Does a financial crisis in the health service mean a crisis in quality of care?

The NHS’ delayed first quarter financial results for 2015/16 hit last week’s headlines in a big way. But does the financial crisis in the health service mean there is – or soon will be – a crisis in quality of care?

The answer, rather frustratingly, is that no one without a fully functional crystal ball can really say with complete certainty. There is no single, overarching number that gives a definitive and rounded measure of quality, and no well-established link between financial distress and problems with quality. Last week's report from the Care Quality Commission highlights trusts in deficit are more likely to have poorer quality ratings, but the association is weak. Besides, correlation is not causation.

We have data on different aspects of quality across a range of different services, but this offers a mixed picture: some things are getting worse, but many others are holding up well or even continuing to get better. And the data that’s available is far from a complete picture: there are a number of important areas where there is very little national data, particularly child and adolescent mental health services (CAMHS) and community services generally. Disturbingly little progress has been made in filling these gaps, even though we’ve known about them for years.

The NHS Outcomes Framework could be the ‘go to’ document for the rounded national picture of what’s happening to quality. The Outcomes Framework was created in 2010 as the primary mechanism for the Secretary of State for Health and the public to hold NHS England to account for the performance of the health service. Great idea, but a recent assessment by the UK Statistics Authority found that the published data is currently of limited use to most users. The Health and Social Care Information Centre is making progress, and the issues raised in the assessment shouldn’t take too long to resolve, but further work will be needed to make the most of a big opportunity.

It may be that the biggest pressures on quality are in the areas outside the spotlight, where any reductions in quality are much less visible through lack of decent data. There is little national information about CAMHS, and what information there is suggests quality is declining. Unfortunately, that same lack of data often makes it difficult to get up to date insights about what’s happening. The recent review of mental health crisis care is a great piece of work, for example, highlights examples of good care as well as too much variation across England. But one off reviews can never provide regular information about whether quality is getting better or worse over time. 

It may also be tempting to use the four hour A&E target as the ‘canary in the mine’ – not least because there’s lots of easily accessible data about how the NHS is performing against it. Access to emergency care is obviously important, and recent performance against the target reflects a range of different pressures across the system, but the four hour target doesn’t offer anything like a complete picture of quality.

There are certainly a number of problems with access more generally, which seems to be more visibly affected by financial issues than other aspects of quality. NHS England's last monthly performance summary highlighted Winter-like levels of performance against the A&E and ambulance targets – in August. Latest data on delayed transfers of care, plus waiting times for diagnostics, cancer services and elective care also offer little comfort.

About three years ago I suggested to a colleague that the real acid test for quality would be health care-associated infections. The logic for my ill-informed speculation was that keeping infections at bay is largely about rigid adherence to good practice in infection control, and that the pressure of rising demand may cause that discipline to falter. The number and rates of MRSA continue to fall, but there has recently been a jump in Clostridium difficile: though whether that’s a blip or the first sign of a wider problem is currently unclear.

That public satisfaction with the NHS remains high can largely be attributed to the efforts of NHS staff. But even here there are signs of pressure: the number of staff across all parts of the health service reporting feeling ill due to work-related stress is worryingly high. While no single measure is a perfect proxy for quality, if the pressures on NHS staff are even broadly indicative of the broader pressures on quality there’s very real cause for concern.

But the bigger question for me, given all of the issues with the data, is if the NHS is in the middle of a quality crisis, how would we know? NHS staff are feeling the strain, while there are clearly problems with access and – as far as we can tell – some aspects of mental health. But other aspects of quality are holding up, or even getting better: last week's report suggests most patients receive safe, effective care. Given the pressure the NHS is under, that’s a pretty spectacular achievement. Part of the answer lies in having enough data. It would be inconceivable for the NHS to report financial data that excluded vast areas of activity, but it’s what happens on quality.

In a recent speech, Sir David Nicholson – who, as NHS Chief Executive during the last big financial crisis, can justifiably claim to know his onions – recently suggested the actions the NHS takes to resolve deficits are much more damaging than the fact that deficits exist. Sooner or later, the NHS will probably have to take fairly drastic action on the financial crisis: if that action is informed by a complete picture of the money but only a partial picture of quality, we may well walk into a quality crisis without even knowing it.  

Tim is Senior Policy Fellow at the Health Foundation www.twitter.com/TimGardnerTHF