The domains of the NHS Outcomes Framework which address the so-called ‘effectiveness of care’ dimension of quality – ie numbers 1, 2 and 3 – are likely to receive most of the political attention. They are what Andrew Lansley had in mind when he initially voiced his intention to refocus the efforts of the NHS on delivering improvements in outcomes.
Yet it is domains 4 and 5 (patient experience and protecting people from avoidable harm) which can have the most immediate impact on people’s perceptions of the NHS. Put simply, clinical effectiveness outcomes are necessarily longer term in nature, whereas a person’s experience of care and whether they were treated safely are more immediate and easier for them to assess themselves. They mean something to patients and the public, and are of immense political importance.
It is a curiosity that accountability for delivery of the NHS Outcomes Framework is divided. The leads for domains 1, 2 and 3 will, once appointed, report to Professor Sir Bruce Keogh. However, leads for domains 4 and 5 will report to Jane Cummings, the new Chief Nursing Officer.
Quite why this split in accountability has occurred is intriguing. Are nurses, somehow, more responsible for experience and safety, whereas doctors take the lead on clinical effectiveness? This argument seems hard to sustain, given that it is often the communications skills of doctors that determine the quality (or not) of a patient’s experience of care, and medical errors that may lead to patient safety issues. Equally, nurses would rightly point to the contribution that they make to improving active treatment rates, managing ongoing care and supporting rehabilitation – all important factors in the clinical effectiveness domains.
So the divide is not explained by clinical logic. Instead it appears to be classic gesture politics, providing a nod towards both professions, signalling their respective importance in improving outcomes. This is all good and well, but it must not be seen as a signal that some domains are more important than others, or are more the responsibility of one group than another. A key task for whoever leads Domain 5 will be to ensure that this does not occur. Again, the domain lead roles will only be as powerful as the people who fill them are effective.
The Mid Staffs domain
Domain 5 is also different in that it is as much about what doesn’t happen as what does. The improvement areas say it all: reducing the incidence of avoidable harm; hospital-related venous thromboembolism (VTE); healthcare associated infections; newly-acquired pressure ulcers; and medication errors causing serious harm. For ministers and senior NHS managers, Domain 5 is the stuff that keeps them awake at night. For them, I suspect that success looks like avoiding another Mid Staffs or keeping dirty hospitals off the front pages.
Yet for the domain lead, it has to be about more than simply dodging bullets and avoiding scandal. Instead, it should be about creating a culture of safety whereby incidents can be identified, discussed and learned from, preventing recurrences rather than simply sweeping issues under the carpet until the bulge is so big that another public inquiry is necessitated. It has to be about the small things which add up, as well as the big things which hit headlines.
What is good safety?
As my colleague Nicola Jacobs wrote last year, defining what quality looks like (beyond reducing the headline numbers of ‘bad things’) is difficult. Reporting a patient safety incident is a good thing, but is also an indication of when things go wrong. So, you wouldn’t want to penalise those organisations which do report incidents, or indeed create an incentive for them to under-report. Yet you also need to be able to hold providers to account for incidents and to reward those with genuinely good safety records.
The National Reporting and Learning System (NRLS), until recently, hosted by the new defunct National Patient Safety Agency (NPSA) and now transferred to the NHS Commissioning Board, provides a valuable and under-utilised resource to help address this challenge. Based on the principle borrowed from the airline industry, that all mistakes or potential safety issues – however minor – should be reported in a spirit of openness so they can be learned from, it reveals intriguing differences in both the nature and extent of incidents reported by seemingly similar providers.
Whoever is lead for Domain 5 will need to make better use of this resource than has been the case over the past few years. They will also need to devote considerable time and effort to understanding the patterns and seeking to explain them, as well as convincing providers to act upon the conclusions. The mantra that both high and low reporting rates can be good and that the data alone should not be used to identify safe and unsafe practice is all good and well, but it should not be used as an excuse for failing to exploit the resource provided by the NRLS, or ignoring lessons which should be learned from it.
This is easier said than done. That something is difficult to explain can easily translate into not trying to explain it, or ignoring the lessons that could be learned. Equally, when politicians, managers and clinicians believe that nothing is wrong, they may be less than happy to publish data and pose questions which might suggest otherwise. Ensuring this temptation is avoided must be an important part of the domain lead’s role.
Part of the challenge for the lead will be that many of the new reform levers – incentives, transparency and quality reporting – may not lend themselves to the open, honest and learning culture which is required for patient safety. It is easy to see how a provider could be inclined to err on the side of secrecy if transparency could cost both money and reputation. This problem can be surmounted by the careful design of levers, but the danger of encouraging perverse behaviour will need to be guarded against.
The temptation to play it safe on patient safety will always be strong, but if the lead for Domain 5 is to genuinely embed a safety culture in the NHS and take forward the recommendations of the Francis Inquiry – which will no doubt come his or her way for implementation – then some bold leadership will be required. A safety first approach may not actually put safety first in the NHS.
Read more about what we think about the NHS Outcomes Framework: