National Quality Board Annual Report - 2010

Annual Report
2009/10
National Quality Board

Contents
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Foreword 2
Chapter 1
Introduction 4
Chapter 2
Aligning the system around shared goals 14
Chapter 3
Advising and prioritising for quality improvement 18
Chapter 4
Overseeing the development of tools and system levers for quality improvement 24
Chapter 5
International healthcare comparisons for quality improvement 34
Chapter 6
The continuing quality challenge 42
Annex 1
Summary of OECD Health at a Glance 2009 Quality of Care Indicators 46
Annex 2
Expert Advisory Group on International Healthcare Quality Comparisons 53

Foreword
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quality has meant different things to

different people.
Through Lord Darzi’s Next Stage Review,

patients, the public and staff told us that they
wanted the NHS to focus on quality. What
that review has done is to clarify what the
NHS is here for – to improve the health of the
population and to make quality the organising
principle of the service.
The review has also given us a definition

of quality that the system can sign up to
– spanning patient safety, experience and
effectiveness of care. This is an incredibly
powerful tool, allowing clinicians and managers
I am pleased to introduce the first annual report
to unite in a common purpose to improve quality.
of the National Quality Board (NQB).
The establishment of the NQB was just one
Over the past decade, the NHS has been on a
line in Lord Darzi’s final report, High Quality
fantastic reform journey, seeking to become
Care for All, to “provide strategic oversight
more diverse and focused on the individual
and leadership on quality”. Eighteen months
needs of patients. There have been three
later and it is a fully functioning body with
phases so far, starting with a big increase in
an impressive membership, including lay and
investment and capacity which has grown
expert members.
the NHS by a third. The second stage was the
introduction of reform levers to expand choice
The NQB plays a unique role. It is the only place
and contestability. And now the third phase is
in the system where the national organisations
bringing all that together to improve quality
tasked with safeguarding and improving quality
for patients.
come together. And it is the only national body
with the express aim of aligning the system
When we talk about quality, it is not a concept
around quality.
that has been discovered overnight. Everyone
in the NHS is for quality. In the past, though,
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Annual Report 2009/10
How we measure quality needs to make A key remit of the NQB is also to report on the
sense to patients and to the health service. state of quality in England using international
Achieving a common understanding across comparisons. This is not about generating
the system of what we mean by success and league tables of healthcare systems, but about
failure has enormous potential to drive quality helping us to understand which areas should be
improvements and productivity gains, for the priorities for improvement, and which countries
benefit of patients. we can learn from.
The NQB provides us with the opportunity to Generating meaningful international

bring together the key organisations in the comparisons is difficult and takes time, but the
system, to set aside organisational sovereignty NQB believes it can provide real insight and
and politics, and to bring clarity to what is a fresh challenge. Wehave laid the foundations
complex and often crowded field of work. this year by significantly improving the data
we send to the Organisation for Economic
The NQB was tested in trying to achieve this Co-operation and Development, and will build
in 2009, but it is a sign of the commitment on this in future years by broadening and
and expertise of the people involved that it has diversifying the comparisons we make.
made steady progress. They have approached
this work with energy and enthusiasm. A key theme of the Next Stage Review is the
power of transparency to drive improvements
Key achievements in 2009 include: in quality. While the NQB’s work may not grab
the headlines, it is focused on forging stronger
• commissioning the National Institute for
links with the NHS to raise awareness of it. It is
Health and Clinical Excellence (NICE) to
a resource for all of the NHS to use.
produce the first four quality standards
on dementia, venous thromboembolism
The state of public sector finances mean this
prevention, stroke care and specialist
is a critical time for the NHS. The service has
neonatal care;
been set the challenge of releasing between
• developing a transparent, objective process £15 billion and £20 billion in efficiency savings
for determining clinical priorities in the NHS; by the end of 2013/14 in order to reinvest in
year-on-year improvements in quality. This is a
• describing, for the first time, roles and
massive undertaking and will require changes
responsibilities for safeguarding quality
in the way organisations and staff think and
to prevent serious failures occurring in
behave.
NHS hospitals;
• advising the Secretary of State on a new The NQB is committed to playing its part in
MRSA Objective, to provide safer care for achieving a step change in quality, by bringing
patients; and clarity to what we mean by quality and by
seeking to harness the power of the system
• advising on reviewing the criteria for Clinical
working together, for the benefit of patients.
Excellence Awards to reflect the importance
of high quality care.
Sir David Nicholson KCB CBE
Chair, National Quality Board
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Chapter 1
Introduction
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it clear that the whole system should share

this focus. The Next Stage Review showed that
this simple goal – high quality care – is a
unifying force, bringing together the ambitions
of NHS staff, the hopes of patients and the
expectations of the public.
High Quality Care for All set out a vision for an

NHS aligned around quality – what it would
look like and how we would know if it were
achieved. The report described an overarching
framework for achieving this vision, building on
the strength of existing local clinical leadership,
such that an NHS aligned around quality would:
• be clear about what constitutes high
Origins and purpose of the National quality care– clinicians, hospital managers
Quality Board and commissioners should have a shared
understanding of what high quality care looks
In June 2008, Lord Darzi’s final report of the like and what is required to deliver it;
NHS Next Stage Review, High Quality Care for • systematically measure quality – clinicians,
All, was published.1 clinical teams and hospital managers
should use robust indicators of quality to
The year-long engagement process that measure the quality of the care they are
preceded publication shaped the central theme providing to patients. These should be
of the report – that quality should be the benchmarked against peer clinical teams and
organising principle for everything the NHS organisations, supporting the creation of
does. Quality was defined as care that was safe a self-improving NHS;
and effective and that provided as positive as
possible an experience for patients. Improving • routinely publish quality performance –
quality has long been the motivation of staff providers of care should publish information
across the NHS, and Lord Darzi’s report made about the quality of care they are providing
High Quality Care for All: NHS Next Stage Review Final Report, Department of Health, 30 June 2008. Available at
1
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825
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to patients in order to strengthen board- To strengthen the leadership for quality needed
level accountability for quality and to bring at a national level, High Quality Care for All
about greater openness and transparency for announced the creation of a new National
patients and the public; Quality Board (NQB) to provide strategic
oversight and leadership on quality across
• recognise and reward quality and quality
the NHS system and at the health and social
improvement – there should be professional
care interface.
and organisational incentives to encourage
and reward quality improvement;
The Department of Health worked closely with
• provide leadership for quality – local, key stakeholders from across health and social
regional and national tiers of the NHS should care to co-design the NQB. Three design events
demonstrate strong leadership for quality and held between late 2008 and early 2009 helped
quality improvement to support the NHS in produce the membership model of the Board
delivering high quality care; and its broad remit, as described below. This
example of co-production is a feature of all the
• safeguard quality – there should be robust
work that we do.
and independent mechanisms in place to
ensure that essential levels of quality and
safety are in place and delivered, with swift Who are we?
and effective action being taken if concerns
Ministers appointed the Chief Executive of
arise; and
the NHS, Sir David Nicholson, as the first
• innovate and continuously strive for Chair of the NQB. The design process led
improvement– the NHS as a whole should to a membership of three broadly equal
stay ahead by learning from high-performing constituencies:
clinical teams and organisations, and
international exemplars, so that the worst • ex-officio members – also appointed by
Ministers as representatives of the national
would learn from the best and the essential
health and social care system;
levels of quality and safety experienced by
patients would rise continuously. • expert members – appointed following an
independent recruitment process run by the
High Quality Care for All emphasised the Appointments Commission to bring expertise
importance of leadership at every level of the from across the health and social care sectors;
system in order to deliver this vision: and
• locally – from the clinical teams delivering • lay members – also appointed following an
front-line services to patients, the independent recruitment process run by the
organisations responsible for providing Appointments Commission, to bring wider
those services and the primary care trusts perspectives to the Board.
responsible for commissioning them;
Inevitably, these broad descriptions do not
• regionally – from the strategic health always do justice to the depth of expertise
authorities responsible for the overall individual members bring.
operation of the NHS in their region; and
• nationally – from the Department of Health,
its agencies and the regulators.
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The members 2009

