The quality of care delivered to NHS patients and service users in England has improved in many key areas over the past decade.
But some issues should cause concern including urgent care and the prevention of emergency admissions, and the continuing challenges of health inequalities whereby people in more deprived areas of the country continue to fare worse on a whole range of indicators.
These are among the key findings of the first annual assessment of the quality of care in England from a new research programme, QualityWatch, launched today. This is a five-year collaboration between independent health research organisation the Nuffield Trust and healthcare improvement charity the Health Foundation.
The project seeks to assess whether the quality of Government funded health and social care services is improving or worsening over the next five years.
This period will be characterised by significant challenges on care services: spending constraints, organisational change and growing care needs in an ageing society. But there will also be significant opportunities to improve care from innovation in part driven by necessity.
The assessment draws on analysis of nearly 150 quality indicators spanning primary care and community services, hospital care, mental health services and social care. These have been evaluated in relation to six domains of care quality: access; safety; effectiveness; person-centred care and experience; capacity; and equity.
The findings will be regularly updated as part of the research programme’s aim to provide on-going authoritative and independent scrutiny on the quality of health and social care.
The assessment also incorporates findings from two in-depth ‘Focus on’ reports (also published today). The first investigates trends between 2001 and 2013 in emergency admissions for people with ‘ambulatory care sensitive’ (ACS) conditions – these are clinical conditions for which an emergency admission could be prevented by good quality primary and outpatient care.
There is no one simple measure of quality of care
The second study examines trends in treatment for people with hip fractures between 2001 and 2011. Together they suggest that the quality of urgent and preventive care require immediate attention.
Commenting on the results, Nuffield Trust Chief Executive Andy McKeon said:
“Given constraints in resources for the NHS and social care in the next decade, a key concern must be the extent to which the gains made in improving quality of care over the past decade may be lost.
“But despite recent high-profile failures and fears of deteriorating care standards, our research suggests that the constrained funding levels have so far not had a major impact on the overall quality of care received by patients and service users.”
“It is very important that as many eyes as possible are watching the quality of health care over the next few years. The good news is that on most indicators examined, quality appears to be at least maintained.
“But urgent care stands out as being an area to watch, in particular the quality of care outside of hospitals and timely access to it by the public. This should be a high priority for action and a test of intelligent policy making as well as management at the front line.”
Lead researcher on the project, Dr Martin Bardsley, Director of Research at the Nuffield Trust, said:
“Our aim is to provide an authoritative and independent analysis of the quality of health and social care over time, putting the latest changes into their historical and, where possible, international context.
“We will highlight where there are clear and compelling gaps between what is being achieved and what is possible in order to prompt action. But, there is no one simple measure of quality of care and we need to improve the ways we make assessments.
“So we will be looking to improve the indicators available and the way in which assessments are made. We also know that there may be a time lag between the onset of constrained budgets in the NHS and social care and their potential impact on patients and service users.
“Therefore, this programme will continue to monitor and analyse a range of indicators and specific topics over the next five years to examine how and whether the quality of care is changing over time.”
Findings from the indicator analysis include:
- Consistently low waits for elective outpatient and inpatient care, diagnostic tests, ambulance and for cancer treatment when compared to five or 10 years ago, maintaining the progress made.
- Improvements in the management of healthcare related infections – since 2007/2008 the number of MRSA infections reported to the Health Protection Agency has reduced by 79 per cent from 4,451 to 924 in 2012/13.
- Positive reports from patients about their experience of NHS care. In hospitals, however, a quarter of patients reported that doctors talked in front of them ‘as if they weren’t there’, and one fifth of people reported that nurses did the same.
- The number of nursing staff (full time equivalent, FTE) has dipped slightly over the past two years. However, the number of hospital medical staff (FTE) has shown a large increase (40%) over the past decade. Numbers of managerial and other ‘infrastructure’ staff have fallen significantly over the past two years as a consequence of cutbacks and NHS reforms.
A more general point emerging from the study is that urgent care appears to be a significant issue across both primary and hospital care. A&E services are facing unprecedented demand, which has been associated with the recent increase in the numbers of patients waiting more than four hours.
Urgent care appears to be a significant issue across primary & hospital care
Rates of emergency admission for conditions that in most cases should not require hospital treatment are continuing to rise, especially among older people. Many admissions result in a very short stay in hospital (raising questions as to whether alternative forms of care may be more appropriate).
This in part suggests that the quality of preventative care which led up to the admission needs to be investigated.
Ambulatory care sensitive conditions report findings
Digging deeper, the in-depth ‘Focus on’ study into preventable admissions (ambulatory care sensitive conditions) reveals that over the past decade there has been a 26% increase in the (standardised) rates of hospital admissions that should have been avoidable through good quality preventive outpatient care.
Five ambulatory care sensitive conditions accounted for half of all such admissions, three of which disproportionately affect older people (urinary tract infection/kidney infection, pneumonia, and chronic obstructive pulmonary disease).
The other two disproportionately affect children and young people (convulsions and epilepsy, and ear, nose and throat infections).
Such admissions appear to also be strongly linked to the levels of deprivation in an area, especially for chronic obstructive pulmonary disease (COPD).
However, even after adjusting for age, sex and deprivation of the population there are significant differences between areas, suggesting that differences in the quality of and access to preventive care provided by local health and social care organisations may be a factor.
Hip fracture report findings
The in-depth ‘Focus on’ study into hip fractures concludes that management of hip fractures in the English NHS has changed over this decade generally for the better, with reductions in 30-day mortality rates and length of hospital stay, and an increase in the proportion of people undergoing surgery within 48 hours of admission.
However there has been a 41.2% increase in emergency re-admissions within 28 days. There also appears to be room for improvement in primary and secondary hip fracture prevention services, as the population level rate of hip fracture has not decreased over this period.
Likewise, efforts to reduce health inequalities in this area do not seem to be working, with health inequalities in hip fracture incidence and outcomes persisting over the 2000s, and in some cases appearing to widen.
The researchers recommend that commissioners investigate whether work in their area to reduce inequalities is having the desired effect.
Notes to editors
- To discuss the report with one of its authors, please contact us via email.
- QualityWatch is a major research programme from the Nuffield Trust and the Health Foundation that aims to provide independent scrutiny into how the quality of health and social care is changing over time.
- The QualityWatch website presents findings from the research, including reports on specific topics and analyses of key indicators organised by area of quality and sector of care. This free online resource also will include other outputs, such as interactive charts and blogs.
- QualityWatch is supported by an advisory group consisting of a number of external experts. It is chaired by Professor Sheila Leatherman CBE, Research Professor at the School of Public Health, The University of North Carolina at Chapel Hill, and Visiting Professor of the London School of Economics. Professor Leatherman is also a trustee at the Nuffield Trust.