1. Editorial
Rethinking ‘quality’ in health care
‘Quality’ is a word we encounter repeatedly in relation
to health care and it has become a powerful health
policy driver. In the USA, the Institute of Medicine
characterises high quality care as that which is safe,
effective, patient-centred, timely, efficient, equitable.1
In
England, the NHS is ‘organising itself around a single
definition of quality: care that is effective, safe and pro-
vides as positive an experience as possible’2
enshrined in
the NHS Outcomes Framework, as a set of measurable
indicators.3
General practitioners continue to derive
about 30% of their income through scoring points in
the 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 England
highlighted the dangers of overreliance on targets for
achieving quality in a system as complex as the NHS,
calling for a ‘fundamental culture change’, with all health
care staff striving to place empathy for the predicament
of 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
The
suggestion of a shift towards a system which is appre-
ciated for its shared professional values rather than for
assiduous pursuit of targets is welcome, but doubts have
been 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 and
patient representatives to unpack the notion of
‘quality’.8
We considered questions such as: Are we
confident that there is a desirable match between qual-
ity metrics and the properties we seek to enhance? What
are the trade-offs in privileging one account of quality
over another? What are the professional and patient
values that underpin quality? How do we reconcile dif-
ferent ideological perspectives about quality?
Four key interrelated themes emerged. The first was
that the delivery of high quality health care depends on
a ‘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’; knowing
versus not knowing; universal generalisation versus
local experience; trust in ‘practice’ versus confidence
in ‘the system’. These are not mutually exclusive
dichotomies but they are tensions, and clinicians need
to work creatively and flexibly to embrace them. Every
act of health care is an opportunity for unique tailoring
rather than a ‘one-size-fits-all’ prescription and it is this
response to the complexity of each individual situation
that marks out high quality care from mediocre care, or
worse still, poor care. Organisations must offer both the
stability required to foster relationships of professional
trust and the flexibility to support this responsive crea-
tive work.
Secondly, there was a call for more description and
less measurement in evaluating quality. Overemphasis
on measurement of those aspects of care which are
easily measured is not only unreliable but ‘marks the
growing ascendancy of the body as object over the body
as subject’ (Dr Iona Heath, page 19).8
Systems of exter-
nal accountability, regulation and performance man-
agement may be necessary but run the risk of
unintended consequences, generating new work and
new risks in busy environments where staff are already
overstretched. Proxy measures of quality may offer a
standardised, reassuring appearance of quality whilst
also crowding out professionals’ capacity to deliver
altruistic care, which is less visible and – to all intents
and purposes – unmeasurable. Researchers pointed to
the value of ethnographic and narrative modes of
enquiry, where detailed critical exploration of care
practices brings insights into meanings of ‘quality’
that lie beyond the reach of quantification. Patient
representatives suggested that personal testimonies pro-
vide a better window into subjective experiences of
chronic diseases and addiction, and the key to authentic
engagement between practitioner and patient.
This ‘authenticity’ of engagement with patients is
demanding, challenging work, difficult to sustain in
practice. Practitioners need opportunities to discuss
and reflect on their experiences and concerns with
their peers – the focus of the third theme. This is only
possible if organisations value such activities as
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2014, Vol. 19(2) 65–66
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2. legitimate forms of work and offer the necessary
resources to support them. Such collaborative efforts
within health care teams are fertile ground for local,
innovative and creative approaches to delivering excel-
lence in particular contexts of care. Unfortunately, the
opportunity for such activity is too often marginalised
by the demands of externally mandated programmes
badged as quality initiatives but experienced as bureau-
cratic exercises which fail to acknowledge the complex-
ities of delivering care in its social context and the
intricate professional judgements this entails.
Finally, the centrality of trusting relationships was
highlighted. Trust was identified as fragile, negotiated
and emerging from social practices, and not – as is
often 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 involves
patients trusting their doctors but also doctors trusting
their patients and being willing to manage the inherent
uncertainties that this entails. Challenging us to con-
sider that genuine patient-centred care may yet be ‘the
most disruptive innovation in healthcare’,8
Jocelyn
Cornwell pointed to the potential value of trusting
patients in initiatives such as experience-based co-
design, where patients identify things that really
matter to them as part of an organisation’s approach
to quality improvement.
So how do these themes speak to Francis’s call for
cultural 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 limited
range of meanings captured by systems of standardisa-
tion and quantification. An important paradox is at
play; the act of pursuing ‘quality initiatives’ can
change practice in ways which may be detrimental to
the quality of care. Even the most sophisticated array of
metrics captures neither the intimacy of the clinician–
patient relationship nor the complexity of the NHS. It
is well recognised that complex systems are charac-
terised by unpredictability and paradox, and that the
interconnectedness of agents’ actions makes for shifting
contexts which can never be fully ‘known’.9
We must
also acknowledge that organisational culture is not
simply an entity that can be grasped and managed
but emerges from the ongoing interactions of its mem-
bers.10
The danger is that culture becomes the new
catch-all buzz word, serving to ‘mop up the messy
stuff which forever seems to escape various attempts at
organisational innovation.’10
As such, top-down efforts
to improve organisational culture are likely to meet
with many of the same challenges as top-down efforts
to achieve quality – that is shaping and influencing local
cultures whilst at the same time ushering in a range of
unintended consequences.
Funding
The conference was supported financially by Cumberland
Lodge as part of the Cumberland Colloquium series and
also by the Wellcome Trust through an Ethics and Society
Grant (number: 101145/Z/13/Z).
References
1. Institute of Medicine. Crossing the quality chasm: a new
health 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 many
meanings 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 services
policy and research: ‘third-way’ political fad or policy
development? Policy and Politics 2003; 31: 227–237.
Deborah Swinglehurst1
, Nathan Emmerich2
,
Jo Maybin3
, Sophie Park4
and Sally Quilligan5
1
Centre for Primary Care and Public Health,
Queen Mary, University of London, UK
2
School of Politics, International Studies & Philosophy,
Queen’s University Belfast, UK
3
Policy Directorate, The King’s Fund, London, UK
4
Department of Primary Care & Population Health,
Institute of Epidemiology & Health,
University College London, UK
5
Clinical and Communication Skills Unit,
School of Clinical Medicine,
University of Cambridge, UK
Email: d.swinglehurst@qmul.ac.uk
66 Journal of Health Services Research & Policy 19(2)