Improving Outcomes in the NHS

Professor Sir Mike Richards

The King’s Fund

November 2012

1

Improving outcomes in the NHS: Overview

● A quick look back

Where were we when the NHS was around 50 years old (i.e. late 1990s)?

● What happened between 50 and 60 years?

● What is the NHS doing to improve quality at age 64 (i.e. now)?

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The NHS in the late 1990s

● Pride and complacency were increasingly being challenged (“we have the best health service in the World”) as evidence grew to the contrary

● Very long waits across almost all specialties (cardiac, cancer, A&E, orthopaedics, etc)

● Low investment compared to other developed countries

3

The Liam Donaldson question (1999)

LD to MR at an NHS Executive Board meeting

“Mike, can you name me a single service which has been failing across the NHS and which has been turned around?”

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The Liam Donaldson question - response

MR to LD: “Yes, cervical cancer screening in 1988”

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The Liam Donaldson question - response

MR to LD: “Yes, cervical cancer screening in 1988”

LD to MR: “Ok, but what about a major service?”

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The NHS between 2000 and 2010 (1)● A period of

Financial growth

Strategies, national service frameworks, targets, etc

New organisations (e.g. NICE)

New clinical leadership (National Clinical Directors)

New approaches to service improvement

First steps on choice and competition

Increasing emphasis on data to drive change

New emphasis on quality

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The NHS between 2000 and 2010 (2)

● Progress was undoubtedly made

Workforce and facilities have expanded/improved

Waiting times have fallen markedly (cancer, cardiac, A&E, 18 weeks, diagnostics)

Service organisation has improved

• Multidisciplinary team working

• Coordination through networks

• Some reconfiguration (e.g. Cancer, stroke, vascular)

Service improvement approaches are now better (but not fully) established

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The NHS between 2000 and 2010 (3)

● Improved data collection

e.g. National clinical audits

National Cancer Intelligence Network

● Improved accrual to clinical trials• Through clinical research networks

● Improved safety• Hospital acquired infections, VTE, intrathecal chemotherapy

● Reduced smoking prevalence (from 28% to around 20%)

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Progress on outcomes 2000 – 2010?

● Mortality from most of the ‘big killers’ has improved (cancer, cardiovascular, respiratory), but we could still do a lot better

● Liver mortality is increasing, against the trends in some other countries

● Diabetes in increasing and could have a major negative impact on cardiovascular mortality

● Cancer survival in the UK still lags behind that in other countries

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ICBP: 5 year relative survival. Coleman et al, Lancet 2011

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ICBP: 1 year relative survival. Coleman et al, Lancet 2011

Progress on other outcomes 2000 – 2010?

● Patient experience is broadly static (though improving for cancer patients, partly because it is being measured and reported at team/service level)

● Quality of life for patients with long term conditions is poorly understood as it is only measured in very broad surveys

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Patient experience survey

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The NHS Outcomes Framework

Question:

How many people here today are confident that they can name all 5 domains of the

NHS Outcomes Framework?

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Focus on outcomes

What would you want if you were seriously ill? Probably...

● To have your life saved (D1)

● To have a good quality of life thereafter (D2)

● To recover quickly from treatment (D3)

● To have a good experience of care (D4)

● To be treated in a safe environment (D5)

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Priorities for reducing premature mortality (D1)

● Improving the NHS contribution to prevention of ill-health (e.g. NHS Healthcheck)

● Earlier diagnosis: ‘Finding the missing millions’

● Improving management in the community

● Improving acute services and treatment

● Preventing recurrence after an acute event

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Enhancing quality of life for people with long term conditions (D2)

● Improvements in primary care

● Patient empowerment

● Coordination and continuity of care

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Helping people to recover from episodes of ill health or following injury (D3)

● Keeping people out of hospital when possible/desirable

● Effective working between primary and secondary care

● High quality efficient hospital care

● Coordination and support following discharge

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How will the new system deliver?

● Through...

Clarity of roles within the new system

Empowering commissioners

Engaging clinicians and providers (e.g. through clinical networks)

Improving data to drive change

Using financial incentives selectively

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New organisations and structures● Department of Health (DH)

● Public Health England (PHE)

● NHS Commissioning Board (NHS CB)

+ Regions + Local Area Teams (LATs)

● Clinical Commissioning Groups (CCGs)

● Local Authorities (LAs)

● Health & Wellbeing Boards (HWBs)

● Commissioning Support Units (CSUs)

● New Improvement Body (nIB)

● Clinical Senates

● Networks (SCNs and ODNs)

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Summary

● We have come a long way on improving quality in the past 10 – 15 years

● We still have a long way to go to equal the best in Europe (or the World)

● The new focus on outcomes provides us with a new opportunity, but it will not be easy – especially at a time of financial austerity

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