- Email: [email protected]
What next for the NHS?
Comment
7
8
9
Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high risk patients (MATCH): randomised double-blind, placebo controlled trial. Lancet 2004; 364: 331–37. Markus HS, Droste DW, Kaps M, et al. Dual antiplatelets therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using Doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation 2005; 111: 2233–40. Kennedy J, Ryckborst KJJ, Demchuk AM, on behalf of FASTER investigators. The Fast Assessment of Stroke and Transient ischemic attack to prevent Early Recurrence (FASTER) trial—results of the pilot phase. Cerebrovasc Dis 2007; 23 (suppl 2): 56.
10
11
12
13
Lavallée PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007; published online Oct 9. DOI:10.1016/S1474-4422(07)70248-X. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369: 283–92. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischaemic stroke or transient ischaemic attack: a statement for health care professionals from American Heart Association/American Stroke Association Council on Stroke. Stroke 2006; 37: 577–617. Rothwell PM, Eliasziw M, Gutnikov SA, et al. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischaemic attack and nondisabling stroke. Stroke 2004; 35: 2855–61.
What next for the NHS? See Editorial page 1393
The provision of good-quality health care is the goal of all clinicians. So the focus of our interim report on the UK National Health Service (NHS), Our NHS, our future,1 had to be on improving the quality of care the people of England receive from their health service (panel). Patients, NHS staff, and the public identified four dimensions of good-quality care (fairness, responsiveness, safety, and effectiveness) and assessed the potential for improvement. Our final report will be released in June, 2008. Fairness is a great strength of NHS care. The Commonwealth Fund placed the UK first for equity in a comparison of six health-care systems.2 While 47 million US citizens do not have health insurance, the NHS is free at the point of need.3 The NHS might lead the way, but we can still improve. For instance, inequality in infant mortality has widened in recent years. In 2003–05, infant mortality was 18% higher in the routine and manual working classes than in the total population, whereas in 1997–99 it was 13% above average.4 At the same time, the areas with the greatest need have fewest doctors per head. So Oldham has half the number of primary clinicians compared with Northumberland.
Panel: Our NHS, our future • NHS should be focused on improvement of quality of care • In four dimensions of quality care—fairness, responsiveness, safety, and effectiveness—NHS is not currently performing as well as it could • Initial solutions include improving access to general practices, reducing health-care associated infections, and championing of innovation • Future proposals will mainly be developed locally with some national focus on overarching issues
1400
This imbalance needs to be addressed—as Bierman argues, equity needs to be central to how we measure performance, to how we assess the quality of care.5 If the NHS cannot rest on its laurels with regard to fairness, improving responsiveness is an even bigger challenge. No one would suggest that the NHS is a world leader in patient-centred, personalised, and convenient care. Yet the NHS could be if we listen to what people want. When we asked over a thousand people at events across England as part of the review, most wanted general practices to be open in the evenings or on Saturdays, or both. More than half the population want to die at home, but less than a fifth of deaths take place there.6 The NHS should respond to these desires when possible, so we are increasing the options available locally to encourage more flexible opening hours for general practices and end-of-life care will be one of the topics to get detailed consideration by clinicians in working groups across England. Some people may quibble that responsiveness is not a priority, but no one would dispute that goodquality care is safe care. Do no harm is a central tenet of clinicians and was identified as one of the Tavistock Principles for ethical health care.7 However, the current incidence of health-care associated infections means that sometimes we are harming the very patients we seek to cure. Although only 1% of Staphylococcus aureus infections in Denmark are meticillin-resistant, the proportion in the UK is 44%.8 The announcement in our interim report of bacteriological screening of elective and emergency admissions for meticillin-resistant S aureus infections should help to tackle health-care associated infections, but there also needs to be a local focus on cleanliness across the NHS. www.thelancet.com Vol 370 October 20, 2007
Comment
