{"id":38873,"date":"2017-04-05T09:46:37","date_gmt":"2017-04-05T08:46:37","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=38873"},"modified":"2017-04-11T13:41:46","modified_gmt":"2017-04-11T12:41:46","slug":"richard-smith-quality-in-the-nhs-in-2017","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2017\/04\/05\/richard-smith-quality-in-the-nhs-in-2017\/","title":{"rendered":"Richard Smith: Quality in the NHS in 2017"},"content":{"rendered":"

\"richard_smith_2014\"<\/a>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 \u201csemi-integrated\u201d health and social care system. Link it all together and, Keogh said, you are only a stone\u2019s 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.<\/p>\n

When he became medical director 10 years ago the NHS had \u201cdropped the ball\u201d on quality, and it\u2019s been a major part of his job to increase quality. (I think that I could produce a convincing argument that the NHS hadn\u2019t dropped the ball, but had never picked it up, but I\u2019ll 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.<\/p>\n

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<\/a>.<\/p>\n

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.<\/p>\n

Leatherman\u2019s 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, \u201cI never use the word quality; it\u2019s a manager\u2019s word.\u201d) 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 \u201cnot so good\u201d on the second, patient experience.<\/p>\n

(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\u2014on the grounds that the company wants people to come to it because it\u2019s the best.)<\/p>\n

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 \u201cno-blame culture\u201d saying that it shouldn\u2019t mean that you can\u2019t be blamed for parking on a double yellow line.)<\/p>\n

The fifth and crucial step is leadership, particularly clinical leadership. Keogh regretted how \u201cthe profession [doctors] had walked off the pitch\u201d some years ago, but clinical leadership is now being promoted.<\/p>\n

The seventh step is to \u201cstay ahead,\u201d which means encouraging research and training. Maintaining gains you have made is the final step, which means, said Keogh, regulation. He regretted that when \u201cthe going gets tough,\u201d as it has at the moment, there is a tendency to \u201cover-regulate,\u201d making it feel to people in the health system as if they are walking through \u201cthick treacle.\u201d Instead, he said, people should be freed up to change the system because only people within the system can change it. (I wasn\u2019t sure about this: thinking back on my days at business school, I remembered how \u201cnew entrants\u201d\u2014for example, budget airlines\u2014can be powerful agents for change. But perhaps Keogh would say that the budget airlines were within the air transport system.)<\/p>\n

Keogh then described what the Department of Health thinks a health system should do. Firstly, it should help you avoid dying prematurely\u2014and, he said, tobacco and poor education were two of the main drivers of premature deaths. (I don\u2019t 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\u2014like a broken leg or meningitis. The final two requirements are that the system should treat you decently and safely.<\/p>\n

(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.)<\/p>\n

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.<\/p>\n

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 \u201cpolitically acceptable.\u201d He wasn\u2019t sure why, but I can\u2019t have been the only one in the audience who might have thought that it wasn\u2019t politically acceptable because it would be appallingly low.<\/p>\n

Richard Smith<\/strong>\u00a0was the editor of\u00a0<\/em>The BMJ\u00a0until 2004.<\/em><\/p>\n

Competing interest<\/strong>: RS spoke at the meeting. He wasn\u2019t paid but was given a gift of upmarket Easter chocolates. He hasn\u2019t eaten them yet.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n

More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":38364,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[955],"tags":[],"class_list":["post-38873","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-richard-smith"],"yoast_head":"\nRichard Smith: Quality in the NHS in 2017 - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2017\/04\/05\/richard-smith-quality-in-the-nhs-in-2017\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Richard Smith: Quality in the NHS in 2017 - The BMJ\" \/>\n<meta property=\"og:description\" content=\"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 [...]More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/bmj\/2017\/04\/05\/richard-smith-quality-in-the-nhs-in-2017\/\" \/>\n<meta property=\"og:site_name\" content=\"The BMJ\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/bmjdotcom\/\" \/>\n<meta property=\"article:published_time\" content=\"2017-04-05T08:46:37+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2017-04-11T12:41:46+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/blogs.bmj.com\/bmj\/files\/2017\/02\/Richard-Smith.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"540\" \/>\n\t<meta property=\"og:image:height\" content=\"350\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"BMJ\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@bmj_latest\" \/>\n<meta name=\"twitter:site\" content=\"@bmj_latest\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"BMJ\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"5 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2017\\\/04\\\/05\\\/richard-smith-quality-in-the-nhs-in-2017\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2017\\\/04\\\/05\\\/richard-smith-quality-in-the-nhs-in-2017\\\/\"},\"author\":{\"name\":\"BMJ\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/#\\\/schema\\\/person\\\/ba3da426ed20e8f1d933ca367d8216fe\"},\"headline\":\"Richard Smith: Quality in the NHS in 2017\",\"datePublished\":\"2017-04-05T08:46:37+00:00\",\"dateModified\":\"2017-04-11T12:41:46+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2017\\\/04\\\/05\\\/richard-smith-quality-in-the-nhs-in-2017\\\/\"},\"wordCount\":1063,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2017\\\/04\\\/05\\\/richard-smith-quality-in-the-nhs-in-2017\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/files\\\/2017\\\/02\\\/Richard-Smith.jpg\",\"articleSection\":[\"Richard Smith\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2017\\\/04\\\/05\\\/richard-smith-quality-in-the-nhs-in-2017\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2017\\\/04\\\/05\\\/richard-smith-quality-in-the-nhs-in-2017\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2017\\\/04\\\/05\\\/richard-smith-quality-in-the-nhs-in-2017\\\/\",\"name\":\"Richard Smith: Quality in the NHS in 2017 - 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