To hold the responsibility of setting MPs’ expenses and salaries, as Chair of the Independent Parliamentary Standards Authority, must be no easy task in itself. However Professor Sir Ian Kennedy manages to juggle this role with chairing the King’s Fund inquiry into the quality of general practice in England and is still able to take time out to attend an interview with OnMedica.
Sir Ian is an academic lawyer who has specialised in the law and ethics of health throughout his career. He has been a member of numerous committees and inquiries, perhaps the most notorious of which was his role as Chair of the public inquiry into paediatric heart surgery at Bristol Royal Infirmary. This resulted in him becoming Chair of the Healthcare Commission, now the Care Quality Commission. The new government’s health policy is rather unclear at present, but one thing that is clear is the need to simultaneously improve quality whilst making huge efficiency savings. So, in these interesting if slightly uncertain times, who better to approach for counsel than Sir Ian?
The first stage in improving quality in the NHS is, as Sir Ian explains, to acknowledge that we are, at least, now having a conversation about quality. “Admittedly, it has taken a while to get here since the birth of the NHS, but at least we have finally got round to it. We need to use the various levers that the government has, like workforce, money and regulation, to inject a sense of direction into whatever the service is seeking to deliver. The agenda is now quality.”
If you think that there are a million contacts between patients and healthcare professionals every 36 hours, the level of patient satisfaction is up in the 80’s%
So, what exactly are the key areas that require a boost in quality? “Actually,” Sir Ian reiterates, “if you think that there are a million contacts between patients and healthcare professionals every 36 hours, the level of patient satisfaction is up in the 80’s%. This proves that by and large, things aren’t going wrong.” However, with the NHS previously described as ‘islands of excellence in a sea of mediocrity,’ Sir Ian highlights that it is this ‘sea of mediocrity’ that we need to tackle. “A mediocre service is not what £110 billion taxpayers’ money should be spent on. A key step in tackling this is to re-engage the professionalism and psychological motivation of all professionals.”
With regards to the King’s Fund inquiry into the quality of general practice, something that Sir Ian believes in almost as an article of faith is that we simply do not know enough about the level of performance of GP’s. “We know a lot about cardiac surgery, as we can collect data which tends to be binary. However we have virtually no data on aspects of GP performance which are critical to patients, such as the extent of late or missed diagnoses.” Sir Ian concludes that improving quality relies on two factors; the availability of data and agreed benchmarks of performance, neither of which are easy to develop.
To all intents and purposes, the Quality and Outcomes Framework (QOF) was released as a performance indicator. However perhaps the government did not predict that doctors would achieve the levels they did, with most practices now hitting up to 90% of QOF targets. So just how can we obtain quality indicators that have measurable outcomes for the interaction between doctor and patient? Sir Ian agrees that QOF is not up to this task. “Firstly, in my mind, the QOF system was not sufficiently demanding, as evidence immediately demonstrated. Secondly, it incentivised some behaviour and not others. Thirdly, the notion of injecting internally accepted benchmarks into this system is still being argued about.” However, he notes that it is possible to measure certain aspects of the chemistry of the doctor-patient interaction. “An intriguing finding from the King’s Fund inquiry, is that patients love solo practitioners. This is because as well as delivering healthcare, they also play the role of the modern priest.” Asking a sufficiently randomised cohort of patients if their expectations have been met is obviously a measurable outcome, however Sir Ian acknowledges that this is not without its challenges, as patients are experts in terms of knowing what their own needs and wants are, but they are not experts in the delivery of healthcare. In summary, Sir Ian explains that improving quality will rely on “getting data, asking the right questions regarding performance, and having agreed benchmarks of what it is that constitutes good performance. It will be a long journey to get there and that is what the King’s Fund is for.”
The principle is that no one is given a licence to lay their hands on patients without having to demonstrate from time to time that they are competent
Another big concern on the minds of many GP’s is the new accreditation system that is on the horizon. Does Sir Ian incorporate this accreditation system into the equation that will produce a continent of excellence, rather than just mere islands? “The first thing to say is that accreditation is part of a process, which is about coming to terms with the notion that all professionals have a fundamental duty to serve those who approach you for your professional skill,” he says. “We now need to monitor moral and ethical conduct and ensure doctors remain educated to an appropriate level. Details of how to do this, is just detail. The principle is that no one is given a licence to lay their hands on patients without having to demonstrate from time to time that they are competent.”
Is it really going to be feasible to improve quality whilst committing to efficiency savings? Many practices are already witnessing cuts to frontline care. How does Sir Ian envisage the two marrying together? The first thing to note is that he believes and has been arguing as such for many years, that general practice is the key to the future of health care, in terms of preventative care and health promotion. However, the bottom-line is that “there will be mouth-watering cuts, and so we need to start embracing the notion and be creative to deliver the service that we have a duty to deliver, efficiently and effectively.” Sir Ian’s key message is to “avoid spending money downstream by spending money upstream.” By this, he is illustrating how billions could be saved if we invested a little and early. An example he gives is of a new project in Tower Hamlets which, with modest financial investment, resulted in six children being kept out of care during its first year. Bearing in mind the huge costs accrued by placing one child in care for one week, avoiding this is clearly financially beneficial, but it also benefits the child’s social wellbeing.
Where does Sir Ian see management tiers fitting in to a high quality NHS? Surely the solution would be to give healthcare professionals more autonomy? Well Sir Ian certainly recognises that there is a significant clinician management divide, admitting that many clinicians describe managers as semi-human. “I believe that this divide has been very unfortunate for patients, as they are now managed in an environment of trench warfare,” he says. “I would wish for clinicians to be more involved in management, because they know about how services are delivered and how they need to be organised.” However, clearly the NHS requires managers with a range of backgrounds and expertise. Sir Ian feels that a good starting point to resolve this issue is for both clinicians and managers to recognise the existence of one another, and accept that “managers care for and about patients, just as doctors have management capabilities.”
The NHS is really part of this country’s DNA and sense of social justice
We’d all like a few ‘Mystic Meg’ powers to allow us an insight into what the future holds. Using his mystical abilities, how does Sir Ian envisage the NHS in 10 years time? He confesses that he can’t recall the number of times the NHS has been pronounced on its last legs, but emphasises that despite this, it is still standing strong. “Firstly, this is because it’s the closest thing the UK has to a national religion. Secondly, it has become rather like a democracy, in that it’s the least bad system you can think of. It has, intrinsic within it, elements of fairness, social justice and easy access, which are enviable to others,” he explains. “The NHS is really part of this country’s DNA and sense of social justice. It would be very difficult to radically move away from what the NHS represents; care which is free at the point of need for all who might need it.”
That said, he admits that the coming years will bring with it the usual upheavals that we are so accustomed to, but nothing will make a huge difference to the fundamental values and ethos of the professionals that enter a career in healthcare. Quoting a line from the famous novel The Leopard, Sir Ian depicts how we should endure the forthcoming changes to the NHS: “If we want things to stay as they are, things will have to change.”