Richard Smith: Painfully slow progress improving health care

Richard Smith Are we making good progress with improving health care? If not, why not and how could we do better?

I tried to answer these questions as I spoke to a thousand enthusiasts for health care quality in Nijmegen at the launch of IQ Scientific Institute for Quality of Healthcare. There were probably 50 people in the room better qualified than me to answer the questions, but it’s the Promethean fate of ex-editors and roving pundits like me to sound off to people who know more than we do. The solution is to get out as fast as you can.

The first question is the easiest to answer. Despite 30 years of the quality movement health care is still unsafe (more so than bungee jumping), often ineffective, wasteful, inequitable, slow, and impersonal. It might be slightly better than it was 10 years ago, but a study in the BMJ three weeks ago and similar studies from the US (New England Journal of Medicine and Rand) the show health care providers achieve only about half of quality indicators.

And — very distressingly — it’s about 30% for the care of patients with “geriatric conditions” and less than 20% for end of life care.

So why aren’t we doing better? Firstly, improving health care is a hard problem, requiring complex and sustainable change on a huge scale. Secondly, there are no simple solutions. Accreditation, targets, markets, incentives, guidelines, pathways, information technology, and a dozen other interventions all have a place, but mostly they have small effects—and our understanding of how to make them work is primitive.

A bigger problem, I suggested in Nijmegen, is that quality improvement remains a minority sport. There may be thousands who attend the forums of quality improvement in health care and increasing numbers of clinicians trained in quality improvement, but improvement is still not the day to day business of most clinicians. They are busy treating patients and understandably may resent the constant refrain that they are not doing as well as they might. It’s uncomfortable for most to reflect on poor quality as they go about their daily work—and probably even more distressing for their patients.

And that’s another failing. Despite the Bristol scandal (and as I wrote these words I’m thinking that soon I will have to explain what I mean by “the Bristol scandal”) and hundreds of studies showing extreme variation in the quality of care, most patients assume, again understandably, that their doctors and hospitals are providing high quality care.

(Plus, suggesting to clinicians that their care is not high quality feels insulting. The day after my oration in Nijmegen I went to a clinic with my mother. I could see 20 ways in which the clinicians and hospital could have improved the quality of what they did, but it would have been rude and ungrateful to point them out. We smiled and said “thank you” repeatedly.)

So there is no great push for improvement from patients, and little appetite among clinicians for the permanent revolution that is needed to raise quality. Yet substantial improvement cannot happen without every part of the system changing.

How might we engage (an already tired word) clinicians and patients? Might we, one of the themes of my talk, be able to create an energised, effective social movement not only with evidence but with stories, campaigns, images, songs, marches, and passion? Such a movement abolished slavery in 20 years.

Could a social movement transform health care? Possibly, but my bias is that such a movement is much more likely to come from patients than clinicians.