Deputy Head of Library Services, KnowledgeShare, Royal Sussex County Hospital, Brighton, UK
Received date: 11 June 2010; Accepted date: 13 June 2010
March 2010 saw the publication of the most recent edition of the NHS Constitution for England, which was originally proposed by Lord Darzi in the final report of the NHS Next Stage Review. Both documents highlight the prominent role that patient choice now has to play in the way that NHS services are delivered, with the constitution giving patients ‘the right to make choices about (their) NHS care and to information to support these choices’. In order to make this right a reality, the NHS commits to letting patients know what NHS services are available and to provide information about the quality of these services. 
Arecent survey, conducted by the King’s Fund across four disparate healthcare economies, looked into the realities of patient choice: do patients know about the choice available to them, how do they choose, how are they supported and what impact do their choices have? Some of the results are surprising. Around half of patients questioned were aware that they had the right to choose an NHS provider, with older patients more likely to know about this choice, and threequarters felt that choice was important to them. Again, older patients were more likely to value choice, as were those without qualifications and patients from a nonwhite background.
General practitioners (GPs) included in the survey indicated that they always offered patients a choice, although only half of the patients could recall being given one. When offered a choice there is a clear tendency for patients to choose their nearest hospital, regardless of other characteristics; however, there were still around 45% of patients who were willing to choose a non-local provider based on perceived quality of care. In almost all cases, this decision was based on experience and advice from friends and healthcare staff, rather than published information on quality.
This suggests that more needs to be done to make this information available to patients, to help them understand its message, and to convince both patients and GPs of its value.
Whether or not patients are actually basing their decisions on published performance data, there is evidence to suggest that publishing that data may indeed have a positive impact on the quality of services. The intention has always been that choice would create competition, and competition would increase both productivity and effectiveness. A report by the Health Foundation in 20084 systematically reviewed the evidence and found that, although limited, the research does suggest that public release of data stimulates change. This conclusion is partially supported by the King’s Fund report,which found that published information on patient experience outcomes is a clear motivator for service improvement. It also reiterates the point that until patients become more aware of the performance data that are available to them, patient choice will remain a relatively minor driver for change in relation to national targets and penalties driven by the Department of Health.
Knowledge is power, and the more patients know about the quality of their local services, the more their informed decision making will be able to reshape the NHS for the better. The following websites can be used by generalpractice staff, bypractice-based commissioners, and above all by patients to guide their choice of health service provider and drive up the quality of care.
The first port of call for patients should always be NHS Choices (www.nhs.uk), the portal set up by the NHS to provide medical advice, healthy living advice, support for carers and a directory of all NHS services in England. The front page allows a patient to search for GPs, hospitals or dentists in his or her local area, but by clicking on ‘Find and choose services’ it is possible to also search for community pharmacies, accident and emergency departments, opticians and a whole range of other services, from foot health to emotional support.
A considerable amount of information about many of these services is provided, with maps and addresses, opening times and details about the staff given for most GP practices and hospitals. GP practices can be compared side by side, according to the number of male and female GPs, extended opening hours, supplementary clinics and more. Hospital pages indicate which treatments are provided, as well as the patient support and advice that is on offer. In addition to these basics, however, there is also information available about the performance of these services, according to national data and accreditation, as well as local patient opinion.
Each GP practice section of the website has an area devoted to ‘Performance and feedback’. This draws information from the Quality and Outcomes Framework (QOF; see below for more details), presenting the data in clear charts that compare the practice’s outcomes with those of other practices in the PCT and with others across England. Not all QOF data is presented – only the major disease areas are covered, including asthma, diabetes and cardiovascular disease, as well as a rating for the organisation as a whole.
The site also gives patients themselves the opportunity to recommend, or not recommend, a particular GP practice and add comments that can be viewed by other visitors to the site. Data from the most recent National GP Patient Survey by the Care Quality Commission (CQC; see below) are also presented, once again comparing practices with other practices both in the local area and nationally.
Hospitals on the NHS Choices site are given a simple overall quality score of excellent, good, fair or weak, which is taken from the CQC’s accreditation reports. Alongside this, on the ‘Overview’ page, is brief information about waiting times, cleanliness, Methicillin Resistant Staphylococcus aureus (MRSA) infection rates, and the Hospital Standardised Mortality Ratio. As withGP practices it is possible to compare hospitals side by side, according to criteria including; results of the National Inpatient Survey, results of the National Staff Survey, how often patient safety incidents are reported andmeasures related to food and the hospital environment. As with GP practices, one can also see how users of NHS Choices have rated each hospital according to various different indicators of quality.
