Final Report > Chapter 27: Care of an Appropriate Standard > The past: an absence of standards and of monitoring

The past: an absence of standards and of monitoring

2 Clearly, patients wish for a good outcome [1] (where this is possible). But this disarmingly simple proposition is easier to state than to define. It contemplates agreement on what amounts to a good outcome, and sometimes patient and professional may disagree. It further contemplates ways of assessing, measuring, recording and comparing outcomes, so as to produce information which would allow the patient and the professional to come to a view as to what is `good'. It also calls for an understanding of the relationship between outcome on the one hand, and treatment and care on the other, bearing in mind that there can be many variables which affect a person's health, whatever treatment and care they may receive. The link may be more obvious and visible in some areas of medicine (such as therapy with drugs), than in other areas of treatment. Until recently, apart from a few exceptions, this information and understanding have barely existed in any significant way. Thus perhaps the most essential tool in achieving, sustaining and improving quality of care for the patient was lacking. Hospitals and the NHS could tell you about throughput (number of patients treated), bed occupancy (the proportion of beds occupied in the hospital), and, latterly, the costs involved. But, generally speaking, quality of outcome was a closed book.

3 The explanation is complex. One powerful factor lies in the historical origins of the NHS. As we have already said, until at least the early 1980s, the Department of Health (DoH) regarded quality of care as essentially an issue for healthcare professionals: something the Department should not interfere in. Thus there was no imperative from the centre to generate information about the quality of care as we understand the term today, and consequently, there was no reliable national picture of the quality of care. For their part, healthcare professionals often monitored their own work at a local level, reviewing, for example, deaths and complications. But with very little or no comparative data from other units or hospitals, based on agreed criteria and subject to rigorous analysis, all they really had to go on in judging how well they were doing was little more than anecdote. Furthermore, there were no systems, either within the hospital or elsewhere, to identify poor clinical outcomes or take action, unless or until some scandal broke, or a pattern of performance was so poor as to attract attention. Papers were presented at conferences, articles were written in journals, and colleagues met and discussed their work. But all of this was piecemeal and of varying value. [2]

4 Until well into the 1990s, the notion that there should be explicit standards of care which all healthcare professionals and hospitals should seek to meet, and which would apply to patients across the NHS, simply did not exist. We heard evidence in both Phases of the Inquiry, for example, that clinical standards were regarded as a matter for individual doctors to address within their own practice. The Royal College of Physicians, for example, told us that `Quality of care was simply left as a matter for individual doctors to supervise within their own practice until the 1980s.' [3] Such an approach, in which individual professionals were responsible for all stages of their own work, was the norm in healthcare (as it was in other areas of professional practice such as the law). Its weakness lay in the lack of anything against which professionals could test their performance. At its worst, it led to complacency and an erosion of self-questioning. Reliance on experience became a substitute for continuing self-appraisal. Variations in practice were seen as the proper exercise of professional choice rather than as evidence of differing standards. A further weakness lay in the assumption that the presence or absence of decent equipment and decent facilities made little or no difference to the quality of care: that all that was needed was to rely on well-trained professionals to do their best. That was not fair to professionals. One of the crucial insights from Bristol is that leadership and management of a hospital, the organisation of patients' care, and the state of a hospital's buildings and equipment, are as relevant as, and interact with, the competence of healthcare professionals in influencing the standard of care. The conclusion must be that the standards and quality of healthcare are not, and cannot be, a matter solely for healthcare professionals.

Footnotes

[1] We take as our definition of a health outcome one cited by the Royal College of Physicians in its paper for Seminar 6: `A change in health, health related status, or risk factors affecting health. A health outcome may be the result of the natural history of the disease or may be the effect of interventions designed to prevent or to treat it.' (Derived from Pearson M et al. (Eds). `Outcome Indicators for Asthma'; report of a Working Group to the Department of Health, London. Royal College of Physicians Research Unit and Oxford Unit of Health Care Epidemiology. London: NHSE, 1999)

[2] For information about how paediatric cardiac surgeons kept up to date in the 1980s and 1990s see Annex B

[3] Seminar 6. Royal College of Physicians. Position Paper. Also see Summary Report of Seminar 6 at Annex B