Britons invented the first antibiotic, the MRI scanner, in vitro fertilisation, and much more, and Britain punches way above its weight in science, said Sir Bruce Keogh, NHS England’s medical director, at the HCA Healthcare UK conference this week. It also has a “semi-integrated” health and social care system. Link it all together and, Keogh said, you are only a stone’s throw from the best health system in the world. But, he continued, there can be much debate over the size of the stone and how far it has to be thrown.
When he became medical director 10 years ago the NHS had “dropped the ball” on quality, and it’s been a major part of his job to increase quality. (I think that I could produce a convincing argument that the NHS hadn’t dropped the ball, but had never picked it up, but I’ll leave that for another day.) Ara Darzi, who was then minister of health as well as professor of surgery at Imperial College Healthcare NHS Trust, asked Keogh in a corridor to develop a quality framework.
Not entirely sure what a quality framework was, Keogh went back to his office and happily opened a report by Sheila Leatherman, research professor at the School of Public Health, The University of North Carolina at Chapel Hill, that included a quality framework. He adopted the framework.
Keogh, a cardiothoracic surgeon who pioneered the reporting of surgical outcomes in the UK, has a central mantra on quality: all those who are involved in doing things to patients must be able to describe exactly what they are doing and produce data on how well they are doing it. This applies at every level in health systems from individual clinicians to hospitals to, in the case of the NHS, the government.
Leatherman’s quality framework has seven steps, and the first is to define quality. (I suddenly remember a chairman of the consultants committee of the BMA saying to me about 25 years ago, “I never use the word quality; it’s a manager’s word.”) Keogh described somebody who was having a surgical operation who had three questions: Will it work? What will it be like? Is it safe? These are the three components of the NHS definition of quality: effectiveness, patient experience, and safety. The NHS, he said, is “not so good” on the second, patient experience.
(Keogh did not include efficiency or value for money, but Dame Julie Moore, chief executive of University Hospitals Birmingham NHS Foundation Trust, did when she spoke. And Ravi Chari, senior vice president for clinical excellence for HCA, which has some 170 hospitals, included market share in his measure—on the grounds that the company wants people to come to it because it’s the best.)
The second step in the quality framework is to measure quality, and, as Keogh explained, there are measures of effectiveness, patient experience, and safety. The third step is to report the measures transparently, and the fourth step is to reward those who do well. Unfortunately, said Keogh, the NHS is more about punishing than rewarding. (Moore in her talk was sceptical about the fashionable “no-blame culture” saying that it shouldn’t mean that you can’t be blamed for parking on a double yellow line.)
The fifth and crucial step is leadership, particularly clinical leadership. Keogh regretted how “the profession [doctors] had walked off the pitch” some years ago, but clinical leadership is now being promoted.
The seventh step is to “stay ahead,” which means encouraging research and training. Maintaining gains you have made is the final step, which means, said Keogh, regulation. He regretted that when “the going gets tough,” as it has at the moment, there is a tendency to “over-regulate,” making it feel to people in the health system as if they are walking through “thick treacle.” Instead, he said, people should be freed up to change the system because only people within the system can change it. (I wasn’t sure about this: thinking back on my days at business school, I remembered how “new entrants”—for example, budget airlines—can be powerful agents for change. But perhaps Keogh would say that the budget airlines were within the air transport system.)
Keogh then described what the Department of Health thinks a health system should do. Firstly, it should help you avoid dying prematurely—and, he said, tobacco and poor education were two of the main drivers of premature deaths. (I don’t think he meant that the health system should be educating people.) Secondly, the health system should help you live well with a long term condition, and, thirdly, it should rescue you from health conditions that can be treated—like a broken leg or meningitis. The final two requirements are that the system should treat you decently and safely.
(I thought that a sixth function would be to help you die as well as possible. Nigel Crisp, a former chief executive of the NHS, used to say that one of the most important measures of a health system was how well it helped people at the end of life.)
At the end of his talk Keogh reflected on what Aneurin Bevan, the politician who created the NHS, would make of the NHS now, when life expectancy for men is 82 compared with 65 when the NHS began. Bevan would, he thought, look at octogenarians and see them on a spectrum from those playing tennis and doing everything they wanted through to those who were demented and needing complete care. He would then regret the fracture between health and social care and the fracture between different organisations with the health and social care system.
In the questions, Keogh was asked about quality in social care and whether there might be an overall score for health and social care. He answered that such a score had been considered, but had not proved “politically acceptable.” He wasn’t sure why, but I can’t have been the only one in the audience who might have thought that it wasn’t politically acceptable because it would be appallingly low.
Richard Smith was the editor of The BMJ until 2004.
Competing interest: RS spoke at the meeting. He wasn’t paid but was given a gift of upmarket Easter chocolates. He hasn’t eaten them yet.