Unsafe care is both dangerous to the patient and expensive, so there is some overlap with our fourth dimension of good-quality care, effectiveness. However, effective care is much broader, from making the best use of technology for provision of care in the most appropriate place. Guthrie and colleagues9 showed that measuring quality outcomes alone is not enough to tell whether care is effective—we should also be relating outcomes to treatment information. Additionally, too often the NHS is not an early adopter of new techniques and approaches. Healthcare for London: a framework for action10 highlighted how in England we are lagging behind international best practice in interventional stroke care. Given my background in minimally invasive therapies, I am passionate about making the best use of new technology, and I will lead a Health Innovation Council to ensure leading treatments are available to all on the NHS. Improvement of the quality of care the NHS provides in terms of fairness, responsiveness, safety, and effectiveness will be a continuous process, not a quick fix. Our interim report has made some recommendations for areas in which there is a clear need to act, such as access to primary care. Yet, by its nature, an interim report does not have all the answers; rather, it seeks to pose the pertinent questions. Most of the solutions to improvement of the quality of care will need to be worked out locally. Eight clinical working groups in nine specialist health authorities (London has already completed this process) have been tasked with developing proposals appropriate to their area. They will do so by considering the best available evidence and sharing their ideas with patients, the public, and staff. At a national level, the Department of Health’s remit should be to focus on large overarching issues, such as clinical leadership, workforce planning, education and training, the idea of an NHS constitution (to safeguard
the values of the NHS as it reaches its 60th anniversary), and the underpinning business processes that allow clinicians to do their jobs. The Department of Health will also, of course, have a key role in securing the necessary funding to allow improvements in quality of care to be made. By combining a national perspective with local knowledge and experience, the Our NHS, our future review can prove that we are not missing the obvious, and that we recognise that good quality care is absolutely fundamental to the NHS. Ara Darzi Department of Health, London SW1A 2NS, UK [email protected] I declare that I have no conflict of interest. 1
2
3
4
5 6
7 8
9 10
Darzi A. Our NHS, our future. NHS next stage review: interim report. Oct 4, 2007. http://www.ournhs.nhs.uk/files/283411_OurNHS_v3acc.pdf (accessed Oct 11, 2007). Davis K, Schoen C, Schoenbaum SC, et al. Mirror, mirror on the wall: an international update on the comparative performance of American health care. May 2007. http://www.commonwealthfund.org/publications/ publications_show.htm?doc_id=482678 (accessed Oct 15, 2007). DeNavas-Wlat C, Proctor BD, Smith J. Current population reports, P60–233. Income, poverty, and health insurance coverage in the United States: 2006. Washington, DC: US Government Printing Office, 2007. http://www.census. gov/prod/2007pubs/p60-233.pdf (accessed Oct 15, 2007). Department of Health. Departmental report 2007. http://www.dh.gov.uk/ en/Publicationsandstatistics/Publications/AnnualReports/DH_074767 (accessed Oct 11, 2007). Bierman A, Clark J. Performance measurement and equity. BMJ 2007; 334: 1333–34. Higginson IJ. Priorities and preferences for end of life care in England, Wales and Scotland. London: The Cicely Saunders Foundation, Scottish Partnership for Palliative Care and the National Council for Hospice and Specialist Palliative Care Services, 2003. Berwick D, Davidoff F, Hiatt H, Smith R. Refining and Implementing the Tavistock principles for everybody in health care. BMJ 2001; 323: 616–20. Department of Health. Winning ways: working together to reduce healthcare associated infection in England. Report by the Chief Medical Officer, Dec 2003. http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/Browsable/DH_4095070 (accessed Oct 15, 2007). Guthrie B, Inkster M, Fahey T. Tackling therapeutic inertia: the role of treatment data in quality indicators. BMJ 2007; 335: 542–44. Darzi A. Healthcare for London: a framework for action. July 2007. http://www.healthcareforlondon.nhs.uk/framework_for_action.asp (accessed Oct 11, 2007).
Can the WHO Ministerial Forum lead to the eradication of TB? The WHO EURO region’s Ministerial Forum1 on tuberculosis on Oct 22, 2007, in Berlin will bring together European ministers of health, finance, justice, and foreign affairs to declare tuberculosis as a regional health threat and to announce new political and financial commitments to tackle the threat. But, as in the European framework to decrease the burden of TB/HIV,2 www.thelancet.com Vol 370 October 20, 2007
the perspective of the threat is from within the regional boundaries of Europe and overlooks the threat from the devastation caused by tuberculosis outside Europe. If the European ministers intend to reduce tuberculosis at home, they must first completely recast the framework. In a 21st century that is becoming more and more global, to reduce the incidence of tuberculosis within 1401
7
8
9
Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high risk patients (MATCH): randomised double-blind, placebo controlled trial. Lancet 2004; 364: 331–37. Markus HS, Droste DW, Kaps M, et al. Dual antiplatelets therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using Doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation 2005; 111: 2233–40. Kennedy J, Ryckborst KJJ, Demchuk AM, on behalf of FASTER investigators. The Fast Assessment of Stroke and Transient ischemic attack to prevent Early Recurrence (FASTER) trial—results of the pilot phase. Cerebrovasc Dis 2007; 23 (suppl 2): 56.
