Exploring the quality challenges

Chairing the panel discussion, Nigel Edwards, senior fellow at the King’s Fund, opened the debate by referring to the series of “disturbing” reports about healthcare quality that have been published in recent months. He believes that another search for the correct model of regulation is now well underway, referring to the number of enquiries currently in progress which focus on the search for quality. He said: “There have been three reviews of regulations over the past 12 years with the Care Quality Commission (CQC) currently undertaking a further examination. The QIPP challenge is also an important part of the search for quality.” However, he went to voice his concern about the evidence for highquality care always being cheaper. “It is sometimes easier to make efficiency savings which do not positively affect quality, or might even endanger it.” He made it clear that the pressure to make efficiency savings should never be at the expense of quality of care or safety. There can be no doubting the evidence relating to the quality issues in healthcare, or significant regional variations between quality and outcomes, which are hard to justify, and are a big concern. These concerns are set against a growing pressure for transparency through the publication of information. “This trend is unlikely to be reversed,” said Mr Edwards. “Indeed, it is likely to become more intense.” He believes that there will be less tolerance of poor quality and the high levels of variation in the future, and believes that policymakers will start to impose payment systems and regulatory mechanisms to mirror this increasing intolerance.

Barriers and facilitators

 Professor Albert Mulley, director of the Dartmouth Centre for Health Care Delivery Science, continued the debate by focusing on the barriers to, and facilitators of, high-quality patient care. He said: “Currently, the most important barrier to achieving both quality and patient centredness, as well as efficiency, is the failure to acknowledge the complexity of medical care. We want to believe that, if we deliver a particular intervention, it will achieve a particular result and that this result will be valued by those who receive the intervention. In reality, as clinicians know, there is a great deal of uncertainty between the intervention and the result. “Patients also disagree about the value of particular results. Interventions demand a trade-off between different domains of health, or physical function. Each patient will be willing to make different trade-offs.” It is this complexity, said Prof. Mulley, that leads to the phenomena of practice variation. In his view, this variation can provide a good resource for learning, however. “If all practice variation were bad, then it would be an easy problem to solve,” he said. “It is a bigger challenge to sort out the bad variation which reflects poor knowledge management or uncertainty that does not need to exist when decisions are being made, from the good variation which often reflects the different trade-offs that the patient is willing to make. “It is not always possible to define processes that will deliver quality and patient-centredness and there is a worry that, when such measures are overspecified, it results in a box-ticking response on the part of physicians which can drive out the intrinsic motivation to achieve quality and to recognise the uniqueness of each patient. “We need to look more deeply at the issues and create measures for quality improvement in transformative ways. Such measures should be more aligned with the forces of intrinsic motivation and more consistent with the values of the profession. They should include knowledge sharing – among clinical team members, and between the patients and communities that have to live with the consequences of the care that is delivered. We also need to measure the quality of clinical decisions – is the patient well informed? Does the care provided match what the patient cares about in life?” Concluding, Prof. Mulley reiterated what he believes is the principal facilitator for improved quality: “It revolves around a willingness to question assumptions, about how things are done and how they could be done, and to question to what extent the quality measures that are applied are focused on managing the present and creating the future. It is important to remember that there will always be a move away from patientcentred care when clinicians are encouraged to focus on processes.”