The NHS brand provides an assurance of quality, but the benchmarking process is murky and doesn’t allow for comparison with independent care providers - calling into doubt whether benchmarking currently can really be a useful tool for measuring performance, says Patrick Carter.
I recently attended a meeting of GPs and commissioners to present data on diagnostics services across London. As an independent provider we are - quite rightly - obliged to publish the results of InHealth’s work, use of the service, patient feedback, and patient outcomes. A GP argued the results were all very well, but the local hospital would do just as well, if not better.
The problem with this argument was that no evidence could be found to certify whether this was true or not. Commissioners had not asked for any evidence from the local hospitals on their work, and if any evidence was being collected it wasn’t being shared.
The NHS brand is used as assurance of quality and value for money but often with no supporting evidence. On the one hand there is no problem with that, it’s a reputation the NHS has built up over the long haul. But should we be in a situation where we don’t always know how good services are and assume that services delivered by the NHS are always exemplary?
Benchmarking as a concept is an activity that is much talked about, yet the NHS Benchmarking Network does not permit independent sector providers to join and share data, undermining any potential for positive and transparent comparison.
Given the changes coming in the commissioning of services, assumptions are no longer good enough. There will be a much greater need for transparency on the effectiveness of services and clinical outcomes in order for the NHS both to confirm its strengths and to pick out where support is needed - support which will protect the viability of the institution for the future.
From the perspective of GPs, with new responsibilities for commissioning services from different providers, transparency will be a critical basis for selecting providers.
Apart from the work of the National Clinical Audit Support Programme on specific health issues such as cancer and diabetes, clinical audit information is not routinely collected or, more importantly, shared among commissioners and other decision-makers. If audit material is not expected, monitored and, if necessary, challenged there is no reason for the kinds of clinical audits which are important to patients and service delivery to be carried out on a sustained basis.
Evidence of the results of diagnostics and imaging audits are of particular importance and a good example of the need. It’s often the pivotal stage in patient care, where MRI, x-ray and other scans confirm the presence of serious conditions and the route for patients through the system. The availability of appointments and the accuracy of the results mean everything to patients. Delays and errors have serious consequences for treatment and waiting lists.
The data we need to collect, for example, shows that GPs with direct access to diagnostics services have a strong record of making appropriate referrals to specialists. The audit data is not just useful reassurance, it can be the basis for decision-making, policy, and a better experience for people using the NHS.
Research has been carried out to look into fears that direct access to GPs could lead to misdiagnosis and over-referrals. The study looked at the cases of 800 patients referred directly by their GP for a diagnostic test (such as an MRI, ultrasound or echocardiagram) as part of the NHS London Diagnostics Service.
Direct access to a diagnostic test resulted in 71 per cent of patients being managed solely in primary care without the need for further referrals to hospitals. Only 234 (29 per cent) of patients were referred to a specialist after they had received an abnormal report. And just 56 (7 per cent) of patients with a normal report were referred to a specialist. 74 per cent of GPs agreed that the availability of direct access tests had reduced the waiting time.
Feedback from patients was consistently positive with 98 per cent reporting that their experience of the service was very good or excellent. It’s the type of evidence which can be used by commissioners in other parts of the UK to improve services and cut costs.
The culture needs to change, both for audits to be the basis for raising standards and for individual NHS service providers - as well as independent sector operations - to have the chance to prove themselves as high quality and value for money. This will be critical for creating a level playing field and fair competition for all potential providers.
Ultimately though, the issue is not about competition but about how transparency can improve patient care. And for NHS managers, the sooner benchmarking processes become the norm, the sooner providers can make self-directed improvements rather than exposing themselves to potential change imposed from above.