19 December 2017
Nick Black LSHTM

Sir Nick Black

Professor of Health Services Research
London School of Hygiene and Tropical Medicine

With so many claims and counter claims as to what is happening to the quality of health and social care, the ready availability of an independent and authoritative source of information is most welcome. The QualityWatch website has been meeting this need over the past five years. Its breadth, with about 300 indicators, means one is rarely disappointed. And just browsing through the multiplicity of graphs always reveals unexpected findings. Did you know that the only high income country that has higher flu vaccination coverage than England is South Korea? Despite the plethora of helpful information in a user-friendly format, anecdotal evidence suggests far too few people know about and use this wonderful resource. That is one challenge for the next five years.

Annual statements

Looking back over the first five years, the annual reports provide an insightful account of the changes that have occurred that anyone working in health and social care will recognise. The titles of the annual reports provide a fitting narrative. At the outset in 2013, Is the quality of care in England getting better? reflected the first questioning of the effects of austerity on quality, after the steady progress in improvements observed over the preceding decade.

A year later, Cause for concern suggested that those early fears were starting to be justified. Although previous gains in quality were largely being maintained, the signs of strain from inadequate nurse staffing levels and rising emergency hospital admissions for ambulatory care sensitive conditions suggested that despite attempts to transform services, the adverse effects of financial pressures were starting to be detected in some of the available metrics. The main message was that, at best, progress in improving quality was slowing but that increased stress on staff, particularly in mental health services, would inevitably result in harm if left unchecked.

By 2015 the warnings of what lay ahead were apparent in the report’s title, Closer to critical? Though still suggesting that it wasn’t too late to prevent serious harm being done to quality, the inexorable slide towards a crisis seemed more likely. While still stressing there was plenty to celebrate given that the quality of some aspects of care continued to improve, warnings about the adverse consequences of tighter finances on people’s access to services and on the morale of staff were more strongly espoused.

In addition, the haemorrhaging of experienced and valued senior managers was noted and a call for a “stronger sense of urgency from those in charge” was made. The report detected a lack of a coherent approach to managing poor staff morale. Overall, it was felt that “the warning lights about the impact of austerity on quality were glowing more brightly”. More worryingly, the dangers of sudden and catastrophic collapse had to be considered.

Hard choices

Recognition that any relaxation in the financial constraints of austerity seemed unlikely was apparent in the 2016 report, Quality at a cost. Reluctant acceptance of the government’s determination not to change tack shifted the narrative to addressing the thorny issue of the hard choices that need to be made. Different aspects of quality would need to be traded off. First in line, for practical reasons, was access to planned care (higher thresholds of clinical need, increases in waiting times) and to urgent care (longer waits in A&E departments, tighter criteria for ambulance response times).

Even though urgent care performance still remained superior to that of many other OECD countries, the high profile of this aspect of health care meant that public perceptions were of a system tottering on the edge of survival. There was less public awareness that the quality of other aspects of care was being maintained thanks to the goodwill of staff. Professional ethos was undeniably a key factor in avoiding the earlier suggestion of the spectre of catastrophe.

Tracking quality

And so to the present day. The need for fair and transparent monitoring of the quality of health and social care remains as strong as ever. Regardless of political views of how best to fund and provide services, everyone who is concerned about the quality of care needs QualityWatch. It enables the necessary debates to take place based on shared, objective evidence of the situation, of temporal trends and of international comparisons.

Nick Black is chair of the QualityWatch advisory board.

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