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Ex-officio members
NHS Chief Executive Chair of the Care Quality
Sir David Nicholson (Chair) Commission
Baroness Young
(until December 2009)
NHS Medical Director Chair of NICE

Professor Sir Bruce Keogh Sir Michael Rawlins

Chief Nursing Officer Executive Chair of Monitor

Dame Christine Beasley Dr William Moyes
(until January 2010)

Chief Medical Officer Chair of the National

Professor Sir Liam Donaldson Patient Safety Agency
Lord Patel

Director General of Chair, Social Care Institute
Social Care for Excellence
David Behan Allan Bowman

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Expert members
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Professor Ian Gilmore
Ian Gilmore is a consultant physician and the President of the Royal College of
Physicians. He specialises in liver disease at the Royal Liverpool University Hospital
and is Professor of Medicine at the University of Liverpool. He is a commissioner
in the Marmot Review of the Social Determinants of Health, and chairs the UK
Alcohol Health Alliance. He also chairs the Science Group of the Alcohol Forum
at the European Commission.
Professor David Haslam
David Haslam is a practising GP and is immediate past President, and also a past
Chairman, of the Royal College of General Practitioners. He is currently Chair
of the NHS Evidence Advisory Board and National Clinical Adviser to the Care
Quality Commission. He was awarded the CBE in 2004 for services to medicine
and healthcare.
Dr Paul Lelliott
Paul Lelliott is a consultant psychiatrist with a busy community mental health team
at Oxleas NHS Foundation Trust. He is Director of the Royal College of Psychiatrists’
Research and Training Unit and of its Centre for Quality Improvement, where he
leads a programme of national quality improvement initiatives that engage with
most mental health services in the United Kingdom. He has been involved with
clinical audit, locally and nationally, since the early 1990s. He is Chairman of
the Healthcare Quality Improvement Partnership, which is responsible for the
Department of Health funded programme to revitalise clinical audit in England.
Sir John Oldham

John Oldham is a GP who has led national health programmes in the UK and
overseas. One of the most notable of these was the national primary care
collaborative in the late 1990s, which led to major improvements in GP waiting
times and cardiac care in primary care. He is currently the National Clinical Lead for
the Quality and Productivity Programme, where he will lead work to shape and run
a number of national clinical work programmes. These will initially concentrate on
long-term conditions, urgent care and integration of health and social care.
Professor Hilary Scholefield

Hilary Scholefield is the Chief Nurse/Chief Operating Officer at Sheffield Teaching
Hospitals NHS Foundation Trust. She has spent her entire career in the NHS, the
vast majority of it in nursing. She is a member of the National Institute of Health
Research Advisory Board and is a visiting professor within the Faculty of Health
and Well Being at Sheffield Hallam University.
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Stephen Thornton
Stephen Thornton is Chief Executive of the Health Foundation, an independent
charity that wants to make the quality of healthcare in the UK the best it can
be. It is a charitable foundation and operates independently from government,
political parties or other interest groups. He has 30 years’ management
experience in the NHS, having worked at hospital, community health, health
authority, regional and national levels of the service. He has been a non-executive
director of Monitor (the independent regulator of NHS foundation trusts) since
October 2006 and was appointed Acting Deputy Chair in February 2010. Stephen
is a trustee of the Aquaid Lifeline Fund, a charity providing care to orphans in
Malawi. He was awarded a CBE in 2001.
Lay members
Lord Victor Adebowale
Victor Adebowale is the Chief Executive of the leading social care organisation
Turning Point, which provides services to individuals with learning disabilities,
mental health difficulties or drug and alcohol problems. He was Co-Chair of the
Black and Minority Ethnic Mental Health Steering Group. He also holds several
membership positions, including Patron of the Nurse Training Council on Alcohol.
In 2000, he was awarded a CBE in the New Year’s Honours List for services to
the unemployed and to homeless young people. He was appointed as a cross-
bench peer in 2001. He is a Director of the Leadership in Mind organisational
development consultancy and a non-executive director of the health IT consultancy
St Vincents. He is Chancellor and visiting professor at the University of Lincoln.
Sally Brearley
The NHS has been Sally Brearley’s major interest for the last 35 years. She has
worked as both a physiotherapist and nurse. She had a long association with
community health councils and was Chair of the Patients Forum. She is currently
Chair of Health Link, is a member of a Local Involvement Network and holds
visiting fellowships in patient and public involvement at the National Nursing
Research Unit, King’s College London, and the Faculty of Health and Social Care
Sciences at Kingston University and St George’s University of London.
Don Brereton, Chair, Carers UK

