BMA Parliamentary Briefing: Improving quality
November 2006
Introduction
In August 2006, BMA Scotland conducted a survey of members to identify their priorities for health. Around 600 doctors from all branches of the profession responded to the survey and their priorities for improving quality in the NHS in Scotland are reflected in this policy briefing.
Background
The public has high expectations of the care that is provided by the NHS in Scotland. Although the media and public perception of the NHS is considered to be poor, the vast majority of patients trust their doctors and value the services they receive.
The 2005 Social Attitudes Survey revealed that satisfaction with the NHS in Scotland is lower than in England and that negative perceptions relating to waiting times were, in fact, worse than reality [reference 1]. However, despite this, the vast majority of patients trust their doctors and value the services they provide [reference 2].
The services and care provided by the NHS must be safe, appropriate and high quality. However, quantifying the level of quality is not easy, since much of the work within the NHS is immeasurable. Waiting times are often used to ascertain the quality of healthcare delivery but even though they are measurable, they do not provide a comprehensive picture about quality of care provided. Recent developments in clinical governance ensure that NHS organisations can implement measures to improve quality by learning from mistakes. Some examples include assessing rates of healthcare acquired infections, outcomes for patients and incident reporting.
Healthcare acquired infections (HAIs)
HAIs remain a significant problem for the NHS and are a high priority throughout the UK, important in terms of the safety and wellbeing of patients and high costs of managing and treating these potentially avoidable infections.
Research shows that, in Scotland, current levels of MRSA remain within the recommended control limit [reference 3]. Scotland has led the way in the UK in the fight against HAIs introducing a taskforce and developing guidance and policies for NHS organisations. However, 95% of doctors who responded to the BMA’s survey believed that a long-term multidisciplinary approach at both an institutional and individual level is required to help reduce the number of incidents of HAIs in Scottish hospitals.
Clinical outcomes
Nearly 87% of doctors surveyed thought it important that clinical outcomes for patients should be a key measure of quality in the NHS. Monitoring and comparing the outcomes of health care is one way of improving the quality of health care and enables clinicians to identify areas for improvement.
The BMA supports the principle of an open and transparent NHS in Scotland and while it supports the publication of surgical mortality rates in principle, doctors have raised concerns about how this information is presented and interpreted by the general public.
Previous attempts to publish clinical outcomes data has failed to reflect the range factors that should be taken into account, such as age, complexity of case, level of activity, whether the patient has a number of conditions that affect the potential outcome of a surgical procedure etc.
There is a risk that by looking at the figures in isolation, some consultants may appear to have a higher mortality rate when, in fact, they are dealing with much more complex cases. This could deter surgeons from taking on such cases which would be to the detriment of patient care.
These crude attempts to create ‘league tables’ for individual consultants fail to reflect the multi-disciplinary team based nature of patient care. Instead, the BMA has called for data to be presented in a more appropriate format, including details on volume, case-mix and complexity. An audit system should be in place to ensure accurate and complete data.
Recently, the Healthcare Commission (in England) has included Scottish data on outcomes for heart surgery on its UK website. This data is weighted to take into account factors such as age and co-morbidity etc. and it lists outcomes by team as well as by individual consultant [reference 4]. The BMA calls on political parties to ensure that all clinical outcomes data for NHS Scotland is presented in this way.
Incident reporting
In the UK, at least a quarter of a million patients each year are admitted to hospital with an adverse drug reaction [ADR] at a cost of around £466 million a year [reference 5]. In 2002, there were 1369 ADR reported in Scotland [reference 6]. Serious reactions from medications can include sudden death, respiratory failure and heart attacks. In order to learn from mistakes and ensure the highest quality of care is given to patients, doctors must be encouraged to report incidents and adverse drug reactions. That way, lessons can be learnt and changes can be implemented across the whole of the NHS.
Quality and Outcomes Framework in General Practice
GPs are best placed to manage co-morbidity and chronic care in the community and excel at this. The Quality and Outcomes Framework (QOF) is a core element of the new GP contract. It encourages GPs to meet evidence based quality indicators in key clinical and organisational areas. By doing so, it puts chronic disease management, preventative medicine and high quality care right at the heart of NHS general practice.
The QOF is a world first in addressing health inequalities by providing the best primary healthcare to all, regardless of geographical location and socio-economic status. As a result of the QOF we know that there are 558,376 patients in Scotland with recorded hypertension, a condition that puts them at risk of developing cardiovascular illnesses and death. Research by the BMA shows that over a five year period, 820 cardiovascular events such as heart attacks and stroke will be prevented by lowering blood pressure and controlling hypertension effectively [reference 7].
Three quarters of doctors who responded to the BMA survey on priorities for health agreed that it was important that only evidence based interventions be included in the quality and outcomes framework, not simply those that will score political points for governments.
Conclusion
Health professionals in all branches of medicine play a vital role in the quality of healthcare delivery for the benefit of patients and to improve people's health. BMA Scotland believes that improved quality of care is very much dependent on a full complement of a well trained and well regulated workforce. It is also essential however that rather than short term fixes that can cloud clinical priorities, a long term vision on high quality service delivery should take precedent. This can be done by ensuring that:
- The prevention and control of healthcare associated infections is tackled at both an institutional and individual level.
- Clinical outcomes data is used as a mechanism to measure quality in the NHS.
- Incident reporting within the NHS is encouraged.
- Only evidence-based clinical interventions are included in the Quality and Outcomes Framework of the new GP Contract.
1. Scottish Centre For Social Research Public Perceptions of Scotland’s Health Service, 2005 Scottish Social Attitudes Survey. Edinburgh. June 2006.
2. IPSOS MORI. Trust in doctors.2006 (www.mori.co.uk).
3. Health Protection Scotland. Scottish Surveillance of Healthcare Associated Infection Programme. Quarterly Report On Meticillin Resistant Staphylococcus Aureus Bacteraemias in Scotland. January 2003 - June 2006. (Go there )
4. Available online at the Healthcare Commission website
5. British Medical Association. Reporting Adverse Drug Reactions: A Guide For Healthcare Professionals. London. May 2006.
6. NHS Scotland Committee on the Safety of Medicines. Centre for Adverse Reactions to Drugs (Scotland) Annual Report. Edinburgh. 2002.
7. The figures for CHD and Hypertension draw on the following paper by McElduff and colleagues: McElduff et al, Will the changes in primary care improve health outcomes? Modelling the impact of financial incentives introduced to improve quality of care in the UK. Quality and Safety in Health Care 2004;13:191-197
For more information contact:
BMA Scotland Public Affairs Office
Tel: 0131 247 3050/3052
Email: press.scotland@bma.org.uk