The Quality and Outcomes Framework
Patients can see brief information drawn from the QOF via NHS Choices. Further details can be found at the QOF website itself (www.qof.ic.nhs.uk), which summarises all of the data captured as part of this voluntary reward and incentive scheme for GP practices in England.
There are currently 129 quality indicators included within the QOF: 80 clinical indicators; 36 organisational indicators (which cover record keeping, patient information, staff education etc.); five patient experience indicators; and eight indicators to cover additional services such as maternity and child health. The higher a practice scores on these indicators, the higher the financial reward for the practice.
As with the NHS Choices website, patients can use the QOF website to compare practices’ scores with local and national averages, although the level of detail and the range of indicators here is far greater. Users should click ‘Search for practice results’ at the top of the page and type in the name of a practice or postcode. Once a practice has been selected it is possible to view results according to the different areas of quality (clinical, organisational etc.) and to choose to look at data from different years.Onthe right-hand side of the screen one can then select a box to compare the indicators shown with the PCT average and the England average. All of this information is shown very clearly as scores out of 100.
Clicking on a particular indicator, such as ‘Dementia’, shows the detailed questions that practices are asked, for example, ‘What is the percentage of patients with dementia whose care has been reviewed in the previous 15 months?’. Patients and healthcare professionals can also see information about the prevalence of different conditions within a particular practice’s patient list and, again, compare this with the national average.
In April 2009 the Care Quality Commission was made responsible for determining the quality of care provided by both NHS and adult social care services, and from April 2010 all such bodies (plus some independent sector organisations) have been required to formally register with the CQC. All NHS trusts are now subject to quality assessments, and the NHS Confederation is helping trusts to demonstrate that they meet the required standards. They have a web page that provides further details about CQC registration.
The CQC website (www.cqc.org.uk) is clearly written in plain English, with patients in mind. There is information for patients on what to ask when choosing a hospital or social care service, along with explanations of what the CQC does and how the NHS works. There is also a register of independent providers. These sections can be found by clicking on ‘Using care services’, followed by ‘Healthcare’ or ‘Social care’.
The CQC collects information from healthcare organisations on the quality of services and on financial management. Both measures rate trusts as excellent, good, fair or poor, and it is from here that NHS Choices draws its data. But again, the information available from the CQC website itself is more detailed. Quality of services is broken down into: compliance with core standards, such as safeguarding children or medicines management; performance against longstanding targets, which mainly deals with waiting times and access to clinics; and national priorities around specific disease areas. Each trust is rated on each of these indicators and information is available on how well other trusts across the country have scored.
As well as the data resulting from CQC quality assessments, the Commission also runs the annual patient surveys for inpatients and outpatients. The results are presented simply, with the questions grouped by topic, such as questions about the ward environment or about the nursing staff, and then given an average score out of ten. One can then click on a question group to be presentedwith more detail about each question asked. For each question, or set of questions, a bold icon indicates whether the trust in question performs about the same as others, worse than others or better than others.
To access this information the user must search for a particular hospital, in much the same way as one searches for a GP practice on the QOF website (see above). Click on ‘Find care services’ from the menu at the top of the screen and search for an organisation by name or location.
Additional performance information on those NHS trusts that have achieved foundation status can be found on the website of Monitor (www.monitornhsft. gov.uk), the independent regulator of foundation trusts and the body which ensures that these trusts adhere to the more stringent standards expected of them. The site provides information about what it means to be a foundation trust and how a trust applies for foundation status, and provides a variety of reports on the progress of foundation trusts in the ‘Our publications’ section.
In truth, the information of interest to patients here is minimal. The ‘Reports on foundation trusts’ section includes quarterly reports that show how many foundation trusts there are by region, and gives an overview of which trusts are meeting or missing a handful of targets related to high profile healthcare acquired infections and waiting times. These reports take each foundation trust in turn, consider their risk in terms of clinical governance or financial performance, and rate them as red, amber or green.
Additional information of interest can be found if one searches for a trust by name in the foundation trust directory (found under ‘About NHS foundation trusts’). Each trust’s annual plan, which discusses performance over the past year and strategic aims for the future, is available.
