Are the new clinical commissioning groups (CCGs) taking note of the content of Quality Standards? Why are Quality Standards unable to address concerns around late diagnosis? How can patients make use of Quality Standards to demand best practice care from their local health service?
These and other similar questions were raised during a roundtable meeting convened by Weber Shandwick last week on the rheumatoid arthritis Quality Standard currently in development. Stakeholders from industry, clinicians and patient groups discussed their experience of the Quality Standard process, and raised questions not just for those of us working in rheumatology, but also for other clinical areas where Quality Standards are being developed by NICE or are pending.
High-quality and cost-effective care
Quality Standards were proposed by Lord Darzi back in 2008 in his report, High Quality Care For All. Produced by the National Institute of Clinical Excellence (NICE) with stakeholder involvement, they are described as, “specific, concise statements, which mark high-quality, cost-effective care across a pathway or a clinical area”, and are derived from existing NICE guidance.
Over the next five years, NICE is producing a library of more than 180 Quality Standards, covering the vast majority of conditions.
At the roundtable, Professor Robert Moots who chairs the Topic Expert Group on the Rheumatoid Arthritis Quality Standard outlined the careful balancing act involved in whittling all the guidance and advice on RA down to just eight or nine sentences.
The group was most concerned about the gap between the best practice set out in Quality Standards and the ability of commissioners across the country to translate this into local service provision. One participant flagged recent conversations with commissioners who said that although they agreed with the content of the Quality Standard, they lacked the resource to commission accordingly.
And so it seems we are back to the same ‘old chestnut’ of lack of implementation.
Addressing issues of implementation
In rheumatology there is persistently inappropriate commissioning, for example, where RA is still treated as an outpatient service when in reality it should be treated as ambulatory care. Furthermore, the long-term care QIPP (quality, innovation, productivity, prevention) savings are not fully understood, as most rheumatology costs sit outside of the musculoskeletal Zone (MSK) programme budget.
Unless these system errors are addressed, there is a risk that cost-effective services will be de-commissioned, for instance, if rheumatology nurses are wrongly perceived as an ‘expensive luxury’, and the savings nurses deliver such as avoidable hospital admissions via provision of patient helpline advice, are not recognised.
In theory it is the NHS Commissioning Board’s CCG Outcomes Indicator Set that will incentivise commissioners to match Quality Standards, so it is the ability of these indicators to measure the contents of the Quality Standards that will be key to improving commissioning.
Quality Standards are not a panacea
One particular shortcoming highlighted during the meeting, was the inability of the Quality Standards to address the problem of patients presenting late and therefore receiving a late diagnosis. The reason this cannot be included, is that NICE considers it impossible for the health service to have control over this part of the patient journey. However, in conditions like rheumatoid arthritis where early diagnosis and early treatment are essential to improving patient outcomes, this omission is worrying.
Nonetheless, from a communications perspective, Quality Standards have huge potential to empower patients to demand best practice care, with the reassurance this has been deemed by NICE to be clinically and cost-effective. Because of their brevity and the accessibility of the language used (part of the drafting process includes ensuring Quality Standards are produced in plain English), they are ostensibly a very useful tool for non-specialists and patients to digest key information about the care they should expect to receive.
Therein lies their power.
But are patients aware of this and are they being used in this way? If one looks at NHS Choices, the Government’s flagship resource for patients, this certainly isn’t yet coming through.
Take for example NHS Choices’ advice on Diabetes – one of the earliest conditions to benefit from a Quality Standard. Although there is a link through to the Quality Standard on the Diabetes landing page, this is hidden within paragraphs of text, some of it historic, much of it tangential.
For Quality Standards to revolutionise standards of care in this country, the principle of streamlined advice that is accessible and consistent needs to be taken up across the NHS. Certainly, Quality Standards need to take better hold both among commissioners and patients for their aspirations to become the reality of care on the ground for everyone.
