Why no one is responsible for ensuring best practice in hospitals

In August, Sir Mike Richards, the Care Quality Commission’s chief inspector of hospitals, told HSJ of his disappointment that many hospitals were reluctant to look outwards, and import and implement best practice from other services. Being stuck in this rut was denying patients and local health economies high quality models of care.

‘A free for all based on localism leads to duplication of effort as service leaders reinvent wheels instead of delivering quality improvement’

I agree with this view, but not with simplistically blaming the hospitals as Luddite refuseniks. Acute providers are snowed under with demand, financial and performance pressures – making it hard to lift their heads, horizon scan and adopt. Crucially, there is poor access to free mentorship from other NHS agencies, including practitioners and service leaders who can give pragmatic advice based on hands-on experience of quality improvement.

Some may feel that the NHS is simply too big for clinical quality to be driven from the centre and that localism rules. But in a service where most citizens have but one local acute provider, we have a responsibility to minimise postcode lotteries. Besides which, a free for all based entirely on localism leads to duplication of effort as service leaders reinvent wheels instead of delivering quality improvement initiatives already shown to work elsewhere.  

National clinical audits, National Confidential Enquiry into Patient Outcome and Death reports and the NHS atlases of variation also show unwarranted variation and care gaps at an unacceptable scale.

The recent interest in US style hospital chains such as Intermountain Health Care has some interesting lessons around clinical leadership and intelligent use of clinical data. But before we have too much of a “cultural cringe” to all shiny baubles from overseas, we must remember that in the US hospitals can compete for clinicians and for patients, are rarely running at 95 per cent bed occupancy (or more) and can get into our out of “service lines”. Whereas our own hospitals have to provide all services for local populations, free at the point of delivery – context is key.

• Interactive: HSJ Clinical Leaders 2014
• Video: Sir Mike Richards interviewed on the new CQC inspections
• David Oliver: Beware the false solutions to the NHS’s challenges

In the spotlight

Going back a few years, there were some fine examples of quality improvement drives across the whole service, led by national clinical directors; notably strategies for stroke, heart disease and cancer. Strategic health authorities also had a role in trying to even up quality. Andrew Lansley’s vision was counter to such approaches, defining high level outcomes and leaving the form and function of services to localities. This was despite a range of clinical processes and service models being clearly shown to deliver those very outcomes and yet not universally in place.

‘Too often “solutions” focus on pushing hospitals to commission a consultancy report and on pressurising executives’

Sir Mike’s remarks took me back 30 years to the phrase in the Griffiths report on NHS management: “If Florence Nightingale were carrying her lamp today, she would be searching for the people in charge.”  In 2014, we might add: “…of ensuring all hospitals implement evidence based, high quality clinical care and service models reliably shown to deliver this”.

Florence’s lamp might fall first on the CQC itself. Praise is due for making the new hospital inspection process more rigorous, broad and deep, with reports focusing on domains of quality. Reports and transparent data may focus clinicians’ minds. But the CQC mission is not to help poor performers implement best practice. Inspection teams are light on hands-on expert clinicians and many aspects of clinical quality don’t feature in the reports. Nor do inspections always aid morale, which is key to clinical quality.

Next, Monitor and the NHS Trust Development Authority might blink in the lamplight. Their focus so far has been on organisational leadership and finance rather than clinical quality. Less than 0.5 per cent of Monitor’s staff have clinical experience. Too often its “solutions” focus on pushing hospitals to commission a consultancy report and on pressurising executives.

Untapped skills

The NHS Institute for Innovation and Quality Improvement had plenty of staff with the right skills and background, but it has now been subsumed into NHS England and may have a role to play once its successor, NHS Improving Quality, us up and running – but it’s early days.

What about NICE? Well it does a grand job in producing evidence based guidelines and quality standards for clinical care. Support for implementing them isn’t its job though. Although NICE’s role is enshrined in the NHS constitution, there are no real consequences for failing to implement its guidance.

‘Financial pressures on services are no excuse for poor quality, even though the same politicians created those pressures’

Florence might cross Westminster Bridge from her base at St Thomas’ and turn her attentions to Whitehall, perhaps with a quick visit to Quarry House in Leeds. The coalition’s health reforms explicitly devolved day to day oversight of the NHS to the “arm’s length body” of NHS England.

NHS England is full of experienced, credible clinical leaders with expertise in their field and a fair share of managers with good track records. It is organised around the domains of the NHS outcomes framework and is working on commissioning instruments to support delivery. But the range of outcome indicators is small, leaving many clinical areas “orphaned”. The consequences for commissioners failing to deliver against them aren’t clear and it has been too preoccupied with its own birth to give effective system leadership as yet. Nor does it appear to see its role as supporting providers.

Meanwhile, ministers and Number 10 are engaged in doublespeak. Quality improvement and performance management in services isn’t their role – unless it is, such as the fixation over the four hour target or single sex wards or hourly nurse rounding. Financial pressures on services are no excuse for poor quality, even though the same politicians created those pressures.

What needs to happen

It seems that in our brave new world, ensuring quality is everyone’s job, yet no one’s.

What I think needs to happen is this. The best evidence for large scale quality improvement is about clinically led standards of care; clinically led innovations in models of service delivery, linked to transparent publication of data on processes and outcomes; and a community of practice and peer support from clinical leaders. All the better if the change is then embraced and supported by the centre and linked to some financial incentives.

Examples include the push over several years to improve and standardise stroke care, the “surviving sepsis” campaign, the mainstreaming of critical care early warning scores and outreach teams, the drive to transform care for hospital inpatients with dementia and the Gold Standards Framework for End of Life Care.

The National Hip Fracture Database and best practice tariff is perhaps the best example of all and is transforming approaches to the care of patients with hip fracture to the extent that several other countries want to learn from the model. Invited service review, peer accreditation and kite marks from Colleges and Specialist Societies can also deliver.

Lead from the front

But we can’t rely just on the goodwill and spare time of clinical leaders and colleges. These initiatives should be delivered in formal and close collaboration with NHS England and NHS IQ and properly funded.

‘It’s no good blaming hospitals for being slow to deliver best practice when there is no one to help them’

Then for help with implementation we surely need an NHS consultancy arm of clinicians and managers providing help for their colleagues and which is free. This is particularly pressing given that NHS consultancy spending has nearly doubled during this parliament to around £700m – a group not hit by austerity.

The NHS emergency care support team provides a working example of this approach. Initial advice and ongoing support on emergency care pathways is provided for hospitals who invite the team in. The advice comes from experienced clinicians and managers steeped in frontline service leadership. It’s cheaper than the private sector and it comes from people who actually do the job.

Why not make these approaches mainstream and support them properly? It’s no good blaming hospitals for being slow to deliver best practice when there is no one to help them.

David Oliver is professor of medicine for older people at City University London and a member of the HSJ Commission on Hospital Care for Frail Older People. The commission’s launch report will be published on 21 November.

• Find out more about the commission