Don Brereton is Chair of Carers UK, the organisation for carers fighting for
recognition of the true value of carers’ contribution to society and striving for
carers to get the support they need. He was previously Director of Motability, the
charity that enables disabled people to use their government-funded mobility
allowances to obtain a new car, powered wheelchair or scooter. He was awarded
a CB in 2001 for service to government and the voluntary sector.
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Dr Stephen Duckworth
Stephen Duckworth is the Contract Director for Serco Flexible New Deal in the
West Midlands. Prior to this he was Chief Executive of Disability Matters Ltd.
He has advised UK Ministers on welfare reform, the Polish government on
introducing antidiscrimination legislation, and more than 400 public and private
sector organisations on how to improve services for disabled customers while
increasing the representation of disabled people in their workforce. He was
awarded an OBE in 1994 in recognition of his service to disabled people. He sits
on the Board of the Olympic Delivery Authority and is a member of the Disability
Equality Delivery Board, which advises seven government departments.
Margaret Goose
Margaret Goose is a lay trustee of the Royal College of Physicians, and a member
of its Patient and Carer Network, and sits on the Stroke Joint Speciality Committee.
She is a lay member of the management board of the National Clinical Guidelines
Centre and of NICE’s vascular topic selection consideration panel. She became
a governor and trustee of the Health Foundation in 2006. A former Chief
Executive of the Stroke Association, she is now a Vice-President. She spent
30 years in NHS senior management, including eight years as Chief Executive
of North Bedfordshire Health Authority, and was head of the Health and
Management Development Division at the Nuffield Institute for Health in Leeds.
She was awarded an OBE for services to healthcare in 2004.
Tim Kelsey
Tim Kelsey is Chair of the Executive Board of Dr Foster Intelligence, the UK’s
leading health and social care informatics organisation, which is committed to
improving the accessibility, coverage and use of intelligent information among
frontline care professionals. He was also the programme director of NHS Choices,
which helps patients, carers and clients to make informed choices about
treatments and services.
Special adviser
Donald Berwick
Don Berwick is the President and Chief Executive Officer of the Institute for
Healthcare Improvement and acts as a special adviser to the NQB. He is also clinical
professor of pediatrics and healthcare policy at the Harvard Medical School and a
professor in the Department of Health Policy and Management at the Harvard School
of Public Health. He has served as Vice Chair of the US Preventive Services Task
Force, on the Board of Trustees of the American Hospital Association, and as Chair
of the National Advisory Council of the Agency for Healthcare Research and
Quality. An elected member of the Institute of Medicine, he served two terms on
the institute’s governing council and was a member of its Global Health Board.
He served on President Clinton’s Advisory Commission on Consumer Protection
and Quality in the Healthcare Industry. He was awarded an Honorary KBE in 2005.
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A unique body, a unique opportunity • advising the Secretary of State on clinical

priorities for quality improvement and the
The NHS is not a single organisation, but a standards to be set by the National Institute
complex system. However, all too often it has for Health and Clinical Excellence (NICE);
been viewed by those working within it, and
• providing advice to the Advisory Committee
by those whom it is there to treat and care for,
on Clinical Excellence Awards on how to
as a system that can pull in multiple directions.
strengthen the awards scheme to drive quality
As a Board, we recognise that our unique
improvement; and
membership model provides us with a unique
opportunity to act collectively in this respect • reporting to the Secretary of State on
and ensure that the system is aligned around the state of quality in England using
a single objective – the pursuit of high quality internationally agreed comparable measures.
care for all patients.
As the timeline on pages 28–29 shows and this
For the first time, the NQB has provided a report describes in more detail, we have made
formal mechanism for the key representatives significant progress in all of the above areas,
of the national system to sit around the same and in many more. While much of this work
table and work together to tackle the complex will continue during 2010/11, this report also
issues involved in enabling the delivery of high describes where else we, collectively as a Board,
quality care. While the individual independent have decided to focus our efforts in the year
organisations represented remain independent, ahead. Overall, our established and future work
the NQB provides an opportunity to ensure that programme will support us in meeting three
their actions and the way in which they exercise overarching aims we have set ourselves:
their functions are aligned, with a view to
• aligning the overall system around shared
making sure that the overall system pulls in the goals for quality improvement;
same direction.
• advising on priorities for quality
How we plan to fulfil our role improvement; and
• overseeing the development of tools and
The NQB was set up to provide strategic oversight system levers to support front-line staff to
and leadership for quality. Our inaugural meeting bring about quality improvements.
was held on 30 March 2009. Since then, we have
met on a further four occasions. In order to maximise the contribution we can
make, much of our work takes place outside
Although the Board is still in its infancy, the formal Board meetings. During 2009 we
we have already embarked on an extensive established a number of sub-groups to drive
programme of work and we are optimistic forward specific projects; these have helped
about our potential to make a difference. To us to extend our reach and bring in other
date, our work has primarily focused on the expertise where required. However, the work
specific tasks set out for us in High Quality Care of these groups is always brought back to
for All. These included: the full Board before decisions and final
recommendations are made. All papers and
• overseeing the work to improve quality minutes of these meetings are routinely
measurement in the NHS; published on our website.2
www.dh.gov.uk/nqb
2
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About this first annual report
This first report combines a description of our

work to date with setting out our plans for the
year ahead.
This first chapterhas described how the NQB

came about, who we are and the nature and
opportunities of the Board.
The next three chapters focus on how we have

begun to exercise our strategic leadership role
for quality in 2009 and our plans for 2010:
• Chapter 2 looks at our role in aligning
the system;
• Chapter 3describes our work on advising
and prioritising for quality improvement; and
• Chapter 4sets out how we have started and
will continue to oversee the development of
a number of tools and system levers designed
to help quality improvements to be made at a
local level.
Chapter 5then looks at how and what we

can learn from other countries to support
improvements in quality here in England
through the use of international comparisons.
Chapter 6concludes by setting out some of

the continuing challenges facing both the NHS
and us as a Board. It describes the context
within which we will approach our role in the
year ahead and our continuing goal to provide
strategic oversight and leadership on quality.
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Chapter 2
Aligning the system around
shared goals
the previous Secretary of State for Health into

the early warning mechanisms in the NHS for
preventing and responding to serious failures in
quality. This important piece of work is nearing
completion and is described in more detail in
this chapter.
Building on this work, in 2010 we plan to take

forward three new pieces of work where we
feel that greater alignment across the system
could reap significant benefits. These include:
• aligning the system to achieve large-scale
quality improvement;
• developing proposals for a quality information
strategy; and
As described in Chapter 1 of this report, our
membership model provides us with a unique • setting out what good governance for quality
opportunity to align the system around quality. within NHS provider organisations looks like.
This alignment potential is probably where
we can make the greatest difference and, These new projects, which we will be taking
as such, needs to feature in all our work. forward in 2010, arealso described in this
For example, the next chapter sets out how chapter.
we will go about identifying priority areas
for quality improvement. Once priorities Preventing and responding to serious
have been identified, we will then have the failures in quality
opportunity to consider how to align the roles
and improvement levers at the disposal of the In March 2009, we were asked by the
organisations represented on the NQB in order Secretary of State for Health to conduct a
to maximise quality improvements. review into the systems and processes in place
for safeguarding quality. This followed the
In 2009, our ability to align the system was put Healthcare Commission’s report into the serious
to the test through one specific piece of work failings that occurred at Mid Staffordshire NHS
– the review we were asked to carry out by Foundation Trust.3
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Our terms of reference were: Review of Early Warning Systems

