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Quality counts

In the third article in our latest Policy in Focus series we put the spotlight on quality.

The government across the UK is aiming to drive up standards of health and well-being services to achieve consistently high quality of care across the NHS. But how can this be achieved and what will it mean for the profession?

Reports and research by Matthew Limb.

What's happening and why?

Lord Darzi's 2008 report, High Quality Care for All made quality the guiding principle and basis for the future development of the NHS in England.

We need to move from an NHS that has rightly focused on increasing quality of care to one that focuses on improving the quality of care.

Lord Darzi, Minister for Health

In the health blueprint that set the direction of travel for the health service for the next 10 years, the health minister signalled that variations in care standards persisted, despite increased capacity in recent years and improvements in specific areas such as waiting times.

The NHS should now move from 'high quality care in some aspects to high quality care in all', Lord Darzi said. He defined quality as care that is 'clinically effective, personal and safe'. As a result, there is now a new emphasis on 'getting the basics right', such as improving safety and reducing healthcare-associated infections.

Fundamental to improving quality more widely across health and social care is the ability to generate valid data and information that can be measured, compared, published and widely understood.

The idea is that clinicians and patients will produce and use this information to drive up quality standards, resulting in safer, more effective and more valued outcomes.

Patients' own views on the success of their treatment and the quality of their experiences now have greater prominence than before.

Subject to legislation, all registered healthcare providers working for or on behalf of the NHS, will be required by law to publish 'quality accounts,' just as they publish financial accounts.

The Care Quality Commission, which came into force on 1 April, has a role in developing new quality standards as well as a range of enforcement powers. And the new National Quality Board will offer transparent advice to ministers on what the priorities should be for clinical standard setting by the National Institute for Health and Clinical Excellence.

What will it mean for physiotherapy?

Physiotherapists, like all healthcare practitioners, may believe they are benefiting patients and delivering high quality care already. But policymakers, service commissioners and increasingly patients, are asking, 'how do you know, what evidence can you show us?'

Karen Middleton, chief health professions' officer at the Department of Health, explains: 'You can still improve a service without measuring it, but you won't know what you've done and how you did it.' Data collection and the development of 'metrics' that measure outcomes across care pathways are therefore seen as crucial to delivering improved quality.

Increasingly, practitioners will need to describe their services in terms of safety, outcome of intervention and the patient experience (Darzi's definition of quality). The Allied Health Professional Services Improvement Programme was launched to provide a minimum data set for AHPs to use in collecting fairly basic data.

This has been largely focused around the 18-week target, and from 2010 it will be mandatory for AHP services in England to collect referral-to-treatment data. Other parts of the UK are also concerned with improved access to services and variously collect data to identify compliance with targets. But work is also underway, led by the DH, to develop more 'sophisticated' metrics.

Ms Middelton says: 'It's crucial that, over time, we move the service from thinking about life and death metrics, to a much broader understanding of outcomes for patients, even beyond the medical model. So function, independence, these are very important and will be key metrics that we will need to measure.'

What are the challenges?

The new generation of quality indicators is being developed, based on careful consideration of evidence and produced with the involvement of a wide range of people, including clinicians and patients. The challenge is for physiotherapists and other AHPs to be actively involved in this process, shaping the development of quality metrics.

This means playing a significant role nationally, at a policy-making level, where decisions will be taken about what metrics come into use. However, as with the application of payment by results, it is far more straightforward for a surgical intervention than for rehabilitation. The CSP and other AHP bodies must therefore play their part in ensuring that AHP-led and delivered services are not, once again, left behind under the heading of 'too difficult'.

Meanwhile locally, some physiotherapy services have shown they are already progressing well with collecting standardised data from patient assessment and intervention records.

This is being used for a range of purposes – making the evidence-based case for physiotherapy services, monitoring productivity, auditing clinical services against standards, and benchmarking outcomes against similar service providers. Standardised data collection is also a good mechanism for getting academics, clinicians and researchers working together to form solid research questions.

However, the overall picture and rate of progress is regarded as variable. The challenge is for all physio services to capture and present the relevant data to evidence physios' contribution to improved safety, outcomes and user experience, and support the development and maintenance of services.

There is a risk that services that cannot demonstrate appropriate evidence of quality standards and relevance to populations' health needs will be decommissioned.

What are the opportunities?

There are more opportunities than ever before for physiotherapists to facilitate benefits to patients and improve health and well-being and quality of life. However, whether changing services incrementally or completely, or introducing an entirely new service, the data must be present to articulate the existing service and to support the change.

The success of physiotherapy self-referral schemes was demonstrated in pilot studies in the UK before being given the go-ahead by the government. In addition to conventional 'hard' data, the patient-reported outcome measures and recorded experience of patients made a significant contribution to demonstrating the value of the services. Its adoption as part of the NHS Operating Framework for England shows clearly the value of collecting and disseminating evidence.

By demonstrating what they do, how they do it and how well, physios will bolster the profession overall and ensure services can thrive locally. The Commissioning for Quality and Innovation scheme allows commissioners to incentivise payment based on quality.

Resources

It is critical that physiotherapy services consider what information they need to make the case for improving the health of the population through their service, and set about collecting the relevant data to inform those needs.

The Allied Health Professional Services Improvement Programme has devised an AHP Services Information Management Handbook in consultation with clinicians, educators and researchers, including CSP members.

The handbook is an interactive 12-step guide to help AHPs improve their data collection, identify areas for improvement and assess progress from changes made. Topics covered include referral management, managing and monitoring patient contacts, analysing and reporting, and a suggested AHP dataset.

There is also an AHP dataset mapping tool – available on the 18 weeks website – to help with assessing data/information needs and plugging the gaps.

Further information

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