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18 December 2024 | Country Update
Review critical of English quality and safety regulator -
08 October 2024 | Policy Analysis
Independent investigation of NHS performance and long-term plan in England
7.4. Health care quality
There is consensus that United Kingdom citizens have access to a high-quality and well developed primary care system, evidenced by relatively low rates of avoidable hospital admissions for congestive heart failure, hypertension and diabetes-related complications (Fig7.3). This thinking is further supported by international comparisons that indicate the United Kingdom has a relatively strong primary care system compared with other European countries (Kringos et al., 2013), and evidence that the greater concentration of GPs in England correlates to improved quality of care across a number of indicators related to cardiovascular diseases, arthritis and diabetes (Vallejo-Torres & Morris, 2018). As discussed in Box5.3, patient satisfaction is also higher for primary care services than for inpatient or emergency services. The United Kingdom does, however, report relatively high avoidable hospital admission rates for respiratory diseases including asthma and chronic obstructive pulmonary disease (Fig7.3). Suggested factors driving these trends include limited availability of pulmonary rehabilitation, poor adherence to inhaler therapy and delayed referral to specialist services (Taskforce for Lung Health, 2018).
| Fig7.3 | Box5.3 |
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For hospital care, the United Kingdom reports particularly poor performance in terms of mortality following hospital admission associated with ischaemic and haemorrhagic stroke when compared with other high-income countries (Fig7.4). Mortality rates are also poor for hospital admission associated with acute myocardial infarction when compared with other high-income countries, and only lower than those reported in Japan and Germany (Fig7.4). National audits of stroke care have identified several areas for improvement across the patient pathway, including increasing the number of patients receiving reperfusion treatment, admission to specialist stroke units and follow-up within six months (SSNAP, 2020). National audits of myocardial infarction care have also identified aspects of care that can be improved including shortening delays in accessing timely percutaneous coronary intervention for ST segment elevation myocardial infarction and increasing the proportion of non-ST segment elevation myocardial infarction patients receiving coronary angiography within 72 hours after admission to hospital (NICOR, 2020).
Fig7.4
The United Kingdom also performs poorly in relation to cancer outcomes when compared with other high-income countries, with five-year cancer survival rates for 2010–2014 being the lowest of G7 countries for colorectal and breast cancer (Fig7.5). This has been attributed to problems in access, including delays in referrals for specialist investigation and care, and lack of diagnostic and imaging services relative to other OECD countries (Maringe et al., 2012, 2013; Walters et al., 2013). However, for some cancers such as leukaemia, the United Kingdom has not only managed to bridge the gap with other high-income countries, but has overtaken many countries to report some of the highest survival rates in the G7 (Fig7.5).
Fig7.5
Broadly speaking, the NHS in each United Kingdom constituent country has developed several mechanisms to monitor unwarranted clinical variation and patient experience. The NHS Atlas of Variation, for example, has demonstrated substantial variation in compliance with guidance and evidence-based standards across a variety of clinical areas such as for respiratory diseases, orthopaedics, cardiology and mental health (NHS England, 2021b). The United Kingdom’s programme of national clinical audits, including the National Clinical Audit and Patient Outcomes Programme, also highlights variation in compliance against guidance but goes a step further by identifying targets for improvement and demonstrating sustained change over time (Rudd et al., 2018). The United Kingdom has also invested in several data sets to understand patient experience and satisfaction with the NHS. The British Social Attitudes Survey, for example, which has been conducted on an annual basis since 1983, found, in its most recent survey conducted in 2019, an increase in overall public satisfaction with the NHS at 60%, a 7% increase from the previous year (Wellings et al., 2020). In England, the NHS Patient Survey Programme has also been in place since 2005, gathering data from a variety of settings including primary care, maternity services, mental health services and adult inpatients (NHS England, 2021l).
The Care Quality Commission (CQC) plays an extensive role in the regulation of health and social care in England. Its independent regulation, though inspection, confers the necessary registration for providers to offer care services and also gives out tiered ratings from “Outstanding” to “Inadequate” across service lines, and to providers as a whole. Recent reforms have meant it now also does the same for Integrated Care Boards in England. A new review has called into question its operational effectiveness and has resulted in shifts in policy.
