20 / 12 / 2016
Quality at a cost
QualityWatch, December 2016
Dr Liz Fisher and colleagues have produced the fourth annual statement from the joint Health Foundation/Nuffield Trust research programme, QualityWatch. This summary will highlight a concise set of key findings from both the statistics outlined in the report and the discussion on care quality. In their foreword, Jennifer Dixon and Nigel Edwards note that “when pressures bite, the first thing to give is access to care” and warn that the myriad of pressures being placed on the system could “lead to ‘delayed decline’ in areas of quality so far unaffected.”
- This section predominantly draws on the QualityWatch assessment by Davies et al, published earlier this year. The researchers found that while 10 public health indicators had improved over the period between 2009 and 2015, in half of these cases “there was an indication that progress may have slowed.” These concerns were raised in connection with areas such as smoking prevalence, HIV, substance misuse and MMR. Moreover Davies et al found that outcomes had declined in six areas including smoking cessation, alcohol-related admissions and four STIs.
- The continued absence of “comprehensive, up-to-date general practice activity data” and the difficulties involved in understanding quality in primary care are noted.
- GP patient survey data in 2015/16 has shown the recent declines in access measures levelled off in that year. Eighty-five per cent of respondents regarded their overall experience of GP surgeries as very or fairly good in 2015/16 compared to 88 per cent four years earlier.
- The authors do warn that patient choice is an area that “appears to becoming more difficult to satisfy”, with the proportion ‘always’ or ‘almost always’ able to see their preferred GP declining from 42 to 35 per cent between June 2012 and July 2016.
- Ambulance calls overall have increased by 15 per cent between 2011-12 and 2015-16, with Red 1 and Red 2 calls requiring an emergency response increasing by 47 per cent between 2012-13 and 2015-16.
- Concerns are raised about response times, with performance against the eight minute target reaching a low in March 2016. However the authors point to a number of factors beyond call volume for this, including complexity of cases and delayed transfers to alternative care settings.
- The report highlights a positive story about the quality of call handling, with the proportion of patients re-contacting 999 within 24 hours of their case being closed through telephone advice declining from 13.2 per cent in 2011-12 to 6.3 per cent in 2015-16. Over the same period the number of incidents that didn’t require transport to A&E increased by almost 500,000.
- Over the period between 2008-09 and 2014-15, planned admissions (15 per cent) have been found to increase by a higher proportion than emergency admissions (12), even with the former actually falling in the final year.
- While hospital episodes rose by almost six million between 2002-03 and 2014-15, bed days declined by seven per cent, with mean length of stay falling by three days in that time.
- The report discusses the recent breaches of the 18 week target, but also notes “there does not appear to have been an associated negative shift in patients’ views on treatment waiting times.”
- Between January 2006 and January 2016 the proportion of people waiting more than six weeks for a diagnostic test has ‘fallen dramatically’ from 55 to two per cent.
- While cancelled operations have risen in recent years, it is highlighted that the rate overall has remained very low, at 1.2 per cent in the fourth quarter of 2015-16.
- Trust-apportioned MRSA cases increased in 2015-16 for the first year since 2007-08, although the overall rate was only 1.5 cases per 100,000 population. Meanwhile C difficile cases within hospitals have fallen by 85 per cent between 2007-08 and 2015-16.
- The report also discusses the positive trend in people reporting being involved in decisions about care and treatment in the CQC inpatient survey, with the proportion feeling ‘definitely’ involved having risen from 53 per cent in 2005 to 60 per cent by 2015. Nonetheless the authors contend that “more still needs to be done to decrease the number of people who are not treated in the way they were expecting.”
- Statistics are cited from the NHS England Mental Health Taskforce, including that mental health accounts for 23 per cent of NHS activity and 90 per cent of people with more severe mental health conditions are supported by community services.
- The main focus in this section is on the views of service users in mental health. Seventy-two per cent of respondents to the CQC’s 2015 community mental health (CMH) survey rated their care as six out of 10 or higher, in line with previous years. However the authors express concern about the disparities seen between both the results of the CMH survey and others undertaken by CQC and the scores of people with and without mental health conditions in the research within other care settings. For example the proportion of people rating their inpatient care as six or more out of 10 was only 79 per cent for people with a self-reported mental health condition compared to 91 per cent for other respondents. The authors conclude that “all of this points toward a lack of parity of esteem in the experiences of patients with and without mental ill health.”
- This section looks at the care provided to those suffering from hip fractures and strokes. While admissions for the former have increased by 17.9 per cent between 2002-03 and 2014-15, the standardised 30-day mortality rate has declined by 29.8 per cent over the same period.
- The authors also offer a range of evidence that care is improving for those who have had a stroke. For example the proportion having a swallowing assessment within four hours of admission has risen from 64 to 72 per cent between 2013-14 and 2015-16 and the proportion having a mood and cognition screening on discharge increasing from 79 to 89 per cent over the same period.
The report then moves on to discuss the broader implications of its findings. There are concerns expressed about areas that have “historically improved” which “have started to slow or stagnate”, with MRSA and C. difficile infections particularly identified. Other key points include:
- The ongoing financial squeeze to the DH budget prompting a call for the Government to be honest with the public about the impact on access and care standards “if additional funding is not forthcoming.”
- The authors warn that maintained quality in relation to safe and effective care “is happening at the expense of timely access” and that more such 'trade-offs' should be expected in future years. It is argued that “this could make the NHS vulnerable to serious lapses in care.”
- Investment should be made in a range of areas to maintain quality improvement, such as education and training, analysis, technology and policy frameworks.
- Calls for wider availability of data and linked datasets are reiterated from previous annual statements.
- Ultimately, the authors conclude the year ahead “will prove a crucial test for the resilience of the health and social care system.”