• to review, in the context of the Healthcare in the NHS Sub-group
Commission’s investigation into high mortality NQB members
ratios at Mid Staffordshire NHS Foundation • Barbara Young
Trust, the national systems and processes • William Moyes
in place for the early identification of • Naren Patel
potentially serious failings in patient care

and the subsequent response; External members
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• Una O’Brien (Director General of Policy and
• to make findings as to the alignment Strategy, Department of Health)
of those systems and processes across • Ian Carruthers (Chief Executive, South
the different national bodies responsible for West Strategic Health Authority)
ensuring that patients receive high quality

care; and In conducting the review, the sub-group
• to reach conclusions and to make did not seek to further examine or pass
recommendations in relation to the national new judgements on what happened at Mid
system that could further secure high quality Staffordshire NHS Foundation Trust. Three
care across the NHS. reports had already been published that had
looked in depth at what had gone wrong at the
As well as seeking to address the above trust. Instead, the group built on the analysis
terms of reference, we also used the review and recommendations of these reports and
as an opportunity to address a specific used the review not simply to write a report,
recommendation made in a separate review into but to work together closely and constructively
the failures at Mid Staffordshire NHS Foundation to ensure that systems and processes – some
Trust conducted by Dr David Colin-Thomé:4 long-standing, others new – are aligned around
improving quality and ensuring safe care.
“A key lesson has been about the need for
clarity of role and responsibility to ensure that The sub-group reported back to the full
each organisation understands where it fits and Board in December and our final report, to be
what accountability it has. This was not clear published shortly, will describe how the system
in Mid Staffordshire and there were cases of should work in future to prevent and respond
issues falling between organisations.” to serious failures in quality. An important part
of this will be providing a clearer description
We established a sub-group of the Board to of the roles and responsibilities of individuals
drive the review forward, comprising ex-officio and organisations throughout the system for
members of the NQB and a chief executive safeguarding quality in the face of a changing
from a strategic health authority. performance and regulatory regime. It will
describe the roles and responsibilities of
individual healthcare professionals, clinical
teams and the boards of NHS trusts, right
3
Investigation into Mid Staffordshire NHS Foundation Trust, Healthcare Commission, March 2009. Available at www.cqc.org.uk/
usingcareservices/healthcare/concernsabouthealthcare/midstaffordshirenhsfoundationtrust.cfm
4
Mid Staffordshire NHS Foundation Trust: A review of lessons learnt for commissioners and performance managers following the
Healthcare Commission investigation, Dr David Colin-Thomé, Department of Health, 29 April 2009. Available at www.dh.gov.uk/
en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098660
13
through to the roles and responsibilities of We will look at all activity in each of these areas
commissioners, strategic health authorities, and across the three domains of quality (safety,
the regulators and the Department of Health. effectiveness and patient experience) in order
to determine the key barriers and enablers
Although we expect that our final report to improving quality. We will also consider
will indeed provide the greater clarity that where and how we could particularly bring the
Dr Colin-Thomé called for, the real value of NQB’s weight to bear in order to accelerate the
the review has been in its co-production, with delivery of quality improvements.
the NQB providing a much-needed mechanism
for aligning the system around safeguarding These two strands of work should reinforce each
quality. It has shown us the potential of the other – work relating to the NICE quality standard
NQB to align the system, and marks the topic areas will help inform the NQB’s more
beginning of a new way of working. strategic, high-level view. Similarly, there will
be lessons from the strategic work that can be
Aligning the system to achieve large- applied to the specific strands as they progress.
scale quality improvement
This work is only just starting and will be driven
In 2010, building on our work to date and the forward by a number of sub-groups we are in
wide-ranging expertise of our members, we will the process of setting up. We anticipate the
examine how best to drive quality improvement work leading to recommendations about how
in the NHS at scale and pace. We will take a and where greater alignment and integration
strategic view of how greater alignment of across the system positively impacts on the
the NHS system, including across the interface NHS’s ability to improve quality for patients.
between health and social care, can support the
drive to improve quality. System Alignment Sub-group
Strategic level
In order to prevent this piece of work from
Chaired by: Paul Lelliott
becoming too abstract, we will underpin
it with an examination of how greater NQB members (or representatives)
alignment across the system can support • Stephen Thornton
quality improvements to be made within a • Hilary Scholefield
number of specific care pathways. The • Chris Beasley
care pathways we have chosen are the first • Allan Bowman
four topics for which the National Institute • Bruce Keogh
for Health and Clinical Excellence (NICE) will • Jo Williams (CQC)
be developing quality standards – prevention • Adrian Masters (Monitor)
of venous thromboembolism (VTE), stroke, • Val Moore (NICE)
specialist neonatal care and dementia. We have External members
deliberately picked these pathways as they • Paul Plsek (large-scale change expert)
cover care of different types and in different • Andrea Young (Chief Executive, South
settings spanning health and social care. Central Strategic Health Authority)
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System Alignment Sub-group System Alignment Sub-group

VTE prevention Specialist neonatal care
Chaired by: Bruce Keogh Chaired by: Chris Beasley
NQB members (or representatives) NQB members (or representatives)
• Sally Brearley • Bruce Keogh
• David Haslam • Sally Brearley
External members • Naren Patel
• Anita Thomas (Chair, Chief Medical • Ann Close (CQC)
Officer’s National VTE Implementation External members
Working Group) • Sheila Shribman (National Clinical Director
• Gerard Stansby (Professor of Vascular for Children, Young People and Maternity
Surgery, Newcastle Hospitals NHS Services)
Foundation Trust, and Chair of NICE quality • Tahir Mahmood (President, Royal College
standard topic expert group) of Obstetricians and Gynaecologists and
• Ian Cumming (Chief Executive, West Chair of NICE quality standard topic
Midlands Strategic Health Authority) expert group)
• Further members to be confirmed • David Field (President, British Association of
Perinatal Medicine)
• Andy Cole (Chief Executive, Bliss)
System Alignment Sub-group
• Further members to be confirmed
Stroke care
Chaired by: Margaret Goose
System Alignment Sub-group
NQB members (or representatives) Dementia care
• Bruce Keogh
• Ann Close (CQC) Chaired by: Tim Kelsey
External members NQB members (or representatives)

