Patrick Keady

NHS65: how does the NHS definition of quality measure-up relative to Germany, Australia and the USA?



In this article, I give suggestions as to how NHS England can refresh it’s definition of quality, in the interests of patients, providers, commissioners and in time for the NHS65 celebrations taking place early next month.


I am often reminded that I am a non-clinician. That said, it seems strange to me that while the purpose of healthcare in western Countries is very similar – treating cardio-vascular disease, cancer, long-term conditions etc – that there continues to be differing views about what quality in healthcare is all about. 


Does this matter?


In risk management terms, it matters a lot. The effect of differing definitions of quality introduces uncertainty which in turn means that providers, clinicians and commissioners are less likely to know when they are delivering quality healthcare.


For example, are Clinical Commissioning Groups more interested in the number of patient episodes or do they know how they can use their massive purchasing-power to motivate providers and clinicians to deliver clinically effective care that fully satisfies the expectations of patients ?


The current definition of quality in the NHS in England comes from Lord Darzi and his findings that were first published in the NHS Next Stage Review Leading Local Change (2008).


Lord Darzi simplified quality into three elements which are separate and at the same time, they are part of the same thing – clinical effectiveness, patient safety and patient experience. It continues to interest me that patient experience comes last rather than first, and this is something that I might write about at another time.


Clinical Effectiveness


We are told that clinical effectiveness is measured by clinical outcomes and patient-related outcomes. While there could be more agreement on what clinical outcomes and patient-related outcomes look like, feel like and sound like, there is growing evidence of wide variation in the clinical effectiveness of healthcare delivered in England.  My view is that the NHS definition of clinical effectiveness would benefit from five ideas raised by our colleagues in Germany and the USA:


German National Institute (BQS)

o   minimizing the impact and effects of illness, and freedom from its symptoms

o   re-establishing normal physical and psychosocial function

o   healing and improving the quality of life


Institute of Medicine (USA)

o   avoiding waste, including equipment, supplies, ideas, and energy

o   delivering care so that the use resources is maximised and waste is minimised



Patient Safety


While much has been written and said about the paramount importance of patient safety, I believe that we still have some way to go in getting a common understanding of what good patient safety looks like, sounds like and feels like.

There seems to be too much emphasis on what clinicians must avoid and not enough on what clinicians should achieve – perhaps we need to think much less about the ‘never’s and more about ‘always’s ?


While there is general agreement that the NHS definition of patient safety is more helpful than the USA Institute of Medicine definition – “avoiding injuries to patients from the care that is intended to help them” and “minimising risks and harm to service users” – this is probably due in part, to the relative timings of the definitions – 2008 (NHS) and 2001 (USA).


In my view, the NHS definition of patient safety can benefit from considering these two ideas:


German National Institute (BQS)

·      avoiding preventable complications (patient safety)


Australian Commission

·      reducing the risk of unnecessary harm associated with healthcare to an acceptable minimum


Patient Experience


The experience that people have on their journey through healthcare can be even more important to individual patients than how clinically effective their care has been. 

In my view, the NHS definition of patient experience can be enriched by considering five ideas from our colleagues in Germany and the USA:


German National Institute (BQS)

·      level of patient experience

·      level of patient satisfaction.


Institute of Medicine (USA)

·      Patient-centredness – providing care that is respectful and responsive to individual patient preferences, needs, and values taking into account the preferences and aspirations of individual service users and the cultures of their communities

·      Timeliness & accessibility – reducing waits and sometimes harmful delays for both those who receive and those who give care health care that is timely, geographically reasonable, and provided in a setting where skills and resources are appropriate to medical nee

·      Equity – providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status delivering care which does not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location, or socioeconomic status


While many of these ideas already exist and are being implemented in the NHS in England – what I continue to see as I move from NHS provider to NHS provider and CCG to CCG is that they are not always seen as part the Quality agenda.


With just a month to go until we celebrate the 65th anniversary of the NHS, this seems like the perfect time to incorporate these ideas into a shared understanding of what quality is in 2013 and beyond.


What do you think ?  Please enter your thoughs below.


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4 thoughts on “NHS65: how does the NHS definition of quality measure-up relative to Germany, Australia and the USA?

  1. Profile photo of Patrick KeadyPatrick Keady Post author

    Hello David and thank you for your feedback. Equity seems to be a recurrent area for development that continues to be identified in national/local reviews and media reports. Well done for combining the Quality and EIA processes at your CCG. It seems strange that while standardisation (equity) is one of the cornerstones of quality, that other NHS commissioners and providers could do better – they can make quick-wins by following your CCG’s lead.

  2. David Foord

    Thanks for this thought-provoking blog Patrick. I particularly like the descriptions of ‘equity’ from the USA Institute of Medicine that you’ve quoted. At my CCG we have a combined Quality & Equality Impact Assessment process, which is a really good idea, as it enshrines within impact assessment the inter-relationship between the two.

  3. Profile photo of Patrick KeadyPatrick Keady Post author

    Dear Peter, thank you for your helpful comments. The approach that I use in CCGs, PCTs and an SHA is to start with the data and then to compare seemingly unrelated sources. My guess is that the readers of your discussion paper will be more interested in how the combined data gives a more accurate assessment of quality. In primary care, one place to start is to compare patient feedback from Patient Opinion, NHS Choices and I Want Great Care, mortality, safety thermometer, complaints and the data behind QOF. During consultations, GPs can note the experiences of their patients at NHS and other healthcare providers. As an aside, at a Social Media conference on Friday, an NHS Foundation Trust CEO (and former Pathologist) told us how his Trust subscribes to TweekDeck and monitors the names of their hospitals in real time for mentions on Twitter, Facebook, Newspapers etc – this is another opportunity to help CCGs and Providers to spot quality problems much sooner. I will write more about the conference in this Saturday’s newsletter (8th June). In the meantime, best wishes with the discussion paper, Patrick.

  4. Dr Peter Patel

    Dear Patrick,

    I am working on a discussion paper on ‘Measuring Quality in Primary Care.’ Your article is interesting and informative. The key question we would like to raise in our discussion paper and recommendation for future is going one step beyond definition of quality. How do we assess or measure quality? There are areas where it is quantifiable and there are many areas where quality is subjective – opinion based and could be scewed by the methods used to assess quality (eg Patient experience domain). Should quality always be measured in quantitative manner and if not how much weighting should be given to non-measuratble parameters for quality?


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