Health secretary Andrew Lansley was recently interviewed by Professor Derek Bell, director of the National Institute for Health Research’s collaboration for leadership in applied health research and care (CLAHRC) for northwest London.
The interview covered topics that cut across all four areas of the NHS reform listening exercise, specifically focusing on the continuous quality improvement potential of the Health and Social Care Bill.
Here’s the interview, which first appeared on the Department of Health website:
Prof Bell: The CLAHRC research programmes assimilate research and evidence into practice, recognising international problems in implementation. We know much about evidence-based medicine, but less about evidence-based implementation. How does the Bill reflect this and help solve the problems?
Andrew Lansley: I don’t think it is all about the Bill, there is a boader vision about focusing on quality and outcomes and that patients should have a say in their care and we need clinical leadership. Our outcomes framework is the starting point for that. But in the NHS we didn’t have too much evidence on the service we are providing - but we want to know about the quality of service we are providing so we can monitor that.
We published the Atlas of Variation in December and there were huge variations from 1.6% to 5.8% average for mortality following bowel cancer surgery. We know the publication of data drives improvements in outcomes - we need an evidence-base and clinical leadership to drive this.
PB: Picking up on ‘information for improvement’ rather than information for performance, one of the problems we face is to do with the timeliness of data. Clinical leadership is clearly needed to make this information relevant and timely for frontline clinicians, but what is your view on how to establish more effective, timely data for quality improvement?
AL: Some of it can be very contemporary - we’ve extended the reporting of healthcare acquired infections and we are doing this on a weekly basis, and expanded it and the rate had dropped so we know that’s working.
We knew patients didn’t want to be in mixed sex accommodation but there wasn’t any data, so in December we started publishing this data and we’ll now do this monthly and we have seen a 77% reduction so we know this is working. This is at trust level and some of it will be at hospital level.
So we’re shifting from NHS level data where months and months later we get the results, where now we’re getting patient experience data on measures like when someone presses the call button did people respond quickly enough - we are publishing this data in a straight forward way.
Some things are more longer term, for example cancer mortality results will be seen over years. But in the East of England where I launched the bowel cancer awareness programme - they had good staging data so we could see the importance of early diagnosis.
PB: You mentioned patient experience in local surveys and national approaches with annual services, but how do you think patients and the public can get involved in the co-design of services, and generally be much more systematically integrated into improving quality, including the improvement of patient experience?
AL: Returning to the Bill, one of the things we are intending to do is create much greater opportunities for patients’ voices to be heard - including through Healthwatch and local authorities.
But we need to ensure that patient involvement in their own care is in-built into how the NHS works. Consortia and networks need to do more to involve patients. We need to make sure they are integral to how they work.
David Tucket wrote about the meeting of experts - the expert is the patient about themselves.
If you want to design a really good stroke service you need patients because we need to know what services they are expecting and how we deliver them - it is about the needs and expectations of patients, and that is where the legislation will help them and help to integrate services.
PB: A few points in response: 1. A key improvement challenges is sharing knowledge across organisational boundaries, and our research shows we need to spend significant investment to work towards a sustainable approach to collaboration. And 2. It is clear that collaboration and competition have been linked in the debate so far.
How do the proposed plans and new structures within the Bill balance collaboration and competition within the context of this knowledge and experience re: knowledge sharing and cross service collaboration?
AL: The job of commissioning consortia is to secure for their patients the best possible care - they have a duty of continuous improvement in quality. They will look to a range of providers to make that happen. GPs used to have the freedom to refer, they could even refer to a named consultant - people didn’t call this competition but that is exactly what it is, they could make that choice.
It is just about making sure you get the right service for patients. Now the patients themselves demand more involvement in the decision about who provides their care and what treatment they receive - does that give rise to competition, ‘yes’ but as a means to an end, not an end in itself. I don’t know any healthcare system where clinicians don’t experience competition in the quality of their services they provide.
PB: Continuous quality improvement is different to quality, i.e. a drive towards systematic improvement. Improvement Science is an emerging field to help establish a stronger basis for improvement. What are your views on the development of Improvement Science and the role of research in improvement?
AL: It is one of the things the NHS R&D programme is supporting - the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care.
It is not for me to tell the NHS how it should apply the latest evidence on how to secure these improvements. David Cameron and I have been clear what we want in terms of outcomes for patients but we would let the NHS decide for itself how it would deliver it.
The key is leadership. It is about leadership at every level and closer to patients. Those in the NHS who manage the clinical teams should also lead the clinical care - we shouldn’t separate clinical care and management. Leadership is the key to making those two things come together.
PB: Within our research programme, local LINks have helped drive improvement projects. Looking ahead to Healthwatch, how do you think this dimension of involvement help influence and improve research for improvement, and what are the differences with LINks?
AL: They should be the link to the Care Quality Commission and they should be directly linked in to what patients say about their care.
They should have the ability to input into the Commissioning Board nationally and the consortia locally. They should be able to look at the needs of the local people in their area, alongside the local council. Healthwatch should be able to say from a health perspective what we need to do to respond to the needs of local patients.
Sometimes this is through research, sometimes this is through service provision. This often comes through in the public health arena - so we know there may be a problem with childhood obesity but we need is evaluation and research into the solutions.
PB: Specifically regarding academic input into commissioning, with the new commissioning agenda how do you perceive the academic community contributing effectively to this and make the most of the new landscape?
AL: It seems clear to me from talking to people at academic health science centres that if you want to be the best providers of healthcare, putting research and innovation alongside clinical practice is essential.
The moment you start thinking about academic health systems, you need start to work alongside commissioners in designing as well as providing services. If commissioners are looking at getting the best outcomes they will work with more research-based organisations to innovate.
This interview was conducted prior to David Cameron’s latest announcement.
Tags: Andrew Lansley
