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Bruce's Dozen: A turning point for quality improvement?
Tuesday, 16 July 2013
Sir Bruce Keogh’s report on 14 English hospitals with the worst mortality rates, published today, is a review for our time. Commissioned in the wake of the second Francis inquiry into Stafford hospital and launched in a period of political recriminations over the NHS, its existence reflects the mood of the day: growing concern about the capacity of the NHS to deliver safe, compassionate care and anxiety that there might be “more mid Staffs” lurking below the radar. It provides plenty of material for those who would seek to discredit the NHS, the regulators, the coalition government and its Labour predecessor. Indeed some of the seamier politics were clearly on display in the weekend before the launch of the report.
The review itself is a balanced and thoughtful study of the 14 hospitals concerned, what needs to happen to sort them out, and lessons for the wider NHS.
Declaration of interest: I sat on Sir Bruce’s advisory group. Underlying the whole exercise were two big, related problems that bedevil the health service and perplex patients and the public: (1) why don’t we have better information about how well or otherwise NHS bodies are performing ? And (2) why is poor performance allowed to persist? As Sir Bruce notes, overall mortality in English hospitals has fallen 30 per cent in the last decade (a fact you could be forgiven for not knowing if you only read the press) and the rate of improvement in the 14 hospitals studied has been similar to other hospitals.
Yet these hospitals were mortality “outliers”. So how bad were they? There was controversy about how much the two main measures of hospital mortality could be relied upon to give an accurate picture of the quality and safety of care. But it was also clear that these hospitals had suffered well documented problems over several years. As Sir Bruce puts it: “these organisations have been trapped in mediocrity”.
In our paper “After Francis: doing justice” published last March, National Voices said “There needs to be a consistent and transparent methodology whereby commissioners and regulators identify and investigate those organisations and services which are causing concern based on their comparative performance on various measures... It is a serious indictment of the NHS that an ad-hoc review of this kind [the Keogh review] should be thought necessary. It would not be necessary if there were already a trusted system in place to deal on a continuing basis with relatively poor performance. A key output of the new Keogh review must be to bequeath such a methodology to the NHS.”
That is exactly what the Keogh review has sought to do. It sets in train work to generate a new measure of “avoidable deaths”. It calls for all the fragmented data about quality in hospitals – quantitative and qualitative - to be brought together in a useable form, and for trusts to invest in the skills to interpret and use them. It calls for real time patient feedback and comment to become routine and “reach well beyond the Friends and Family test” (music to the ears of those, like National Voices, who have criticised FFT for being a superficial and inappropriate borrowing from the world of commerce).
Keogh also trialled an inclusive, data-driven, transparent, multi-disciplinary process of review for each trust. It was seen as a tough but fair process which uncovered things that previous investigations had not – for example the disparity between reported and actual staffing levels on wards. It was the very antithesis of the tick box, generic approach previously used by the CQC and the new chief inspector of hospitals Sir Mike Richards is expected to adopt it. Sir Bruce notes that “involving patients and staff was the single most powerful aspect of the review process” and sets out an ambition that “patients, carers and members of the public will increasingly feel that they are being treated as vital and equal partners in the design and assessment of their local NHS”.
National Voices remains sceptical about the power of regulation and inspection to drive quality improvement in trusts. But if a job is worth doing, it is worth doing well and the Keogh review offers a better blueprint for doing it well.