J R Soc Med 2005;98:224-227
doi:10.1258/jrsm.98.5.224
© 2005 Royal Society of Medicine
Standards in the NHS
Charles Shaw
Charles Shaw, MB PhD, founding Chairman of the RSM's Section of
Quality in Healthcare, has for twenty years been closely involved in clinical
audit and quality assurance. A former President of the International Society
for Quality in Health Care, he now works for international agencies and health
ministries around the world.
Correspondence to: Roedean House, Brighton BN2 5RQ, UK
E-mail:
cdshaw{at}btopenworld.com
 |
INTRODUCTION
|
|---|
Sixty years ago, the new National Health Service promised that
a doctor
would be assured ‘freedom... to pursue his professional
methods in his
own individual way, and not to be subject to
outside clinical
interference’.
1
But after thirty years,
the Chief Medical Officer, Sir George Godber, set out
to define
a ‘Cogwheel’ structure for the accountability and
self-regulation
of hospital
doctors,
2 and soon a
non-governmental inquiry reported
‘It is a necessary part of a doctor's
professional responsibility
to assess his work regularly in association with
his
colleagues.’
3
In
evidence to the Royal Commission on the NHS in 1977, the British
Medical
Association was ‘not convinced of the need for
further supervision of a
qualified doctor's standard of care’.
In its final report, the
Commission responded, ‘We are
not convinced that the professions regard
the introduction of
medical audit and peer review with a proper sense of
urgency.’
4
Thus, thirty years ago, standards in the NHS referred not to clinical
practice or services but to buildings, equipment, capacity and allocation of
resources.5 Any
defects in the system were blamed on shortage of staff, money or
facilities—after all, the NHS was then one of the cheapest comprehensive
health systems in the world. There was little effort to examine how those
resources were used or whether they could yield better clinical results. There
had been several public scandals about the treatment of patients, the
behaviour of doctors and the management of institutions, particularly in
long-term care. But few people were keen for improvement, or even recognized a
need for it. Tradition and the stout defence of clinical freedom made the
management of doctors as easy as herding cats.
|
Quality assurance
|
|---|
The concept of ‘quality’ in the NHS was effectively
launched in
1983 by the report of Roy Griffiths on the management
of the
NHS.
6 He emphasized
the importance of consumers (previously
called patients) in defining
expectations and judging performance.
He also replaced hospital management
committees (administrator,
treasurer, nurse, doctor) with one general manager,
and suggested
that one senior assistant should be responsible for quality.
In
the ensuing scramble for jobs many senior nurses became directors
of quality,
and established committees, structures and systems
for ‘quality
assurance’.
So, in the late 1980s, quality was driven by nurses and supported with
training and research by the Royal College of Nursing. Some medical Royal
Colleges and Faculties—notably the anaesthetists and thoracic
surgeons—had begun to identify and question variations in clinical
outcomes. But most doctors were not systematically involved in the new
movement until participation in medical audit became a formal requirement of
the NHS.
|
Medical audit
|
|---|
Unlike some other propositions in the White Paper (especially
the
purchaser-provider split), the introduction of medical
audit
7 as an
educational tool had a friendly reception from the profession,
albeit with
reservations. The political intent was clear; the
Thatcher Government had
already subdued the unions and the legal
profession, and now was the time to
make doctors more accountable.
The implementation and implications of medical
audit were not
at all clear; civil servants were given six months to make
practical
arrangements.
Audit committees were set up at local, district and regional level and were
mostly unconnected to the existing structures and methods of quality
assurance. Many argued that there was not enough time, money, guidance,
support or reliable information for systematic audit. But then audit budgets
were established, audit assistants were invented and absurd sums were invested
in useless stand-alone computers for consultants. General practitioners were
not accorded the same largesse; the obligation of audit was considered to be
inherent in their existing contracts.
After the teething problems, the underlying weaknesses of the original plan
became clearer. First, doctors were trained to evaluate and treat patients one
at a time; most had neither the knowledge nor the skills to compare clinical
processes and outcomes systematically. Second, the professional bodies and
academic institutions had not been involved from the start; there was no
coordinated plan for research, training and professional development. Third,
evidence for effective medical practice was largely unavailable or
inaccessible; ‘good’ practice was based on tradition and personal
preference. Fourth, nurses, allied professions and, especially, managers were
excluded; doctors were able to change their own practice but were unable to
change the system in which they worked. Finally, the medical audit committees
were more advisory than executive; they were not accountable to the management
or to the public.
|
From audit to effectiveness
|
|---|
Many doctors, particularly the older ones, were uncomfortable
discussing
their clinical results with other doctors; for them,
the move in the mid-1990s
to multidisciplinary clinical audit
came too soon. The concept of working in
clinical teams was
better received in general practice and long-term care than
in
acute hospitals.