• Anthony Rudd (Royal College of Physicians • Bruce Keogh
and Chair of the NICE quality standard • David Behan
topic expert group) • Paul Lelliott
• Roger Boyle (National Clinical Director for • Don Brereton
Heart Disease and Stroke) • Gary Needle (CQC)
• Further members to be confirmed • Tim Kendall (NICE)
External members
• Further members to be confirmed
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Developing a quality information Quality Information Strategy Sub-group

strategy Chaired by: David Haslam
High Quality Care for All said that: NQB members (or representatives)
• Sally Brearley
“The next stage in achieving high quality care • Tim Kelsey
requires us to unlock local innovation and • Richard Hamblin (CQC)
improvement of quality through information – • Nicola Bent (NICE)
information which shows clinical teams where • Toby Lambert (Monitor)
they most need to improve, and which enables • Tanya Huehns (NPSA)
them to track the effect of changes they External members
implement.” • Christine Connelly (Director General
for Informatics, Department of Health)
In 2010, we will be developing a quality Tim Straughan (Chief Executive, NHS
information strategy, which will set out a clear Information Centre)
vision for the future of quality information. • Robert Winter (Medical Director, East
Midlands Strategic Health Authority)
Wefirmly believe that the use of information
• John Carvel (formerly Social Affairs Editor,
is critical to improving the quality of services
The Guardian)
provided to patients. Lord Darzi focused on
• Andrew Vallance-Owen (Medical Director,
quality information in High Quality Care for All,
BUPA)
and we have overseen the development of new
• Robert Cleary (Head of Data R&D,
information initiatives flowing from that review,
NHS Choices)
including Indicators for Quality Improvement,
Quality Accounts and NICE quality standards.
We have recognised that we need to do
more to join together into a coherent vision
However, information on the quality of services
the variety of purposes for which quality
is used by a range of people, not just by health
information is used. Events at Mid Staffordshire
professionals, and for a range of purposes.
and, more recently, at Basildon and Thurrock
Patients and the public are increasingly using
NHS Foundation Trusts showed that there is
information to guide their choices about
public confusion about how quality information
treatment; NHS Choices5 now receives
is being used to make assessments about the
7 million users each month. Regulators
quality of services.
are using information in different ways –
for example, through the Quality and Risk
The strategy will include looking at the information
Profile System being developed by the Care
currently available, including where there are
Quality Commission.
gaps, and at how we can put more information
into the public domain. It will look at how
information is presented, and will examine how
we can improve the communication of complex
information. It will also look at the roles and
responsibilities of the current bodies involved in
quality information, and make recommendations
as to how the system can be improved.
www.nhs.uk
5
16
Supporting provider boards in their organisations. As part of this, the work

governing for quality may result in recommendations for particular
quantitative or qualitative measures to be
There have been several indications over the developed which NHS provider boards could
last few months that some work is needed to use for assessing the state of quality within
examine how best to support hospital trust their organisations.
boards in establishing rigorous governance
arrangements for quality. Indeed, our own Good Governance for Quality Sub-group
review into the early warning systems in the Chaired by: Hilary Scholefield
NHS for preventing serious failure has identified
a need in this respect. NQB members (or representatives)
• Naren Patel
It has also become clear that there is already a • Stephen Thornton
good deal of activity and thinking under way • Paul Lelliott
on this issue that could usefully be aligned. • Jamie Rentoul (CQC)
For example, Monitor is in the process of • Miranda Carter (Monitor)
developing a quality governance framework External members
setting out how foundation trust boards • Elisabeth Buggins (Chair, West Midlands
should monitor trust-wide quality performance, Strategic Health Authority)
including how they should scrutinise cost • Ann Abraham (Health Service Ombudsman)
improvement programmes and manage their • Nicholas Hicks (Chief Executive, Milton
impacts on quality. The National Leadership Keynes Primary Care Trust)
Council has been developing guidance on the • Further members to be confirmed
characteristics of healthy NHS boards. We are
also aware that, in the wake of the failures
at Mid Staffordshire and, more recently, at
Basildon and Thurrock, right across the NHS –
and at various levels in the system – thought
is being given to how hospital boards can best
assure themselves about the quality of care
being provided within their organisations.
We therefore plan to take forward a piece of

work during 2010 that examines what good
governance for quality looks like with a view to
consolidating and aligning much of the good
work already under way. The aim of this work
will be to ensure that NHS provider boards
have access to a coherent and aligned package
of support which enables them to confidently
and competently asks the right questions
about the quality of care being provided in
17
Chapter 3
Advising and prioritising for
quality improvement
To determine future priorities for quality

improvement, the Secretary of State has asked
us to provide advice, drawing on an objective,
transparent methodology. The methodology we
have developed, and that is described in this
chapter, will look at mortality and morbidity,
but will also consider a range of other factors,
focusing on the potential to improve quality.
When formulating our recommendations,
we will listen to experts, as well as considering
a wide range of reports and investigations into
quality in the NHS.
The methodology we have developed will

also be used for the topic selection of NICE
As a Board, we will advise Ministers on priority quality standards.
areas for quality improvement in the NHS,
including at the health and social care interface. Developing the prioritisation
methodology
Over the last ten years, the greatest quality
improvements in the NHS have been made Wehave established a formal standing
in areas agreed upon as national priorities. committee of the National Quality Board,
National Service Frameworks were produced for the NQB Prioritisation Committee, chaired by
a small number of clinical areas, generally those Bruce Keogh, with representation from both
conditions that caused the highest mortality Board members and external experts.6 The
and/or morbidity. While our emphasis now role of the committee is to oversee the use of
is to support local organisations to improve the prioritisation methodology and to propose
quality systematically across all clinical areas, priorities for the full Board to discuss and agree.
it is still important to identify which areas are
particularly in need of quality improvement and
therefore should be prioritised at a national level.
The Prioritisation Committee’s minutes, papers and recommendations are available at www.dh.gov.uk/en/Healthcare/
6
Highqualitycareforall/NationalQualityBoard/DH_106153
18
�
The prioritisation methodology

