Hitting the target and missing the point?

Authors


Spicer’s report in this issue of IJCP should make you stop and reassess how you perceive the quality of care within the English National Health Service (NHS). It provides a striking counterpoint to the claims by the incumbent government that quality of care has improved substantially since 1997 when it took office, not least that the NHS has managed to hit a series of centrally imposed targets relating to access and waiting times. No one reading Spicer’s report can fail to be concerned that some patients, children in this case, have been and are being failed by the NHS. Doctors, nurses and patients know that the reality of care, when assessed across the continuum, often falls short of what is claimed, yet Spicer’s report is valuable because it offers a rare insight into a problem that is invisible to routine measures of quality.

Spicer’s account might be dismissed as an isolated experience if it were not for a number of other recent tragedies; collectively, these might well indicate a disturbing underlying trend in the way healthcare is delivered, but it is hard to generate evidence about how widespread these incidents might be as they involve exploration of what is not routinely measured. It is particularly significant that the mainstream media have been the ones to highlight these issues. In a sign of how far removed medical journalism is now from frontline clinical issues despite widespread coverage in the mainstream media, there has been little coverage within medical journals – the Lancet ignoring the issue completely.

The Healthcare Commission, the independent regulator of health care, has a remit to investigate allegations of serious failings in the NHS in England and Wales: it has the resources to conduct in-depth explorations of quality that probe well beyond the routine data. In 2007, it released a damning report into the quality and safety of care received by patients who became infected by Clostridium Difficile when treated at a Kent hospital, known as the Maidstone and Tunbridge Wells NHS Trust. It found that patients had received abysmal care despite the apparently normal functioning of the hospital over several years. The report highlights many factors: poor hand washing practices by clinical staff, extended periods of high bed occupancy, poor systems for monitoring infection rates and understaffing of nurses. Particularly worrying was a style of leadership, according to the Healthcare Commission, that placed overall patient care secondary to achieving financial balance and meeting government targets. Around 1200 cases were investigated and 90 deaths were reported as being the cause or probable result of infection by Clostridium Difficile.

A closer look at the report reveals that misleading data on infection rates had been submitted before and a previous investigation had been carried out for this reason. Nursing staff described a culture where they were in some instances, discouraged from reporting their concerns. Consultants were left to communicate the concerns of patients who were unable to see their relatives because they were frequently being moved around the hospital. The leadership style was described by many, including senior management, as autocratic or in other cases dictatorial.

In 2009, another tragedy was reported in the media, this time resulting from an investigation by the Healthcare Commission into another hospital, Mid Staffordshire NHS Trust. In this hospital, from 400 to 1200 deaths were estimated to have resulted from gross failings in the operation of the Accident and Emergency department over a 3-year period. As in the case of Maidstone and Tunbridge Wells NHS Trust, targets and cost cutting were implicated in the failure and the views of patients and staff were not taken seriously. Disturbingly, the report found there was not ‘an open culture where concerns were welcomed’. The report went onto say that ‘the board appeared to be insulated from the reality of poor care for emergency patients’. This, and its other findings were virtually identical to the failings at Maidstone and Tunbridge Wells NHS Trust, yet they were occurring when the earlier investigation was taking place.

A slavish devotion to targets at the expense of other priorities by managers and hospital leaders is clearly a feature of both cases and was identified by staff at both hospitals, even though such concerns were angrily dismissed by the then Secretary of State for Health. The government argues that by meeting the targets, the NHS has benefited patients through speedier access and that the vast majority of hospitals have achieved this without apparently compromising other dimensions of patient care. Yet, although in these cases targets can certainly be blamed for obstructing the NHS’s view of its real responsibility – actual patients – several other factors were also identified. It would be unfair to stereotype NHS managers as being the only group vulnerable to target myopia or to deny that there are benefits to targets if used appropriately.

Doctors too, can embrace targets with zeal. Anyone with knowledge of the rules guiding the treatment of heart disease or diabetes will know how ideological debates around clinical targets distort the need to offer individual patient care not only for a single medical condition but across multiple areas. Often emanating from academic clinicians who are insulated from the reality of every day care, the unintended consequences of ‘one size fits all’ clinical targets can disadvantage patient groups with ‘Cinderella’ conditions or marginalised groups such as the elderly, in the fight for resources. ‘One size fits all’ performance measures that are targets in all but name, have received similar criticism although because they do not explicitly specify a time frame their benefits and harms are muted.

