Final Report > Chapter 27: Care of an Appropriate Standard > Recent developments > Problems with regard to monitoring standards

Problems with regard to monitoring standards

20 Local monitoring: the responsibility for delivering care of good quality to patients must be a matter for individual trusts, and for the healthcare professionals within those trusts. The arrangements for clinical governance in the NHS now recognise this. As part of the process of providing care of good quality, there must be systems in place to enable trusts and healthcare professionals to monitor and assess their performance against agreed standards, and to compare or `benchmark' their performance against that of other units in similar circumstances offering similar services. The process of clinical audit, which is now widely practised within trusts, should be at the core of a system of local monitoring. Yet, in order undertake audit effectively, clinical teams need time. They need to generate and have access to data of good quality about their own performance and about that of other teams in similar trusts. Further, they need to know how to analyse and to interpret such data, or to have access to the necessary expertise to help them to do so. And they need to have the necessary support, in terms of administrators and information technology, to be able to do this. Currently, throughout the NHS, there is considerable scope for improvement on all of these fronts. On the matter of data, for example, there continue to be a plethora of systems, of varying quality, for collecting, coding, validating and analysing clinical information.

21 National monitoring: it remains very difficult for a particular trust to compare itself with another equivalent trust, or for a given unit or specialty within a trust to be compared with one in other trusts. We acknowledge the further development, since 1999, of clinical performance indicators, and the DoH's proposals for extending the range and type of these indicators. [13] But we are also mindful of the scepticism with which clinicians continue to view much of the data used for such national clinical indicators. Many are based on Hospital Episode Statistics (HES) data which are collected and collated by the DoH from the various patient administration systems of trusts. This Inquiry's extensive investigations into the HES data have confirmed that their quality and reliability improved steadily in the 1990s. But the data are still not highly trusted by clinicians for a variety of reasons, not least the conventions which are used to code clinical information and the fact that the data are coded in hospitals by non-clinician coding staff. [14]

22 With regard to those clinical audits which are organised on a national basis (which differ from national clinical indicators in that they take a detailed view of the care of patients with a given condition), the few such audits as exist cover only a small proportion of the total of care in the NHS. This itself reflects the shortage of national standards. Yet such audits are an important tool in assessing the quality of care because of the type of comparative data they can produce. The Royal College of Physicians told us that its Sentinel Audit of Stroke considered over 7,000 cases drawn from 80% of the hospitals treating patients who had suffered a stroke. By drawing on such a large number of cases it was possible to identify patterns and make comparisons on a wide scale and thus to separate the best performing from the worst performing units with considerable confidence. [15] Such national audits are vital for the future; they will only come to have real meaning when there are standards to which such audits relate.

23 Currently, the future for national comparative audits appears to be unclear. NICE provides some funding to various Royal Colleges for the audit of certain specialties on a national scale. NICE is also responsible for the four national Confidential Enquiries. It is CHI, however, which has been set the task of monitoring whether the standards set by NICE have in fact been implemented. CHI is also responsible for monitoring the National Service Frameworks and, with the Audit Commission, has already commenced its first review (of the Cancer Framework). A third body, the National Specialist Commissioning Group, commissions and, intermittently, conducts national audits of those services it funds, one example being the UK national audit of intrathoracic transplantation. All of this is important work, undertaken with the intention of developing and improving clinical care. All of it is work which has implications for trusts. It is trusts, at the sharp end of the delivery of healthcare, which must deal with the various apparently unconnected and uncoordinated collections of data and respond to whatever analysis or report emerges subsequently. Looked at from the perspective of the patient, the various collections of information, whether national clinical indicators, national audits or reviews into particular standards, appear to be fragmented, with no proper co-ordination, with variable feedback to trusts and healthcare professionals, let alone to patients themselves.

24 One area in which there remains a serious gap is the absence of a mechanism, outside trusts or individual clinical teams, for taking a view of the whole range of clinical performance, drawing on clinical indicators, the results of national audits, and on other relevant data. We would describe this process as surveillance. Such a mechanism of surveillance would contemplate a body or organisation with the responsibility and the expertise actively to analyse data and other evidence, to spot trends over time and to identify patterns of poor (and good) performance, either in a particular hospital, or in a particular specialty across a number of hospitals. Such patterns would not necessarily be evident to those who provide a service, or, though evident, they may be ignored or overlooked for whatever reason. The DoH acknowledged this gap in April 2001 when it stated: `The NHS does not have a systematic way of monitoring the occurrence of poor clinical outcomes of care unless they are manifest as serious events.' [16] The purpose of such surveillance must be: to identify those whose performance lies outside the ordinary pattern of overall performance; to draw attention to this; to see that questions are asked; to ensure that the reasons for the performance are identified and understood; and to take action if it is needed. Until such a form of surveillance exists, there remains the possibility that patterns of poor performance will continue to go unaddressed or unrecognised. We also have in mind that such surveillance could identify those whose performance is consistently good. Such information could help to prompt improvements elsewhere. Thus, although much important progress is under way, lack of clarity, lack of co-ordination, the continuing possibility that important matters are ultimately not dealt with by any organisation, since each thinks the other is doing it, or because no one has the responsibility to act, all mean that problems remain to be solved.

25 The recent progress to which we have referred in developing standards of care, whatever its drawbacks, begins to point to the way forward which the NHS needs to follow if it is to take standards of care seriously so that patients consistently receive an appropriate quality of care. But they are only a beginning: the magnitude of the task should not be underestimated. It will need to be properly resourced. The development of standards and the production of good guidance takes time and expertise. But without them, there will be no way to evaluate and improve the quality of care. We set out now a number of steps that we regard as essential to future thinking about standards of care, and to future arrangements for monitoring their implementation.

Footnotes

[13] We note in particular a recent document `NHS performance indicators: A consultation'. Department of Health, May 2001. www.doh.gov.uk/piconsultation

[14] See Annex A Chapter 19 and Annex B (Sections 7 and 8) for the disagreements about the quality of HES data between clinicians in Bristol and the Inquiry's experts on statistics

[15] Rudd A, et al. `The national sentinel audit of stroke; a tool for raising standards of care'. `J Roy College Physicians'. London: 1999; 33: 460-5. Other examples of national audits include those led by the Royal College of Surgeons of England on liver transplantation and on sino-nasal surgery

[16] `Building a safer NHS for Patients; implementing An organisation with a memory' ; para 52. Department of Health, April 2001. www.doh.gov.uk