Prioritisation Committee
Chaired by: Bruce Keogh The methodology centres on a set of criteria
NQB members that will then be applied to a wide range of
• Mike Rawlins clinical topics (see box).
• Margaret Goose
• Paul Lelliott Prioritisation criteria
• John Oldham
• Allan Bowman In order to meet our brief to be focusing on
• David Haslam quality improvement, we will give enhanced
weighting to criteria 1 and 2.
External members
• John Appleby (Chief Economist, 1. degree of variability in quality (or absolute
the King’s Fund) poor quality);
• Ian Kennedy (formerly Healthcare
Commission) 2. potential to improve healthcare quality;
• Jan Sobieraj (Chief Executive, Sheffield 3. prevalence of the clinical problem;
Primary Care Trust)
• Fergus Macbeth (Director, Centre for 4. burden of disease (mortality, morbidity
Clinical Practice, NICE) and functional impairment, including the
economic cost of lost work);
In 2009 the Prioritisation Committee oversaw 5. cost (to patients, and to the NHS overall);
the development of the methodology we will
6. potential to reduce cost (to patients, and
use to prioritise clinical areas. This is the start of
to the NHS overall);
a process. We plan to refine and develop this
methodology over the coming years to ensure 7. potential benefit and risk to public; and
Ministers receive the best possible advice.
8. impact on equality.
We ran a stakeholder engagement exercise in
autumn 2009, in which we received over 80 The process has four key stages:
formal responses. The engagement reached
over 300 stakeholders directly and was • Identification of topics for assessment –
circulated among many NHS networks. the committee identified an initial list of 200
topics, which included both clinical pathways
The responses were broadly positive, and cross-cutting topics to ensure that there
with significant support for the proposed was maximum coverage of possible areas
criteria and transparency of the process. for quality improvement. It welcomed the
The committee modified the process in suggestion of further topics put forward
light of the engagement exercise; and we as part of the engagement process. In the
discussed and agreed it as a full Board future, there will be an annual process where
at our December meeting. the committee will ask for suggestions of
topics to be considered for prioritisation.
19
• Gathering of evidence – for each of the We will also use this methodology to
topics referred, the NQB’s Secretariat will recommend to Ministers all topics for NICE
gather evidence on each of the prioritisation quality standards. Over the next five years,
criteria, to inform the process and the scoring NICE will build up a library of around 150
of each topic. This process will be overseen by quality standards. We have recommended that,
the Prioritisation Committee. to give a strategic vision to this library, we set
out in 2010 what 75% of these topics will be.
• Decision making – the Prioritisation
The remaining 25% will be available for the
Committee will meet to consider the evidence
Board to respond to particular areas that rise
gathered and discuss how to develop a
in prominence.
ranked priority list from these results. It will
work to avoid the risk that prioritisation could
The prioritisation process will also be able to
be driven by the information available rather
provide valuable information about which
than by variability in quality. It will also ensure
clinical areas lack evidence. We will make a
that no groups are consistently left out of
number of recommendations to stimulate the
the prioritisation process, such as children,
development of evidence in these areas.
vulnerable or disadvantaged groups.
• Prioritisation outputs – once the Board Weexpect to be in a position to make our first
has identified clinical priority areas, we will prioritisation recommendations in spring 2010.
consider what is required to improve quality Wewill consider how best to communicate
in these areas. As a Board, our power comes our recommendations, so as to highlight
from the wide range of improvement levers mechanisms for quality improvement available
at the disposal of our members. As such, we in all clinical areas.
will recommend actions both to Ministers at
the Department of Health and to the other This process is a real demonstration of how
organisations represented on the NQB. the NQB’s collective expertise can be used to
address complex issues in an evidence-based,
Possible recommendations on actions to
objective way. Another example of this is
support priorities include:
the work that the Board conducted in 2009
to advise the Secretary of State on a new
• highlighting the area as a national priority
Objective for the NHS on MRSA.
through the NHS Operating Framework
for England;
A new MRSA Objective for the NHS
• developing new indicators for inclusion in the
menu of Indicators for Quality Improvement We were pleased, in 2009, to be able to
(see Chapter 4 for further details); provide advice to the Secretary of State on
setting a new MRSA Objective for the NHS.
• developing guidance for NHS commissioners;
The previous reduction target to halve the
and
number of bloodstream infections, met in
• commissioning an international thematic March 2008, represented a huge achievement
review to better understand how to bring by staff working in the NHS. Nevertheless, we
about quality improvement. agreed that there was still significant scope
for improvement and that the variation in
performance between trusts was unacceptable.
20
Our starting point for this piece of work was

New MRSA Objective
that, ultimately, the NHS should be striving
for the elimination of all preventable MRSA The Objective is based around the median of
infections – a zero tolerance approach. We performance7 for acute trusts and primary
therefore wanted to develop a recommendation care trusts:
that would move the NHS towards this goal
while at the same time ensuring that it was • Organisations performing worse than the
achievable. In particular, we were keen to: median are required to reduce rates of
MRSA bacteraemia to the median or by
• reduce the variation in performance 20%, whichever is greater.
across the NHS; • Organisations performing better than the
• deliver further reductions in the number of median are required to reduce rates of
MRSA bacteraemia; MRSA bacteraemia to levels in the best-
performing quartile or by 20%, whichever
• be fair, in terms of recognising organisations’ is lower.
current performance; and
• Organisations within the best-performing
• recognise the low rates of MRSA quartile should set reduction targets
bacteraemia already being achieved by locally, rather than nationally, with the
the best-performing organisations. aims of maintaining their excellent
performance and striving for further
We established a small sub-group of the Board reductions where possible.
to support us in this work. The sub-group
oversaw a six-week stakeholder engagement The MRSA Objective is an annual goal, to be
exercise on initial proposals for the Objective recalculated yearly. It will be reviewed when
and carried out detailed analysis and modelling variation in performance across the NHS is
of various options, with the support of an less pronounced and when there is evidence
external expert advisory group. that performance is levelling, to ensure it
continues to drive improvement.
MRSA Objective Sub-group The Objective applies to:
Chaired by: Paul Lelliott
• primary care trusts as a population-
NQB members based rate, with all MRSA bacteraemia
• Hilary Scholefield in members of their population counted
• Sally Brearley towards their total; and
• John Oldham
• acute trusts as a bed-day rate, with all
MRSA bacteraemia identified after two
The responses to the engagement exercise were
days following admission counted towards
considered by the sub-group and incorporated
their total.
into its final proposals, which we discussed and
agreed at our September meeting.
7
NHS performance on MRSA bacteraemia reported to the Health Protection Agency’s mandatory surveillance system for the
period October 2008 to September 2009 was used to set the MRSA Objective for 2010–11.
21
Our recommendation, which the Secretary of

State accepted in full,8,9 will effect organisations
differently depending on their current level of
performance, meaning that:
• the largest improvements will have to be made

by those organisations performing worse than
the current median level of performance;
• organisations close to the median, on either
side, will have proportional improvements to
make; and
• the position of organisations in the best-
performing quartile is recognised as excellent.
The new MRSA Objective was published in the

NHS Operating Framework10 on 15 December
2009 and will come into effect from 1 April 2010.
8
All NQB minutes and meeting papers can be found on the NQB web pages at www.dh.gov.uk/en/Healthcare/
Highqualitycareforall/NationalQualityBoard/index.htm
9
NQB’s advice to the Secretary of State is available at www.dh.gov.uk/en/Healthcare/Highqualitycareforall/NationalQualityBoard/
DH_102954
10
The NHS Operating Framework for England 2010/11 is available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_110107
22
23
�
Chapter 4
Overseeing the development of tools and
�
system levers for quality improvement
Bringing clarity to quality – NICE

quality standards
High Quality Care for All acknowledged that
more needed to be done to bring clarity
to what constitutes high quality care, and
identified the way standards were used and
set in the NHS as being an area of particular
concern. It found that there were too many
standards in the NHS, with different standard
setters using different methods with variable
use of evidence. This made it difficult to
understand what high quality care looks like.
To address this confusion and bring greater