10
11
12
13
Lavallée PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol 2007; published online Oct 9. DOI:10.1016/S1474-4422(07)70248-X. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369: 283–92. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischaemic stroke or transient ischaemic attack: a statement for health care professionals from American Heart Association/American Stroke Association Council on Stroke. Stroke 2006; 37: 577–617. Rothwell PM, Eliasziw M, Gutnikov SA, et al. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischaemic attack and nondisabling stroke. Stroke 2004; 35: 2855–61.
What next for the NHS? See Editorial page 1393
The provision of good-quality health care is the goal of all clinicians. So the focus of our interim report on the UK National Health Service (NHS), Our NHS, our future,1 had to be on improving the quality of care the people of England receive from their health service (panel). Patients, NHS staff, and the public identified four dimensions of good-quality care (fairness, responsiveness, safety, and effectiveness) and assessed the potential for improvement. Our final report will be released in June, 2008. Fairness is a great strength of NHS care. The Commonwealth Fund placed the UK first for equity in a comparison of six health-care systems.2 While 47 million US citizens do not have health insurance, the NHS is free at the point of need.3 The NHS might lead the way, but we can still improve. For instance, inequality in infant mortality has widened in recent years. In 2003–05, infant mortality was 18% higher in the routine and manual working classes than in the total population, whereas in 1997–99 it was 13% above average.4 At the same time, the areas with the greatest need have fewest doctors per head. So Oldham has half the number of primary clinicians compared with Northumberland.
Panel: Our NHS, our future • NHS should be focused on improvement of quality of care • In four dimensions of quality care—fairness, responsiveness, safety, and effectiveness—NHS is not currently performing as well as it could • Initial solutions include improving access to general practices, reducing health-care associated infections, and championing of innovation • Future proposals will mainly be developed locally with some national focus on overarching issues
1400
This imbalance needs to be addressed—as Bierman argues, equity needs to be central to how we measure performance, to how we assess the quality of care.5 If the NHS cannot rest on its laurels with regard to fairness, improving responsiveness is an even bigger challenge. No one would suggest that the NHS is a world leader in patient-centred, personalised, and convenient care. Yet the NHS could be if we listen to what people want. When we asked over a thousand people at events across England as part of the review, most wanted general practices to be open in the evenings or on Saturdays, or both. More than half the population want to die at home, but less than a fifth of deaths take place there.6 The NHS should respond to these desires when possible, so we are increasing the options available locally to encourage more flexible opening hours for general practices and end-of-life care will be one of the topics to get detailed consideration by clinicians in working groups across England. Some people may quibble that responsiveness is not a priority, but no one would dispute that goodquality care is safe care. Do no harm is a central tenet of clinicians and was identified as one of the Tavistock Principles for ethical health care.7 However, the current incidence of health-care associated infections means that sometimes we are harming the very patients we seek to cure. Although only 1% of Staphylococcus aureus infections in Denmark are meticillin-resistant, the proportion in the UK is 44%.8 The announcement in our interim report of bacteriological screening of elective and emergency admissions for meticillin-resistant S aureus infections should help to tackle health-care associated infections, but there also needs to be a local focus on cleanliness across the NHS. www.thelancet.com Vol 370 October 20, 2007
Comment
