Comment / Finance and quality in the red

The Care Quality Commission has pledged to promote a single shared view of quality. The quality regulator has built its inspection regime around assessing quality using five key questions: is it safe? Is it effective? Is it caring? Is it responsive? Is it well-led?

However, it’s new five-year strategy, in which it makes this pledge, says that ‘multiple definitions of care quality are still being used’. In response, it wants to work with providers and the public to agree a definition of quality and how this should be measured.

What people mean by quality is important. For example, the King’s Fund’s latest quarterly monitoring report found that two-thirds of trust finance directors and more than half of clinical commissioning group chief finance officers in their sample say the quality of care in their area has deteriorated in the past year.

The King’s Fund said it was the most worrying finding since it started tracking this question back in 2012. And it certainly appears to be something of a tipping point, with a majority of all finance leaders now in agreement.

But what do finance directors mean by quality in this context? Access and waiting times (singled out as the most vulnerable aspects of quality by finance directors in a survey for the last HFMA NHS financial temperature check – with new figures out next month) are perhaps what come to mind first – given that they are monitored against national targets.

In this interpretation of quality, how could finance directors say anything different? Performance against the key access targets has fallen.

Or do they mean some broader definition of quality including clinical outcomes, patient-reported outcomes, patient experience and core patient safety?

An understanding of quality in its fullest sense is vital if you are looking at the impact of investment or cost reduction activities on services.

There have been concerns over the years about the relative priorities of quality and finance. And earlier this year NHS Improvement and the CQC wrote to the service saying that ‘success is delivering the right quality outcomes with the resources available’ and that ‘quality and financial objectives cannot trump one another’.

These are nice words, but not particularly helpful for organisations making tough choices at the frontline – particularly when both quality and finance are in the red.

Perhaps what is more galling for providers is that they are being penalised despite their best attempts to achieve this quality-finance balance. Providers reported a £2.45bn deficit in 2015/16 and NHS Improvement said that providers spent £143m on waiting list initiative work to avoid breaches in waiting time targets, as well as outsourcing some £241m of work.

Increases in agency costs will also have been caused in part by striving to meet access targets. But providers still faced net fines and readmission penalties of nearly £500m.

NHS Improvement recognises significant increases in demand – with A&E departments having their busiest year on record and a big jump in the number of people waiting for elective care. So we may have a situation where there are insufficient funds in the system to meet access targets for current levels of demand and then providers being financially penalised for missing these targets.

There is no disagreement about the general principle that everyone should strive for the highest possible quality within the resources available and this should be underpinned by national standards. And there is broad support that transformation of patient pathways and how services are delivered offers the best prospect for creating sustainable services.

However, even accepting that improved efficiency has a role to play, it may well be time to assess whether what the NHS is being asked to deliver right now is in fact achievable.

And if that is the case, we need to start having a more nuanced discussion about quality and its various dimensions.