What does quality in healthcare now mean, how is it measured around the world and how well do the NHS's systems measure up globally? Simon Leary and Rachel Abbott report
If there is a single thing on which patients, doctors and health policy planners agree when it comes to health system reform, it is that everyone wants the highest possible quality in care. But what does high quality look like? Without clear definitions, it is not surprising the quest becomes a conundrum - a universal and complex issue with no easy solution.
PricewaterhouseCoopers' Health Research Institute has examined quality improvement efforts in more than 10 countries, interviewing over 50 industry leaders. It found there were no quick wins but also that innovative groups and individuals are making healthcare better, safer and more accessible. These experiences are collected in a report, The Quality Conundrum: practical approaches for enhancing patient care.
A wide variety of health systems and political environments around the world makes for numerous models of accountability when it comes to quality in healthcare. Despite international differences, experts interviewed for the report emphasised that quality is everyone's problem and responsibility.
In many countries the onus has shifted with the financial and political environments surrounding healthcare. For example, quality programmes are largely run by independent and clinician-led groups in the Netherlands, where the medical profession has a long-honoured tradition of professional self-regulation. In the US and the UK, reports about medical error and high-profile scandals such as the Shipman case have made patients wary, and demands for greater government regulation have grown.
The true cost of factors like medical error and infection, delayed or denied treatment or forgotten test results is almost impossible to quantify. What is certain is that everyone bears these costs.
The good news is that every organisation and person in the NHS has the power to make a substantial difference to how patients are treated. The best systems have physician-led quality programmes, patient survey programmes and active patient groups working alongside Department of Health initiatives.
More than safety
It is easiest to think of quality as the absence of medical error, and indeed it is a critical component. Despite increasing international attention to patient safety over the past five to 10 years, medical error, hospital-acquired infections and other threats to safety remain common.
Ongoing media attention to HAIs keeps patient safety issues in the public eye and encourages continued attention to the issue from managers and regulators. Experts are quick to point out, however, that monitoring and publicising medical error, HAIs and so on is not enough; incentives are needed to seek out and rapidly implement solutions that genuinely help patients.
The World Health Organisation's 2000 world health report identified strategic purchasing as a powerful tool for health system improvement. Directly linking financial incentives to quality may be the most effective road to quality but it is also the most challenging and complex.
The PricewaterhouseCoopers survey found that when commissioning happens at a local level, pay-for-performance schemes are often applied selectively by region and a national or system-wide approach is more effective in influencing quality.
Increasingly, governments are recognising this and building performance indicators into commissioning practices.
For example, the UK's general medical services contract quality and outcomes framework may be the largest and most ambitious pay-for-performance experiment in the world.
And in the Netherlands, recent reforms include changes to insurance reimbursement practices that will now include consideration of provider quality, efficiency and accreditation. Across Europe, managers and policy makers believe that linking meaningful and measurable indicators to financial incentives is crucial to health system quality.
Problems often occur at the contact points between individuals and organisations. The same points that produce bottlenecks and long waiting lists are also where communication and patient information breaks down.
Electronic medical records are often seen as tools to make safer, faster diagnoses and reduce redundant testing, saving both time and money. But this is not possible everywhere.
Nor is IT a panacea - experience with Connecting for Health and choose and book systems has demonstrated that sophisticated health IT systems come with challenges of their own.
According to the survey, the NHS IT systems will put the UK ahead of most of the world in the way it collects and manages health information.
The challenge comes in monitoring and measuring quality in chronic and long-term care where much of the healthcare happens away from the hospital, at home and in day-to-day life. Co-ordinating national disease frameworks and IT capabilities will make a difference and help those with chronic disease.
International health experts feel strongly that patients should be provided with as much objective information about health services as possible. Experience in the US has shown that when patients can understand and respond to information about hospital performance, providers are motivated to improve their performance. Helping patients to use health service quality information is the difference between a patient-led NHS and an NHS led by well informed, quality-seeking patients.
The remit of the NHS no longer stops at its borders. Between 2003 and 2005 hundreds of NHS patients received orthopaedic surgery in Belgium under an arrangement with the DoH. Recent European Court of Justice rulings mean the NHS may increasingly be responsible for paying for treatment abroad.
With the advent of the European health insurance card, patients in Germany can cross into Poland for dental care and UK pensioners in Spain may send medical bills home to the NHS. This means a global quality agenda is critical both to UK patients who want to be assured of high-quality care wherever they are and to the NHS commissioners who want to know what they are paying for.
International experts are coming to a more sophisticated understanding of what quality means in healthcare.
Beyond the absence of medical error, industry leaders say in the survey they are working to understand the indicators that demonstrate quality in patient care as well as quality in health system performance overall.
In doing so, health experts have opened the door to measuring, monitoring and improving services for patients, with practical applications both for the NHS and beyond the UK's borders.
Simon Leary and Rachel Abbott are consultants with Pricewaterhouse-Coopers' healthcare practice.