Editorial

Rethinking ‘quality’ in health care

‘Quality’ is a word we encounter repeatedly in relationto health care and it has become a powerful healthpolicy driver. In the USA, the Institute of Medicinecharacterises high quality care as that which is safe,effective, patient-centred, timely, efficient, equitable.1 InEngland, the NHS is ‘organising itself around a singledefinition of quality: care that is effective, safe and pro-vides as positive an experience as possible’2 enshrined inthe NHS Outcomes Framework, as a set of measurableindicators.3 General practitioners continue to deriveabout 30% of their income through scoring points inthe Quality and Outcomes Framework.

However, there is growing concern about the unin-tended consequences of pay-for-performance, ‘evidence-based’ quality standards and related data gathering.Critics argue that such approaches threaten the human-ity and authentic dialogue that are central to the ther-apeutic endeavour.4,5 The Francis Report in Englandhighlighted the dangers of overreliance on targets forachieving quality in a system as complex as the NHS,calling for a ‘fundamental culture change’, with all healthcare staff striving to place empathy for the predicamentof patients at the forefront of their minds.6 This envi-saged culture should, according to Francis, be charac-terised by openness, transparency and candour.6 Thesuggestion of a shift towards a system which is appre-ciated for its shared professional values rather than forassiduous pursuit of targets is welcome, but doubts havebeen voiced about how this might be implemented; ‘put-ting patients first’ is hardly a new idea.7

A recent colloquium ‘The Many Meanings of‘‘Quality’’ in Healthcare: Interdisciplinary Perspectives’brought together health professionals, academics andpatient representatives to unpack the notion of‘quality’.8 We considered questions such as: Are weconfident that there is a desirable match between qual-ity metrics and the properties we seek to enhance? Whatare the trade-offs in privileging one account of qualityover another? What are the professional and patientvalues that underpin quality? How do we reconcile dif-ferent ideological perspectives about quality?

Four key interrelated themes emerged. The first wasthat the delivery of high quality health care depends ona ‘care’-ful act of holding in the balance a range of(sometimes contradictory) perspectives on what consti-tutes quality. We present some examples as a series of

dyads: biometric assessment versus affective engage-ment; measurement versus description; scientific evi-dence versus imagination; treating the person as the‘end’ versus treating the person as the ‘means’; knowingversus not knowing; universal generalisation versuslocal experience; trust in ‘practice’ versus confidencein ‘the system’. These are not mutually exclusivedichotomies but they are tensions, and clinicians needto work creatively and flexibly to embrace them. Everyact of health care is an opportunity for unique tailoringrather than a ‘one-size-fits-all’ prescription and it is thisresponse to the complexity of each individual situationthat marks out high quality care from mediocre care, orworse still, poor care. Organisations must offer both thestability required to foster relationships of professionaltrust and the flexibility to support this responsive crea-tive work.

Secondly, there was a call for more description andless measurement in evaluating quality. Overemphasison measurement of those aspects of care which areeasily measured is not only unreliable but ‘marks thegrowing ascendancy of the body as object over the bodyas subject’ (Dr Iona Heath, page 19).8 Systems of exter-nal accountability, regulation and performance man-agement may be necessary but run the risk ofunintended consequences, generating new work andnew risks in busy environments where staff are alreadyoverstretched. Proxy measures of quality may offer astandardised, reassuring appearance of quality whilstalso crowding out professionals’ capacity to deliveraltruistic care, which is less visible and – to all intentsand purposes – unmeasurable. Researchers pointed tothe value of ethnographic and narrative modes ofenquiry, where detailed critical exploration of carepractices brings insights into meanings of ‘quality’that lie beyond the reach of quantification. Patientrepresentatives suggested that personal testimonies pro-vide a better window into subjective experiences ofchronic diseases and addiction, and the key to authenticengagement between practitioner and patient.

This ‘authenticity’ of engagement with patients isdemanding, challenging work, difficult to sustain inpractice. Practitioners need opportunities to discussand reflect on their experiences and concerns withtheir peers – the focus of the third theme. This is onlypossible if organisations value such activities as

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legitimate forms of work and offer the necessaryresources to support them. Such collaborative effortswithin health care teams are fertile ground for local,innovative and creative approaches to delivering excel-lence in particular contexts of care. Unfortunately, theopportunity for such activity is too often marginalisedby the demands of externally mandated programmesbadged as quality initiatives but experienced as bureau-cratic exercises which fail to acknowledge the complex-ities of delivering care in its social context and theintricate professional judgements this entails.