The UK Department of Health and Social Care (DHSC) commissioned a review of the operational effectiveness of the CQC in May 2024. The review was initially primarily tasked with assessing the suitability of a new single assessment framework for inspecting and rating health and social care providers, but looked more broadly at CQC’s functioning and effectiveness [1].
The review team, led by Dr Penny Dash, undertook a comprehensive analysis of CQC inspection data from 2014 to 2024, examining the consistency and reliability of the new assessment framework. It also conducted stakeholder consultations with health professionals, care providers, and patient advocacy groups.
The review identified several key areas of concern. Its interim and final reports, the latter in October 2024, warned that CQC “has lost credibility in the health and social care sectors” [2].
- Operational performance was generally low, with a far lower level of inspections than before the COVID-19 pandemic.
- There were inconsistencies in the application of the new assessment framework, insufficient attention paid to the effectiveness of care and a lack of focus on outcomes, with only a minority of inspections considering effectiveness as opposed to only safety.
- The framework’s reliance on quantitative data sometimes overlooked qualitative aspects of care, such as patient experience and staff morale.
- Reports were delayed, the process for reaching ratings was unclear, and there was often a reliance on inspections several years old.
The review made seven recommendations, which the government accepted. In addition to improvements in performance and accountability, these included:
- Reviewing the Single Assessment Framework for a greater focus on effectiveness, outcomes, innovation and use of resources, alongside safety.
- Make results more transparent, particularly showing clearly how long ago inspections relied on for rating were.
- Inspections of Integrated Care Boards are being paused, initially for six months, until processes and the question of whether process or outcomes are being judged become clearer.
Authors
References
On 25 September, the UK Department of Health published a review of National Health Service performance in England by the prominent surgeon Lord Ara Darzi [1]. This was commissioned by the Secretary of State for Health in July, following the electoral victory of the Labour party, presented as a stock-take of their inheritance from the previous Conservative party government [2].
The report warned that the English National Health Service (NHS) is “in serious trouble”, with a crisis marked by unprecedented public dissatisfaction, poor access to care, and declining health outcomes. It also made recommendations for a forthcoming 10-year plan for the service, expected in 2025 following a public engagement process.
Waiting times for GP appointments, community services, and mental health care have surged, with millions waiting for treatment, particularly among vulnerable populations like children. The NHS has not met key performance targets since 2015, leading to further erosion of public confidence. Cancer survival rates remain below those of comparable countries, and the rate of inclusion has slowed over the last 15 years. Despite recent increases in staffing, productivity appears lower than before the COVID-19 pandemic, which has left a difficult legacy of higher need, staff stress, and delayed treatment.
Lord Darzi noted that deteriorating population health, associated with worsening of the social determinants of health, such as housing and income, had exacerbated the situation. The report also pointed to diminished and limited managerial capacity, praising management generally for attempting to “keep the show on the road”, and to a lack of capital investment. It concluded that the move to “Integrated Care Boards” bringing together purchasers and providers “has the makings of a sensible management structure” and applauded the shift towards collaboration over competition. However, it noted that despite attempts to shift care from hospitals to community and primary care, spending and staffing had become even more concentrated in hospitals.
Specific policy recommendations were outside the report’s scope, but it provided a set of themes for a comprehensive 10-year health plan to address systemic issues and strengthen the NHS. These were:
- Re-engage staff and re-empower patients.
- Lock in the shift of care closer to home by hardwiring financial flows, reflecting a government commitment to expanding the share of the budget spent outside hospital.
- “Simplify and innovate care delivery for a neighbourhood NHS”, with multidisciplinary care across primary, community and mental health care.
- Drive productivity in hospitals through better management and capital investment.
- Improve the use of technology, particularly by expanding electronic records and digital data to services outside hospital, and by adopting AI.
- Contribute to the nation’s prosperity by reducing the number of people economically inactive due to health needs.
- Clarify roles and accountabilities, rebalance management capacity, and improve capital approvals so that the health service is better able to deliver on policies.