clarity to quality, High Quality Care for All
The National Quality Board (NQB) has a key announced that the role of NICE would be
role to play in supporting the NHS to drive expanded to develop authoritative quality
up quality by overseeing the development standards.
of quality improvement tools and making
effective use of the system levers available. The NQB was tasked with providing leadership
and oversight in the production and
High Quality Care for All announced a number development of these NICE quality standards.
of new national quality initiatives to support the We agree that the use of standards in the
overarching Quality Framework it described. We NHS has resulted in confusion and welcome
have overseen many of these during 2009, such the role that has been given to NICE, with
as the development of NICE quality standards, the its internationally acclaimed reputation and
Measuring for Quality Improvement programme expertise, in producing quality standards.
and Quality Accounts, as well as providing advice
on how the Clinical Excellence Awards scheme
could be strengthened to have an enhanced
focus on quality. This chapter describes our
work to date, much of which will continue
during 2010.
24
�
We have been involved in the development of We are committed to providing transparent

quality standards from the beginning, agreeing advice to Ministers on what the topics should
their definition in March last year. be for NICE quality standards and will use the
objective methodology for prioritising in the
NHS, explained in the previous chapter, to do
NICE quality standards definition
so. This will be in place from late 2010.
A set of specific, concise statements that:
In the long term, our vision for quality
• act as markers of high quality, cost- standards is that all clinical teams should have
effective patient care across a pathway or recourse to a quality standard for key pathways.
clinical area; To achieve this, we have agreed to a plan that
will see NICE developing a broad library of
• are derived from the best available
evidence; and
� quality standards over the next five years.
• are produced collaboratively with the NHS However, our interest in quality standards
and social care, along with their partners extends beyond the production process. Quality
and service users. standards must have traction within the system
to enable clinicians to deliver high quality care,
In 2009 we advised Ministers on four topics enable commissioners to commission high
for piloting the production of NICE quality quality care, and enable patients to know what
standards. Ministers accepted our advice and level of care they should receive. The Board
NICE has begun work on developing quality will therefore consider how it can best support
standards for: the implementation of NICE quality standards
within the NHS and ensure clear alignment
• stroke; with the Quality Framework as a whole.
• dementia; As described in Chapter 2, we will be driving
quality improvement within these four pilot
• specialist neonatal care; and areas by examining how greater alignment
• prevention of venous thromboembolism (VTE). and integration across the health and social
care systems can bring about positive change
We are following the development of each of at scale and pace.
these quality standards, with a member of the
NQB shadowing the production process in each
topic area. These first quality standards are due
to be published in spring 2010.
25
Measuring for Quality Improvement Indicators for Quality Improvement
In making quality the organising principle of IQI is a resource aimed at bringing together
the NHS, High Quality Care for All signalled quality indicators that already exist in different
that measuring the quality of care was vital parts of the system. Through partnership with
to improving services for patients. Without strategic health authorities, the NHS Information
measuring quality, the NHS cannot orientate Centre, and Royal Colleges, the IQI menu of over
itself towards continual improvements in 200 quality indicators was developed to help local
patient care in terms of safety, effectiveness clinical teams identify robust indicators of quality
and patient experience. This will require a that they could use to monitor improvement.
radical change in the relationship between the
NHS and the information it collects about its IQI quality dimension coverage
daily business. Pathway Safety Effectiveness Experience
Acute care 16
At a national level, we are pleased that the Children’s
8
Department of Health has responded to health
this by launching the Measuring for Quality End of life care 3
Improvement programme. This programme was Learning
1
established to address the need for information disabilities
about the quality of services at all levels of the Long-term
1 31 1
NHS, and in particular, to support NHS staff conditions
in local teams to be able to understand the Maternity and
9
components of delivering a high quality service. newborn
That understanding can only be effectively Mental health 12
supported with good information, which: Other 4 27
Planned care 16 84 25
• accurately describes the service being provided;
Staying healthy 3
• allows changes to be tracked over time; and
• enables benchmarking against standards of We recognise the publication of IQI as an
good practice and against peer groups. important milestone. However, the grid above,
broadly showing where these indicators fall
The NHS Information Centre launched the first in terms of care pathways and the three
key output of the programme – an assured dimensions of quality, clearly highlights major
menu of Indicators for Quality Improvement gaps in coverage.
(IQI) – in May 2009.11
As a Board, our vision is simple – that these
gaps are filled and that over the next five
years all local teams are able to routinely and
systematically measure the quality of services
they are providing to patients using indicators
that are genuinely seen as good measures
of quality.
11
www.ic.nhs.uk/services/measuring-for-quality-improvement
26
Managing quality indicator development Finally, it will ensure that the development of
quality indicators is managed in a systematic
To achieve this, we have led the creation way. It will promote a ‘collect once, use often’
of a national quality indicator development philosophy and in time ensure that obsolete
governance system that will enable indicators to indicators are identified and removed to avoid
bubble up from local clinical teams at the same overburdening NHS staff who need good, up-
time as setting clear national direction to ensure to-date quality indicators to support quality
the development of new indicators in priority improvement.
areas. This governance for IQI is founded on the
following principles: As a priority, we have asked NQIDG to look
at the indicator requirements associated with
• Appropriate professional and patient experts
the first four NICE quality standards (VTE,
should identify what needs to be measured.
dementia, stroke and specialist neonatal care).
• Roles and responsibilities of organisations for We have also asked the group to work with
assuring quality indicators should be clear. the NHS to develop a better set of patient
safety indicators, including the possibility of a
• Robust methodologies need to be applied to
quality indicators. composite patient safety measure to further
support the NHS in safeguarding quality. This
• The focus of development should be on will tie in with our work in 2010 on developing
quality improvement – not top-down a quality information strategy and considering
performance management. what good governance for quality looks like, as
described in Chapter 2.
• New indicators should not add unnecessary
data collection burdens to the NHS.
To support the development of IQI we asked

the Department of Health to convene a
National Quality Indicator Development Group
(NQIDG), which met for the first time in January
2010. This group will report to us and support
us in meeting our vision for improving quality
measurement across all clinical teams.
It will ensure that key indicator gaps are