Although it is clearly important for the public to know how local services are performing if they are to make an informed choice about their care, it is also true that too much information can be as dangerous as too little, especially when information from different sources is contradictory. The Dr Foster Intelligence Unit, based in Imperial College in London and part funded by the Department of Health, made headlines in November 2009 when it published a report on patient safety in NHS trusts that directly contradicted the findings of the CQC.6 The reason for the discrepancy is that measuring the performance of large, complex organisations is not a simple matter, and the Hospital Standardised Mortality Ratio can be calculated in a variety of different ways. Hospitals that have improved, but not as quickly as their peers, can appear to have done worse rather than better.
That said, publishing these data is a good thing if it encourages NHS organisations to improve their own data accuracy and stimulates debate about the best way to assess quality of care. The Dr Foster website (www.drfosterhealth.co.uk) provides a ‘Hospital guide’ that allows patients to search for a procedure, hospital, or NHS trust in their local area. Once a hospital has been found, the site gives information on the number of beds, the proportion that are in single rooms and the availability of parking. One can then choose to view performance data in a variety of different ways. At the top of the page for each hospital there are buttons giving one access to: an ‘A&E scorecard’ showing indicators related to heart attack, abdominal aortic aneurysm and fractured neck of femur; information on the ‘Birth unit’, including what facilities and equipment are, and are not, provided by the hospital, as well as data about modes of delivery; plus a link to the hospital’s full ‘Quality account’. From this front page one can also choose to view information on specific procedures or services provided by the hospital, and see a summary of patient safety information.
The ‘Quality account’ that Dr Foster provides shows detailed information on patient safety, clinical effectiveness and patient experience. There are graphs showing the standardised mortality rate after stroke, heart attack and other conditions, compared with the national average, as well as indicators such as the staffto- bed ratio and a composite score of trust commitment to patient safety. The clinical effectiveness section details the outcomes of a wide range of procedures, from readmission following urinary tract infection to the proportion of heart attack patients who are prescribed beta blockers. Information from the National Patient Survey is brought in and displayed alongside more concrete measures of patient experience, such as whether the hospital provides overnight stay facilities for relatives. In each case, the red, amber, green rating system is used to summarise results clearly for patients.
The King’s Fund survey referred to in the introduction 3 found that patients are far more likely to base their choice of provider on their own past experience, or that of their friends and relatives, than on published data. Another way to find information about patients’ individual experiences of care is via two websites that allow users to post their own comments and ratings of services: Patient Opinion (www.patientopinion.org. uk) and I Want Great Care (www.iwantgreatcare.org).
These sites allow users to search for a hospital, or a particular doctor, and see what others are saying or tell their own story. Both are independent organisations, founded by medical staff and are easy to use. Patient Opinion will contact an organisation after a comment or complaint has been posted in order to give them the right of reply.
Understanding performance data
Data and statistics can be off-putting to many people, which is why the simple ‘traffic light’ rating system is so often used. If healthcare professionals or patients want to understand more about how the quality of NHS services is measured, and what the more detailed statistics mean, there is a whole range of resources available online explaining performance data.
Many of the documents explaining performance have been collected by the NHS Evidence Health Management Specialist Collection (www.library.nhs. uk/healthmanagement). Navigate to ‘Performance’, under ‘Quality and monitoring’ in the left-hand menu, for a range of documents from the Department of Health, Monitor, the Audit Commission and a variety of health consultancy organisations that summarise how the NHS is performing and explain the measures used.
One organisation that is worth singling out is the King’s Fund, an independent think tank that provides clear, bullet point summaries of various health management topics. Their topic overview on ‘Performance’ (www.kingsfund.org.uk/topics/performance) covers the key points and gives a more detailed background, as well as gathering together all the pertinent articles from the King’s Fund on the subject. There is also a list of References to external publications about performance drawn from their own library.
‘Patients place a high value on the quality of care ... but rarely use objective measures of performance to help them choose a hospital.’ Although understanding healthcare data can be difficult, many of the resources listed above present their information in easily deciphered formats that are intended for use by patients and the public. In addition, there are resources available to make sense of the data on offer.
General practice staff need to come to understand the value of information (whether qualitative or quantitative) about the effectiveness, safety and customer focus of their local health service providers. The advice offered by GPs is central to the choices that their patients’ make, and they should try to ensure that this information is taken into consideration, either by themselves or their patients, when making decisions about who should be chosen to provide care.
Commissioned; not externally Peer Reviewed.
Thanks to Sarah Butler, Library Information Skills Trainer at Brighton and Sussex University Hospitals NHS Trust, for her contributions.
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