© Nuffield Trust March 2013 Twitter: #NTSummit Quality In Austerity - Indicators of Quality Martin Bardsley Director of Research, Nuffield Trust

© Nuffield Trust Why is HF/NT investing in work on quality? There is no inevitable inverse relationship between finance and quality but.... Financial pressure may divert attention from quality Search for transformational changes in delivery may have unintended consequences (good/bad) on quality Historically success in areas like waiting times and HAI linked with significant investment Efficiencies likely to be sought in staffing New organisational structures everywhere Implications of austerity on health needs

© Nuffield Trust There a whole lotta monitoring going on User-generated content organisations NHS Ombudsman HealthWatch Experience Complaints Engagement Professional regulators Quality of education Individual competence National Quality Dashboard and corporate intelligence NHS TDA CCGs Contract management Performance against plan NHS CB Provider Patients Continuous monitoring of quality Department of Health Information from people using services third party information support to the commissioners Public Health England Commercial analysts Care Quality Commission Monitor NHS Outcomes Framework. Performance against objectives Data (eg QRP s) and inspection / investigation Data CSUs Data Self monitoringContract monitoring Data monitoringInspection monitoring Experience monitoring

© Nuffield Trust What can Health Foundation and Nuffield Trust add? Provides an independent overview of how quality of care is changing over time. Offers a view across different dimensions of quality that is not linked to any one provider or sectors. Enable flexible analysis of important quality issues as they arise, and uses a range of methodologies. Develops the methods used to measure quality, including innovative analyses across linked data sets at person-level. Looks across the care system and where possible include international comparators.

© Nuffield Trust Quality in Austerity Programme 5 year, multi-stranded programme Compliment existing initiatives looking at quality Developing sets of indicators… …to measure changes in the quality of care over time across care settings. Deeper analyses on ‘hot topics’… …building on our capacity to use complex information to create new approaches and new perspectives on how the quality of care is changing within the NHS.

© Nuffield Trust Topic: Trends in Ambulatory Care Sensitive Admissions Age-standardised rates of admission for ear, nose and throat infections, 2011/12 ACS admissions have increase by 40% in the last 10 years – will they continue to grow?

© Nuffield Trust Individual indicators Effectiveness Access and timeliness Capacity Safety Patient centeredness Equity

© Nuffield Trust Primary and community provision General and acute Mental health Social care provision Population / commissioner level An explosion of indicators… …but some areas better covered than others Outcomes Frameworks, NICE, QRP, QIPP, QOF, Quality Accounts, Dashboards, Thermometers, Atlases… Total Secondary / tertiary provision Effectiveness Access and timeliness Capacity Safety Patient centeredness Equity

© Nuffield Trust Some areas better populated than others Hospital admin systems - strong on activity and coverage but limited detail General Practice – massive data sets with untapped potential Acute care specialist and clinical systems – hugely variable Social Care – tend to be local, not shared. Major problem re self funders Community Care – very variable Independent Sector Care – very limited Even more limited outside acute trusts

© Nuffield Trust And an external body can only see so much in a complex organisation Community Visibility of performance (quality) Though good data exists in places we still rely too much on HES based Corporate Clinical

© Nuffield Trust Failures in quality: the holy histogram theory Weak OK GoodExcellent Basket Non compliant REGULATOR or COMMISSIONING (enforcement) (contracting) ‘IMPROVEMENT’ BODIES COMMISSIONING (contracting, choice, competition…) ‘IMPROVEMENT’ BODIES Number of organisations Quality

© Nuffield Trust In an ideal world, quality indicators would be built from… 1. The information we need to understand clinical quality at organisational level and above should flow from information collected in the course of people doing their jobs Including... Patients views, PREMS and PROMS 2. Data linkage between these encounters / events / episodes at patient level is important: a. To make the most of what data we have b. To measure outcome (“change in patient health status that can be attributed to antecedent health care”) GP Health status Hospital Social care

© Nuffield Trust Some of the most critical areas are the most challenging eg Information from care users Care Users – Surveys, F&F, Complaints, Individual reports/stories Patient reported outcome measures Staff perceptions Quality of medical treatments – limited information Patient outcomes – difficult to assign causality Capturing qualitative intelligence Improving these will help but no guarantee of predicting future failure

© Nuffield Trust So what do we need to do… A.Continue developing information from patients and staff B.Fill the gaps for services that are lacunae – OOH, community, independent sectors... C.Go beyond HES into the quality of services including clinical audits D.Integrate the quantitative and qualitative E.Link data to make the most of what there is and to assess consequences /outcome F.Link the information to subsequent action....