Finally, the centrality of trusting relationships washighlighted. Trust was identified as fragile, negotiatedand emerging from social practices, and not – as isoften assumed – a ‘thing’. Trust is something we ‘do’in relationship with others, and is as crucial to the suc-cess of professional teams as it is to professional–patient relationships. Furthermore, it not only involvespatients trusting their doctors but also doctors trustingtheir patients and being willing to manage the inherentuncertainties that this entails. Challenging us to con-sider that genuine patient-centred care may yet be ‘themost disruptive innovation in healthcare’,8 JocelynCornwell pointed to the potential value of trustingpatients in initiatives such as experience-based co-design, where patients identify things that reallymatter to them as part of an organisation’s approachto quality improvement.

So how do these themes speak to Francis’s call forcultural change in the NHS? We have certainly identi-fied a mismatch between the many and contested mean-ings of ‘quality’ in health care, and the more limitedrange of meanings captured by systems of standardisa-tion and quantification. An important paradox is atplay; the act of pursuing ‘quality initiatives’ canchange practice in ways which may be detrimental tothe quality of care. Even the most sophisticated array ofmetrics captures neither the intimacy of the clinician–patient relationship nor the complexity of the NHS. Itis well recognised that complex systems are charac-terised by unpredictability and paradox, and that theinterconnectedness of agents’ actions makes for shiftingcontexts which can never be fully ‘known’.9 We mustalso acknowledge that organisational culture is notsimply an entity that can be grasped and managedbut emerges from the ongoing interactions of its mem-bers.10 The danger is that culture becomes the newcatch-all buzz word, serving to ‘mop up the messystuff which forever seems to escape various attempts atorganisational innovation.’10 As such, top-down effortsto improve organisational culture are likely to meetwith many of the same challenges as top-down effortsto achieve quality – that is shaping and influencing localcultures whilst at the same time ushering in a range ofunintended consequences.

Funding

The conference was supported financially by Cumberland

Lodge as part of the Cumberland Colloquium series andalso by the Wellcome Trust through an Ethics and SocietyGrant (number: 101145/Z/13/Z).

References

1. Institute of Medicine. Crossing the quality chasm: a newhealth system for the 21st century. Washington, DC:National Academies Press, 2001.

2. National Quality Board. Quality in the new health system.

London: Department of Health, 2013.3. Department of Health. NHS Outcomes Framework 2013

to 2014. London: Department of Health, 2013.

4. Heath I, Hippisley-Cox J and Smeeth L. Measuring per-formance and missing the point? BMJ 2007; 335: 1075.

5. Loxterkamp D. Humanism in the time of metrics – an

essay by David Loxterkamp. BMJ 2013; 347: f5539.6. Mid Staffordshire NHS Foundation Trust. Public inquiry

– chaired by Robert Francis QC. Final report, www.mid-staffspublicinquiry.com/report. Mid Staffordshire NHS

Foundation Trust, 2013.7. Delamothe T. Culture change: Robert Francis’s prescrip-

tion for the NHS. BMJ 2013; 346: 1979.

8. Swinglehurst D, Emmerich N, Maybin J, et al. The manymeanings of ‘quality’ in healthcare: interdisciplinary per-spectives. Colloquium report, www.cumberlandlodge.ac.

uk/quality. Cumberland Lodge, 2013.9. Plsek PE and Greenhalgh T. The challenge of complexity

in health care. BMJ 2001; 323: 625–628.

10. Ormrod S. Organisational culture in health servicespolicy and research: ‘third-way’ political fad or policydevelopment? Policy and Politics 2003; 31: 227–237.

Deborah Swinglehurst1, Nathan Emmerich2,Jo Maybin3, Sophie Park4 and Sally Quilligan5

1Centre for Primary Care and Public Health,Queen Mary, University of London, UK

2School of Politics, International Studies & Philosophy,Queen’s University Belfast, UK

3Policy Directorate, The King’s Fund, London, UK4Department of Primary Care & Population Health,

Institute of Epidemiology & Health,University College London, UK

5Clinical and Communication Skills Unit,School of Clinical Medicine,University of Cambridge, UK

Email: d.swinglehurst@qmul.ac.uk

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