organisation involved in delivering healthcare. There are both 'core' and 'developmental' standards within the domains.

The core standards provide an implicit focus on the patient experience of health services, as well as the basic requirements for good quality in healthcare organisations. The developmental standards, in contrast, focus on the concerns of integration and co-operation between organisations. They address implicitly and explicitly issues of patient choice, service redesign and making the best use of scarce skills.

The core standards are not therefore merely a subset or a less visionary version of the developmental standards. The two sets of standards perform different functions, even though classified within the same domain headings.

Each developmental standard covers a substantial and significant policy development and demonstrates where there is an opportunity for considerable improvement in the design and functioning of services within the whole healthcare system.

The developmental standards work together to provide a vision of a new healthcare system which has the patient at its centre. Each developmental standard should be read within the context of the description of the domain within which it is placed. For example, standard D7b within the domain on patient focus states: 'Patients, services users and where appropriate, carers [should] receive timely and suitable information when they need and want it, on treatment, care, services, prevention and health promotion and are... helped to develop skills in managing conditions, especially longerterm conditions, and in formulating plans for care.'

In other words, patients, service users and carers should receive timely and suitable information when they need and want it, not when professionals or service planners decide they should receive it. In addition, patients should be able and, by implication, actively encouraged to become expert in the management of their conditions, empowered to deal with their conditions and daily lives.

Taken alongside standard D8b, which exhorts healthcare organisations to plan and deliver maximum patient choice, the implication is that such patients should also be actively involved in formulating plans for their care. They should be able to review as many options as possible and to feel fully in control of the plan of care made available to them.

The standards provide a unique opportunity for the complex system of healthcare made up of many organisations, professionals and patients to focus on a single model for quality in healthcare.

The standards also make an important contribution to the developing role of healthcare systems' guardians of quality. The standards have been written to guarantee independence in the selection of assessment criteria by the Healthcare Commission.

Unlike its sibling inspectorate in education, Ofsted, the commission will not examine the health service equivalent of a classroom, such as a clinic or a GP surgery, but will look at the quality of a whole healthcare system.

Without the standards, the commission would be left to determine what is meant by a good-quality healthcare system - in short, defining the future development of NHS healthcare rather than its intended role of assuring the public, patients and service users that the NHS is providing quality healthcare within a universally accepted framework.

The choice of assessment criteria and the amount of detail to be examined will be left to the commission.Detailed criteria should permit non-experts to undertake assessments and, because they specify precisely what is required, prevent inspectors' judgements being criticised for bias. Paying attention to the criteria should also help level quality across healthcare by introducing standard processes and procedures.

However, detailed criteria present difficulties in a healthcare system which is striving to reform its structure and practices. They frequently create a straight-jacket which restricts organisations to following the requirements spelt out in the criteria. To create the healthcare systems required by today's public and politicians, intelligent and creative management is required.

Inspectors will therefore have to be skilled in 'intelligent assessment' and not be dependent on detailed criteria to make their assessments, using instead what commission chair Professor Sir Ian Kennedy has described as 'intelligent information'.

Some critics have claimed that the standards are simply motherhood and apple pie.

Those who subscribe to this view have probably failed to read the standards in depth and to recognise the key policy issues enshrined within them.

The standards are not yet perfect - they do not cover everything - but they are the start of a journey of innovation and improvement for the whole healthcare system. The standards will require continuous review and development to ensure they reflect what is expected of a healthcare system fit for the 21st century.

That is, a system that is continually open to change and which questions its relationship with the public to ensure what it provides is at the forefront of clinical practice and of benefit to those who use it.

Professor Ellie Scrivens is director, Keele University healthcare standards unit.

The Department of Health has contracted Keele University healthcare standards unit to maintain and evaluate the impact of the 'standards for better health'.

The unit will also work with the NHS to provide guidance on interpreting and using the standards.The views expressed in this article are those of the author and not necessarily those of the DoH.

Seven up: quality domains


Clinical and cost effectiveness


Patient focus

Accessible and responsive care

Amenities and environment

Public health www. dh. gov. uk/Consultations/ LiveConsultations/fs/en