Comment / Quality counts

Improving pathways and systems and reducing duplication hold the key to higher quality services at a reduced cost

The renewed focus on quality and outcomes within the operating framework for 2009/10 in England should come as no surprise. It was the major theme in Lord Darzi’s review, High quality care for all. 

So how do we go from a service focused primarily on financial balance and the pursuit of nationally driven targets to one concerned with the delivery of healthcare to consistently high standards?

The early learning from areas where additional payments for quality have been trialled suggests you don’t need huge financial incentives to lever up quality. In NHS North West, for example, primary care trusts have used a quality fund to reward high standards in five specified clinical pathways. Early indications are that performance has improved more in response to peer pressure than financial incentive.

Given this evidence, how should we respond to the proposed Commissioning for Quality and Innovation (CQUIN) system under which 0.5% of contract values in 2009/10 will be held back for quality payments?

This will clearly have an impact on providers’ financial planning arrangements. The presumption for commissioners is that they should assume payment will take place. But how do we avoid a repeat of previous behaviours where some NHS trusts created reserves to pay fines for non-achievement of MRSA and Clostridium difficile targets – effectively planning to fail?

I believe the solution requires a more detailed understanding of CQUIN. The scheme’s success will depend on the ability of the NHS to agree on a system of measurement – one example being discussed is patient related outcome measures (PROMS).

While other industries have focused increasingly on quality, the NHS has come to this relatively late. There is much we can learn from the airline and car industries, where poor quality can have a disastrous impact on safety and customer satisfaction.

The NHS has tended to approach each cash-releasing efficiency savings round with a dilemma: invest in quality services or cut costs. But evidence globally suggests the holy grail – improved quality leading to cost reductions – is achievable. The answer lies in improvements to system quality so reducing duplication. This will ensure we get things right first time far more frequently.

Look at readmission rates after surgery. Often resources are spent treating patients more than once due to the appropriate treatment not being given in the first place. There are numerous other examples, including medication errors, wrong-site surgery and even MRSA and C.diff, where the costs of the system could be reduced if quality were increased.

So where does all this get us as we consider a 0.5% cut of contract values being held back for the implementation of CQUIN? When we consider the estimated costs of medication errors in the NHS each year – estimates start at £500m – it is hard to argue that spending these resources will not provide a better, more efficient system in the long term.

As finance professionals we must all engage in the quality agenda – everything from alignment of the new quality accounts to the financial statements to involvement in the development of CQUIN scheme proposals to ensure robustness and achievability.

We are uniquely placed to add value in this process due to our skill sets and ability to analyse complex information. But if we don’t engage with this agenda, we are unlikely to be presiding over organisations in financial balance in the medium term.