Aneurin Bevan, the NHS’s architect, wanted to roll out the same high standard of care—the best—to everyone.1
According to NHS historian, Charles Webster, Bevan aspired to the standards of the private wing of the voluntary hospital rather than those of the poor law infirmary. Bevan’s wasn’t merely a “good enough” service; he wanted to “place this country in the forefront of all countries of the world” in its medical services.1
Sixty years later, how good are the services provided by the NHS? Are they getting better or worse? The lack of data makes it hard to answer these questions with any certainty, although the data drought is gradually lifting.
Before 1997, published information about the quality of care didn’t extend much beyond statistics on hospital mortality, renal transplantations, and in vitro fertilisation.22
That began to change with the election of the Labour government in 1997 and its pledge to put “quality at the heart of the NHS.”
The best source of up to date summary assessments of the quality of NHS services are the reports of Sheila Leatherman and Kim Sutherland, commissioned by the Nuffield Trust. Five years ago, they were favourably disposed towards the NHS because of its “intention to provide equitable and universal healthcare to all UK residents”22
; in their latest evaluation they admitted to seeing “a very mixed picture of quality of care in the NHS.”12
And this despite an enormous raft of quality initiatives (box).
NHS quality agenda, 1997-200812
Standard setting and monitoring
- National Institute for Clinical Excellence (NICE)*
- National service frameworks
- Core and development standards (set by Department of Health)
- Clinical audit
- Public service agreements
- Clinical governance
- Healthcare Commission
- Audit Commission
- National Clinical Assessment Authority
- General Medical Council
- Appraisal and revalidation
Patient or public engagement
- Patient choice of providers
- Expert patient programme
- Patient and public involvement
- Patient advice and liaison services
Payment and incentives
- Payment by results
- General practitioner contract
- Consultants’ contract
- Agenda for change
- Dr Foster
- League tables
- Healthcare Commission’s annual health checks
- NICE commissioning guides
Adopting the Department of Health’s definition of quality (“doing the right things, at the right time, for the right people, and doing them right—first time”), they analysed data on effectiveness and appropriateness, access, capacity, safety, patient centredness, and equity.
On effectiveness and efficiency, Leatherman and Sutherland note greater efforts being made to achieve evidence based standards of care for several conditions—for example, thrombolysis (fig 3); mortality due to the major disease groups has dropped, though there are continuing deficiencies in a range of clinical areas.
Fig 3 Thrombolysis rates after acute myocardial infarction, England, 2000-712
Access here is defined as “the ability to obtain effective health care services in a timely fashion, when medically needed,” with waiting lists the unambiguous marker of problems with access. Waiting times for hospital admission, outpatient, and cancer care have fallen significantly but problems exist in some specialties and for some investigations (fig 4). Access matters: part of the UK’s relatively poor international performance in cancer mortality has been attributed to delays in referral and treatment. By September 2007, however, 97% of patients with suspected cancer (100% with breast cancer) were treated within the government’s two month target.
Fig 4Number of patients in England waiting 6-11 months and ≥12 months for hospital admission12
Numbers of staff and new facilities (capacity) have gone up. Regarding safety, reports of methicillin resistant Staphylococcus aureus (MRSA) infection have been steadily falling since March 2004, and mentions of MRSA on death certificates look as if they are stabilising. Deaths from Clostridium difficile, however, are increasing sharply (fig 5). Difficulties in monitoring the safety of health services continue.
Fig 5Numbers of deaths involving Clostridium difficile, England12
Patient reported experience of care has not improved, and the gap in life expectancy and infant mortality between the most deprived populations and England as a whole has widened (as discussed in the section on socioeconomic status above).
The authors qualify these findings by observing that international data show trends—particularly in health outcomes and death rates—that are strikingly similar to those seen in England. And time series show few, if any, dramatic changes in trends as a result of reforms or investment. So what has the massive investment in quality initiatives bought? Was it worth it? And are there any new levers available to pull?