About the same time, ‘audit’ slipped off the NHS priorities, to
be replaced by ‘clinical effectiveness’. Attention turned away
from measuring the behaviours of clinicians and organizations and on to more
palatable issues of evidence-based medicine, research, technology and
machines. This transition was celebrated by another renaming for the audit
committees and retitling of audit staff, the launch of a national institute
and, of course, another journal. Many of the lessons of the audit era, though
still relevant, were not followed through at local level, particularly
regarding training needs, clinical systems and professional
accountability.
|
And so to governance
|
|---|
By the late 1990s the NHS was littered with the relics of earlier
expeditions,
and in need of a unifying concept. The solution came from the
future
Chief Medical Officer for England, Liam Donaldson, in the form
of
‘clinical governance’—a term that has been
progressively
adopted in many other countries to fill the gap
between government
‘stewardship’ of the health system
and local
‘management’. And again the committees
and staff were relabelled,
and new journals appeared.
|
...and safety
|
|---|
Latest in the series of quality priorities (patients' rights,
clinical
competence, effectiveness, service performance and
so on) is the safety of
patients and staff. Evidence from around
the world, starting from the Harvard
Medical Practice
Study,
8 consistently
told us that healthcare is dangerous and that the
UK is no
exception;
9 for
example, one patient in ten is damaged
during an inpatient stay. A series of
reports from the Institute
of Medicine (IoM) analysed the causes and effects
of failures
in the USA and made far-reaching recommendations that focused
on
the systems of training and healthcare rather than the individuals
who are
receivers or
providers.
10,11
Most of those messages
could apply to all developed countries, including the
UK.
|
Learning from the Bristol Inquiry
|
|---|
The British equivalent of the IoM reports was triggered by investigation
into
paediatric cardiac surgery in a Bristol teaching
hospital.
12 A
dissection of performance management from one clinical department
all the way
to the Department of Health provided a meticulous
case study not only for
England but also for much of the rest
of the world. Much of the evidence
suggested that, in the early
1990s in one large hospital, several key national
initiatives
to promote quality had failed: external monitoring, performance
management,
market competition, consumer empowerment, clinical managers,
service
contracting, medical audit and data systems had all failed in
this
instance to define, measure and ensure compliance with
acceptable standards of
organization and practice. Many of the
resulting recommendations were not new;
indeed, most of the
proposals on peer review had been formally issued to the
NHS
in the previous ten years but not followed through.
|
Twenty years on
|
|---|
Bristol exposed numerous systematic weaknesses in the NHS but,
despite
these, the UK can fairly claim to have achieved many
quality milestones in the
past twenty years, and to have pioneered
many quality systems in Europe. Here
are some highlights and
lowlights:
- Professional culture: doctors, in particular, have moved from
unfettered clinical freedom towards guarded acceptance of accountability,
transparency, regulation and evidence-based medicine
- Government policy: has changed too much; successive ministers have
started new, largely untested ‘quality’ initiatives without a
coherent and comprehensive strategic plan for improvement which is owned by
stakeholders and able to survive a change of government
- Confusion of leadership: the UK does not clearly separate the
government role of stewardship from the NHS Executive role of management, or
set out to balance top-down control with bottom-up self-regulation. This is a
common defect of predominantly public-funded health systems
- National agencies: organizations were set up including bodies for
clinical practice, competence assessment, patient safety, controls assurance,
clinical negligence, service inspection; many countries have followed suit,
but their agencies are less fragmented, more participative and more stable
- Public/private partnerships: Britain (especially England) has been
slow to adopt public/private partnerships for quality improvement, which have
been promoted by independent commissions in
Australia13 and the
USA.14 Examples of
collaboration in the UK include the Scottish Intercollegial Guidelines Network
with the already reformed Clinical Standards Board (now
QIS15), and the
proposed concordat by which a statutory inspectorate (the Healthcare
Commission) could reciprocate with voluntary and professional peer review
programmes16
- Professional development: postgraduate programmes, staff appraisal
and revalidation have become the norm in the UK but are still rare in many
other countries; in general, Europe lags behind North America in work-place
systems of credentialling and privileging
- Public information: consumers in the UK now have much more access
to information about rights, choices, and services; systematic independent
surveys of patient experience add to routine measures of service performance,
but both sources are compromised by massage and selective publication,
spawning more independent sources (e.g. Dr Foster
[www.drfoster.com])
- Clinical effectiveness: the NHS has been a pioneer in clinical
audit, practice guidelines, indicators and confidential inquiries but their
messages are not consistently heeded, implemented or followed up at local or
national
level17
- Quality infrastructure: ‘audit assistants’ grew from a
junior handful in 1990 into a career pathway of several thousand support
professionals; there is no agreed national training curriculum for them, but
technical skills and knowledge of quality improvement are now required of
medical specialists.