Unsafe care is both dangerous to the patient and expensive, so there is some overlap with our fourth dimension of good-quality care, effectiveness. However, effective care is much broader, from making the best use of technology for provision of care in the most appropriate place. Guthrie and colleagues9 showed that measuring quality outcomes alone is not enough to tell whether care is effective—we should also be relating outcomes to treatment information. Additionally, too often the NHS is not an early adopter of new techniques and approaches. Healthcare for London: a framework for action10 highlighted how in England we are lagging behind international best practice in interventional stroke care. Given my background in minimally invasive therapies, I am passionate about making the best use of new technology, and I will lead a Health Innovation Council to ensure leading treatments are available to all on the NHS. Improvement of the quality of care the NHS provides in terms of fairness, responsiveness, safety, and effectiveness will be a continuous process, not a quick fix. Our interim report has made some recommendations for areas in which there is a clear need to act, such as access to primary care. Yet, by its nature, an interim report does not have all the answers; rather, it seeks to pose the pertinent questions. Most of the solutions to improvement of the quality of care will need to be worked out locally. Eight clinical working groups in nine specialist health authorities (London has already completed this process) have been tasked with developing proposals appropriate to their area. They will do so by considering the best available evidence and sharing their ideas with patients, the public, and staff. At a national level, the Department of Health’s remit should be to focus on large overarching issues, such as clinical leadership, workforce planning, education and training, the idea of an NHS constitution (to safeguard
the values of the NHS as it reaches its 60th anniversary), and the underpinning business processes that allow clinicians to do their jobs. The Department of Health will also, of course, have a key role in securing the necessary funding to allow improvements in quality of care to be made. By combining a national perspective with local knowledge and experience, the Our NHS, our future review can prove that we are not missing the obvious, and that we recognise that good quality care is absolutely fundamental to the NHS. Ara Darzi Department of Health, London SW1A 2NS, UK [email protected] I declare that I have no conflict of interest. 1
2
3
4
5 6
7 8
9 10
Darzi A. Our NHS, our future. NHS next stage review: interim report. Oct 4, 2007. http://www.ournhs.nhs.uk/files/283411_OurNHS_v3acc.pdf (accessed Oct 11, 2007). Davis K, Schoen C, Schoenbaum SC, et al. Mirror, mirror on the wall: an international update on the comparative performance of American health care. May 2007. http://www.commonwealthfund.org/publications/ publications_show.htm?doc_id=482678 (accessed Oct 15, 2007). DeNavas-Wlat C, Proctor BD, Smith J. Current population reports, P60–233. Income, poverty, and health insurance coverage in the United States: 2006. Washington, DC: US Government Printing Office, 2007. http://www.census. gov/prod/2007pubs/p60-233.pdf (accessed Oct 15, 2007). Department of Health. Departmental report 2007. http://www.dh.gov.uk/ en/Publicationsandstatistics/Publications/AnnualReports/DH_074767 (accessed Oct 11, 2007). Bierman A, Clark J. Performance measurement and equity. BMJ 2007; 334: 1333–34. Higginson IJ. Priorities and preferences for end of life care in England, Wales and Scotland. London: The Cicely Saunders Foundation, Scottish Partnership for Palliative Care and the National Council for Hospice and Specialist Palliative Care Services, 2003. Berwick D, Davidoff F, Hiatt H, Smith R. Refining and Implementing the Tavistock principles for everybody in health care. BMJ 2001; 323: 616–20. Department of Health. Winning ways: working together to reduce healthcare associated infection in England. Report by the Chief Medical Officer, Dec 2003. http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/Browsable/DH_4095070 (accessed Oct 15, 2007). Guthrie B, Inkster M, Fahey T. Tackling therapeutic inertia: the role of treatment data in quality indicators. BMJ 2007; 335: 542–44. Darzi A. Healthcare for London: a framework for action. July 2007. http://www.healthcareforlondon.nhs.uk/framework_for_action.asp (accessed Oct 11, 2007).
Can the WHO Ministerial Forum lead to the eradication of TB? The WHO EURO region’s Ministerial Forum1 on tuberculosis on Oct 22, 2007, in Berlin will bring together European ministers of health, finance, justice, and foreign affairs to declare tuberculosis as a regional health threat and to announce new political and financial commitments to tackle the threat. But, as in the European framework to decrease the burden of TB/HIV,2 www.thelancet.com Vol 370 October 20, 2007
the perspective of the threat is from within the regional boundaries of Europe and overlooks the threat from the devastation caused by tuberculosis outside Europe. If the European ministers intend to reduce tuberculosis at home, they must first completely recast the framework. In a 21st century that is becoming more and more global, to reduce the incidence of tuberculosis within 1401