20 Sep 2024
Re-establishing Quality as an organising principle of the NHS
Chris Gush, Chief Executive Officer, HQIP
Lord Darzi’s report candidly highlights key areas requiring urgent attention within the NHS. Those involved in, and connected to, healthcare delivery already know that the ‘system’ of care must function better for both patients and staff. We must improve access, elevate care quality, and boost outcomes for everyone. Shifting care closer to home, preventing illness, integrating services, and embracing technology are all critical—if expected—themes.
We welcome the report’s emphasis on amplifying the patient voice and giving patients more control over their care, on boosting productivity through improved operational management, and on the crucial need to reduce health inequalities. However, it remains unclear how policy and funding will address these areas and how the strategic challenges that have hindered progress to date will be overcome. We aspire to be part of these solutions.
We have selected three areas to comment on that align to our work:
- The importance of data-driven insights and identifying variances from evidence-based provision
- The emphasis on increasing patient and community engagement and patient empowerment
- Improving management within the NHS to enhance productivity and quality.
Clinical Audit: The powerhouse behind data-informed quality improvement
“The extraordinary richness of NHS datasets is largely untapped either in clinical care, service planning, or research” Paragraph 14
“… the availability of data—and in itself demonstrates the need to invest in measurement and transparency across all areas of the NHS” Paragraph 29
Clinical audit reports provide powerful, clinically curated, data-driven insights into the quality of care measured against evidence-based standards, with national benchmarking. A robust design and commissioning process, involving patient engagement, evidence-based guidance (e.g. NICE) and clinician collaboration drives this work.
Numerous clinical audits are referenced in the Darzi report and can continue to play a leading role in tackling the challenges that Darzi highlights.
- Adherence to evidence-based clinical guidelines: A stark finding of the report is the “insufficient adherence to clinical guidelines” across many clinical specialties.
The key focus of clinical audit as a methodology is to provide data-driven insights of variance from evidence-based guidance, which enables sustained improvement in both patient outcomes and operational efficiency.
- Addressing performance variability: Performance variability is a major issue. Darzi highlights troubling variations in elective care outcomes and persistent avoidable harm.
Clinical audit, as a methodology, national or local, can support teams to implement a stronger process reliability approach identifying, unpicking and helping reduce unwarranted variation from the standard as well as tracking the effectiveness of improvement strategies through data dashboards.
- The need for national audits in wider settings: As Darzi reminds us, performance standards are currently heavily focused on hospitals, with insufficient attention to primary care, community services and mental health.
Collaborating with colleagues in primary care to expand clinical audit coverage to these areas would enable more comprehensive quality improvement. Data flow and sharing challenges in primary care are starting to be addressed by OPENSafely, as referenced by Darzi, laying the foundations.
Bringing together robust audit measures across acute, ambulance, primary and social care could elevate quality monitoring still further, for the benefit of population health management, triangulation and national sharing of good practices.
Amplifying the patient voice: A step towards equity
In some respects, particularly in its decision-making and systems, the patient voice is simply not loud enough” Paragraph 4
Darzi is correct in stating that the patient voice needs to be louder. Our patient engagement work shows that genuine co-production of services with patients is crucial for understanding what truly matters to them and for driving meaningful change. Partnerships with patient groups and charities ensure that marginalised voices are heard. However, some patient groups have repeatedly shared their experiences and are now fatigued by the process; they seek action rather than more consultation, as well as personal empowerment – particularly in critical moments like childbirth.
At HQIP, we embed patient engagement in every step of our commissioning processes for clinical audit, ensuring diverse voices—especially from underrepresented groups—are heard loud and clear. By amplifying patient voices, we push for equitable care improvements. But is this enough? Can we do more?
Lord Darzi emphasises that stronger patient engagement is central to creating truly patient-centred care and tackling health inequities. His report highlights the growing dissatisfaction, noting that “patient satisfaction with NHS services has steadily declined, with many feeling their concerns are not being heard.” In particular, the report draws attention to significant disparities in care, such as the threefold higher mortality rate among Black women during childbirth (MBRRACE audit). Addressing these inequities requires urgent action across all healthcare sectors, including cancer care, mental health, and children’s services. This focus on patient engagement aligns with the broader need to address social determinants of health, such as income and housing, which continue to drive disparities in healthcare outcomes.
Quality as an “organising principle”: Systems of quality management
“The problem is not too many managers but too few with the right skills and capabilities. International comparisons of management spend show that the NHS spends less than other systems” Paragraph 24
Darzi’s 2008 report made the case that raising the quality of care should be the organising principle of the NHS. The 2024 investigation report provides an analysis of the NHS’s current state in England, and “there is much work to be done if quality of care is to become the organising principle of the NHS once more”. As expected, ‘productivity’ is a term abundant in the report (59 mentions in the main report), with the key link to Quality for Patients made clear “a productive NHS can mean high quality care for all”.
Darzi’s report outlines deep challenges in leadership and operational processes, stressing that these are systemic, not individual failings. As Darzi outlines “managers are there to ensure efficient organisation and process so that clinicians can deliver high quality care to meet the needs of patients”.
Many of the elements Darzi talks about hint at the benefits of organisational Quality Management Systems (QMS), a term that many will be familiar with from the NHS Impact framework but which are also not yet optimised.
So, what might be the benefits?
- Giving clinicians time back with ‘systems of work’ that function and streamline operations. QMS can help by providing a structured approach to improving processes, reducing waste and enhancing productivity. The QMS methods are not unknown, but not optimised.
- Reducing unwarranted variation systemically, for example by embedding clinical audit standards in EPRs, providing real-time decision support bundles and/or order sets as well as real-time variance data. Darzi’s report acknowledges that the NHS is “in the foothills of digital transformation“, but if we could progress this, the productivity and quality gains could be exponential.
- Effective process management: Ensuring that the NHS has experts in process design and control could further help streamline processes, reduce variability, and alleviate the workload on clinicians, enabling a more focused approach to patient care.
- Culture of learning: A focus on system factors, rather than individual errors, fosters a culture of continuous learning and improvement enhancing patient outcomes, operational efficiency, and care consistency.
While the Darzi report sets out significant challenges, it also points to opportunities for systemic improvement. By leveraging clinical audits as a core tool for quality improvement, the NHS can address some of the critical issues highlighted in the report. HQIP stands ready to support this effort. Data-driven insights and patient voices must guide the NHS as it rebuilds quality as its core organising principle.
For more details, you can view the full report here.