|
And where next?
|
|---|
Irrespective of the outcome of any plebiscite, or of the rules
of
‘subsidiarity’ which leave health services entirely
(well, mostly)
the business of Member States, the greatest formative
pressures on the UK will
come from the European Union. Freedom
of trade, mobility of staff and
patients, reciprocation of biomedical
and health service research,
professional training and regulation,
and protection of public safety will
increasingly define common
standards for the provision, assessment and
improvement of healthcare.
Britain's non-governmental organizations have
already contributed
to this movement—for instance, with clinical
pathology
accreditation
18 and
guidelines for diagnostic
radiology
19—but
public bodies
also must be prepared to export, and to import. This will demand
that
national policies become more explicit and joined-up within
and between
countries, that national support agencies (such
as for clinical guidelines in
France, Scotland and England)
share rather than duplicate work and resources,
and that performance
data are standardized and available across the borders of
Europe.
Even though the UK shares fewer patients and services with the rest of the
world, it should still watch and learn from the experience of others, such as
the ‘new rules to redesign and improve care’ proposed by the
IoM,11 standards
for health service
assessment20 and
the public inquiries into health service scandals elsewhere. Someone needs to
be actively scanning the horizon, and that government and the NHS must listen
and be able to respond. Whose business is that?
|
REFERENCES
|
|---|
- Ministry of Health. A National Health
Service. London: Stationery Office, 1944
- Godber G (chairman). Organisation of Medical Work in
Hospitals. London: HM Stationery Office,1974
- Alment EAJ (chairman). Competence to
Practise. London: Committee of Enquiry,1977
- Royal Commission on the National Health Service.
Report. London: HM Stationery Office,1979
- Shaw CD. Monitoring and standards in the NHS.
BMJ1982; 284:217
,294[Free Full Text]
- Griffiths R (chairman). NHS Management
Enquiry. London: DHSS, 1983
- Department of Health. Working for Patients: Medical
Audit. Review working paper 6. London: HM Stationery Office,1989
- Brennan TA, Leape LL, Laird NM, et al. Incidence of
adverse events and negligence in hospitalized patients. N Engl J
Med 1991;324:370
-6[Abstract]
- Vincent C, Neale G, Woloshnowych M. Adverse events in British
hospitals: preliminary retrospective record review.
BMJ2001; 322:517
-19[Abstract/Free Full Text]
- Kohn LT, et al. To Err is Human: Building a Safer Health
System. Washington: National Academy Press, 1999
[www.nap.edu/openbook/030906837/html]
- Institute of Medicine. Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington: National Academy Press, 2001
[www.nap.edu/openbook/0309072808/html]
- Learning from Bristol: The Report of the Public Inquiry into
Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995.
Command Paper: CM 5207 2001
[www.bristol-inquiry.org.uk]
- National Expert Advisory Group on Safety and Quality in Australian
Health Care. Report. 1998
[www.health.gov.au/about/cmo/report.doc]
- President's Advisory Commission on Consumer Protection and Quality
in the Health Care Industry. Quality First: Better Health Care for All
Americans. 1998
[www.hcquality/commission.gov/final/]
- NHS Quality Improvement Scotland
[www.nhshealthquality.org/]
- Healthcare Commission. Concordat between regulatory bodies auditing
and inspecting, regulating and auditing health care, 2004
[www.healthcarecommission.org.uk/assetRoot/04/00/43/01/04004301.pdf]
- Wilson B, Thornton JG, Hewison J, et al. The Leeds
University Maternity Audit Project. Int J Qual Health
Care 2002;14:175
-81[Abstract/Free Full Text]
- Clinical Pathology Accreditation UK
[www.capa-uk.co.uk]
- European Commission. Referral Guidelines for Imaging, 2000
[http://europa.eu.int/comm/environment/radprot/118/rp-118-en.pdf]
- International Society for Quality in Healthcare. Standards for
External Assessment of External Evaluation Bodies, 2nd edn. 2004
[www.isqua.org/isquaPages/Accreditation/ISQuaSurvStandards2.pdf]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
TOP
INTRODUCTION
Quality assurance