Contrast this with the comments of the newly appointed Chair of the Care Quality Commission, a body that has now replaced the Healthcare Commission, who described a legal vision where doctors might face legal action for not following guidelines developed by the National Institute of Health and Clinical Excellence (NICE). In order for her vision of a patient sitting in front of their GP or consultant interrogating their healthcare provider with NICE guidance to be consistent with her legal vision, the pressure for the doctor to interrogate the patient with the guidance is obvious. It ignores the fact that there are multiple ways is which equally valid guidelines can be drafted and that their recommendations cannot be prescriptive as autonomy rests between the patient and their care giver. Moreover, guideline recommendations are rarely ever definitive.

Is Spicer’s claim credible that other tragedies are inevitable? Reliance solely on the quality paradigm, a limited number of measures and a target driven culture indicate that similar tragedies on a hospital scale can easily occur. Smaller scale, ‘micro-events’, occurring below the hospital scale, are not only possible but probable, happening now and measured only by personal experience. Larger, ‘macro events’ or crises are the black swan phenomena of quality improvement i.e. unforeseen because they do not lie within accepted dogma that rests on the limited information afforded by a narrow measurement windows, yet puzzling, high impact and serious when they occur.

Reassessing quality improvement

So, what can be done? The most important thing is a sea change in the target culture in the NHS so that real patients are centre stage, with people recognised and respected as individuals rather than as members of a population and the role of targets relegated to reflecting part of the picture rather than the entire picture - in other words, a sense of proportion. In June 2007, the government promised such a change in the English NHS. A vision of quality as defined by local clinicians and high quality evidence was laid out by a senior clinician turned government Minister, Lord Ara Darzi. Darzi’s vision implies a change in policy direction, a decisive shift away from the command and control approach and much more autonomy to local clinicians and managers.

Delivering this vision in a way that addresses the experiences described by Spicer is going to be challenging in the NHS for three reasons. First, the target culture originated from an underlying characteristic of the NHS which has not changed: accountability for the tax-generated funding from the NHS is still largely upwards, with government ministers held ultimately responsible for how care is delivered at a local level. Media reports of crises and quality failures tend to generate directives from the centre, a reflex action from ministers under fire from a hostile press and public. The government’s promise not to resort to such tactics and to allow more autonomy to local clinicians, will be continually tested in the future, particularly as NHS budgets are squeezed.

The second challenge relates to the problem of measuring quality in a way that gets at the realities of patient care. Even if NHS organisations enjoy more autonomy from the centre, they will also be trying to balance priorities, juggling speed of access with clinical need and limited resources. Devolution does not remove the accountability dilemma, it just relocates it. Hospital management needs a set of quality indicators that tell them whether patients’ clinical needs are being met or compromised by waiting time goals, as Spicer describes.

Finally, the biggest challenge relates to how data should be supplemented by human intelligence from clinicians. The culture of governance urgently needs to be addressed by changing the way it is practiced. Clinical leadership was also a missing factor within the tragedies described earlier. This is not the fault of the clinicians involved, but the design of the system in which they work. The current approach to instill leadership through ‘Czars’ and now the inevitable Soviet style top down ‘leadership councils’ is an anachronism.

Clinical governance is a social construct and too amenable to operational preferences, political and financial pressure and an instinct for self preservation, to ever safeguard patient safety by itself. There is also a risk that clinicians become increasingly subsumed into the role of a ‘bought priesthood’ and one of the few checks and balances that safeguard the individual patient is removed. Patients, doctors, nurses and other health professionals need to be more involved in setting local priorities and a greater role for them should be created within health service governance, but their appointment must be through transparent and democratic methods. Other weaknesses in the current system, like the reliance on self reported performance data, must also be addressed.

Probably, the most important lesson to emerge from this series of tragedies is that the current approach of using agencies such as the Healthcare Commission to assure quality is tantamount to measuring failure after the fact. Whether the shortsightedness with which the measurement mandate is applied can be overcome by a sea change in the governance culture of the NHS remains to be seen. Overcoming the problems with the current application of measurement mandates ultimately requires confidence that independent and trustworthy alternative points of redress exist together with a ‘no blame’ culture that is supported by a written commitment that the careers of healthcare professionals are not threatened when raising concerns about patient welfare. Until then, medical and other healthcare professionals will best serve the interests of patients by diligently reporting the human consequences of maladministration, through appropriate channels where possible, but with more timely intervention than has been so far evident, whenever institutional failures do not make this possible.

Disclosures

RM is a Harkness Fellow in Healthcare Policy and Practice, supported by the Commonwealth Fund, New York. Any views expressed within this article are those of the author, not the Commonwealth Fund.

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