addressed, support innovation in local
measurement with good practice guidance
and tools for indicator development, and
identify organisations that can assure those
developments. It will also ensure that quality
measurement supports the development of
NICE quality standards and other national
quality improvement activities.
27
work of the nQb In 2009
�
National Quality Board Annual Report 2009/10
28 January 16 March 30 March 18 May 8 July 4 August 22 September 27 october 10 november 17 December
A wide range of Spanning health The Board meets Advice on the How the NHS The stakeholder A new governance Staff from across Stakeholder A busy final
stakeholders are and social care, for the first time, first four NICE can learn from engagement model for developing South West Strategic engagement on meeting of 2009
involved in the final the 12 expert and agreeing the quality standards other countries period closes for quality indicators Health Authority how the NQB sees the NQB
design event for the lay members are publication of the topics is agreed is discussed the NQB’s work is discussed by the discuss the NQB’s should advise on agree a new
NQB, jointly drafting appointed. They join initial list of the by the NQB at its at the third to develop a new Board, giving structure developing work on clinical priorities approach to service
the Statement the nine ex-officio Indicators for Quality second meeting, meeting, laying MRSA Objective to the development of NHS early warning concludes. Overseen accreditation,
of Purpose to be members announced Improvement (IQI). along with ways foundations for for the NHS. new quality indicators mechanisms. This by the Board’s as proposed by
considered at the in December 2008. to strengthen the a programme The six-week in the future. work follows on new Prioritisation the Academy of
Board’s first meeting. Clinical Excellence of international exercise involved from failings at Mid Committee, Medical Royal
Awards scheme. comparisons. stakeholders from Staffordshire NHS the proposed Colleges. The Board
all over the NHS. Foundation Trust. methodology receives also confirms its
broad-based support. work programme
for 2010 and
agrees the need
for a strengthened
assurance
mechanism for
Quality Accounts.
Service
accreditation
Clinical We agreed with the
proposals for the
Indicators prioritisation
core model of service
for Quality review of early The prioritisation accreditation, and
improvement methodology was asked for further
warning systems revised following
The IQI website has policy development
Quality standards new indicator We formed a sub- stakeholder
been visited over and consultation to
International development group to conduct engagement, and
200,000 times since The first four NICE MrSA objective take place. Plans are
comparisons detailed work, which was agreed by the
its launch – meaning quality standards The Board agreed already under way
The Board’s reported to the full Board in December.
that thousands of – on dementia, The Department that a National to incorporate the
recommendation Board in December. Analytical work is
clinicians across the stroke, specialist of Health accepted Quality Indicator model in forthcoming
for a new MRSA The report, to be now under way to
NHS are able to use neonatal care and the NQB’s advice Development Group schemes for stroke
Objective was published shortly, provide the required
the best available prevention of venous on the direction of should be formed care and physiological
agreed in full by the will provide clarity data against the
indicators to improve thromboembolism the international to advise on how to measurement. By
Secretary of State on the roles and agreed criteria in
the quality of care (VTE) – will be healthcare quality expand the quality encouraging clinicians
and subsequently responsibilities time for the Board
they provide. published in spring comparisons project, indicators available, to aspire towards
published in the in spotting and to consider again in
2010. These will including carrying and on which areas excellence, service
2010/11 Operating acting on serious March.
provide a valuable out a thematic to focus on. The accreditation will
Framework. The failures, helping
tool to clinicians review of stroke Group met for the improve patient care
new evidence- to avoid repetition
and commissioners care. The review of first time in January across the NHS.
based objective will of the events at
in delivering high stroke care will learn 2010, when it agreed
require acute trusts Mid Staffordshire.
quality care and from international to focus initially on Quality Accounts
will help the NHS in and primary care indicators for patient
comparisons All acute trusts will
reducing the 25,000 organisations to safety and to support
to ensure that be publishing Quality
inpatient deaths achieve significant the first four NICE
outcomes in Accounts in 2010.
every year from year-on-year quality standards.
England are as These will allow
preventable VTE. reductions in the
good as those in patients and the public
rates of MRSA
the best performing unparalleled access to
bacteraemia.
countries. information regarding
keY DeVeLoPMentS the quality of local

hospital services.
28 29
Quality Accounts advised the Department of Health to build

on, and align with, Monitor’s proposals for
In June this year, all acute trusts will be an external assurance process for foundation
publishing Quality Accounts for the first time. trusts’ Quality Accounts. In the first half of
They are annual reports to the public from 2010, we will consider the results of the
local NHS organisations about the quality consultation on Monitor’s proposals and take
of the healthcare services that they provide. a view on the next steps for the development
of a proportionate and cost-effective
Many countries are beginning to see that assurance mechanism that can be equally
public reporting of comparative information applied to all NHS providers, ahead of making
about the quality of healthcare is an recommendations to Ministers.
important way of improving transparency and
accountability, stimulating quality improvement There is significant flexibility in the framework
and empowering patients and the public. By for Quality Accounts this year. We support this
providing a balanced view of the organisation’s approach as it will help foster local ownership
successes and challenges, Quality Accounts have and accountability in the first year. However,
the potential to help the public understand: as Quality Accounts – and the underlying
processes of engagement and accountability
• what an organisation is doing well; – become more familiar to providers and the
public, we feel that there is likely to be a case
• where improvements in service quality
for moving towards greater standardisation
are required;
of their content. This will help accounting for
• what the priorities for improvement are for quality reach the same degree of maturity
the coming year; and and trustworthiness as financial accounts.
We will therefore also review this year’s
• how service users, staff and others with an
Quality Accounts, with a view to making
interest in the organisation are involved in
recommendations to Ministers on greater
determining priorities for improvement.
standardisation in the future.
Last year, all NHS foundation trusts and
A process of testing and evaluation is now
acute trusts in the East of England piloted
also under way across the North East and East
Quality Accounts, publishing quality reports in
Midlands NHS regions, led by the Department
summer 2009. At our September meeting, we
of Health, to develop Quality Accounts for
considered the results of the pilot and heard
providers of primary care and community
directly from two medical directors who had
care services for 2011. We will consider the
led the exercise in their trusts.
results of this work and will develop advice for
We are agreed that Quality Accounts will play Ministers about the scope for rolling out Quality
a significant role in supporting the quality Accounts to these sectors in 2011.
agenda. However, to maximise their potential
we are clear that they will need to become as
reliable and robust as financial accounts. We
therefore recommended that the assurance
mechanism needed to be strengthened and
30
Clinical Excellence Awards NQB’s advice to the ACCEA on

clinical quality
High Quality Care for All said:
We provided advice in four key areas:
“For senior doctors, the operation of the
Clinical Excellence Awards Scheme will be • Three dimensions of quality. We
strengthened… the independent Advisory recommended that, as far as possible,
Committee on Clinical Excellence Awards will applicants should be required to
have regard to advice from the National Quality provide evidence demonstrating their
Board and the NHS Leadership Council.” performance across all three dimensions
of quality (safety, effectiveness and
We want clinicians to be recognised and patient experience) while recognising that
rewarded for delivering high quality care. One their exceptional contribution may focus
way for this to happen is through Clinical on just one.
Excellence Awards. In May, we discussed how
• National clincial audits. We advised
the Advisory Committee on Clinicial Excellence
that applicants should be required to be
Awards (ACCEA) could strengthen the quality
fully participating in any relevant National
aspects of the awards.
Clinical Audits or relevant National
Confidential Enquiries.
Our advice to the ACCEA is shown in the box.
We were pleased to work on the awards in • Use of quality indicators. We emphasised
partnership with the NHS Leadership Council, the importance of applications being
which advised the ACCEA on how to improve underpinned by strong evidence, and
the leadership aspects of the scheme. David encouraged applicants to have regard to
Nicholson, Chair of both the NQB and the NHS the Indicators for Quality Improvement.
Leadership Council, set out joint advice in a
• Quality improvement. We advised that
letter to Jonathon Montgomery, Chair of the
the scheme could do more to recognise
ACCEA, in June.12
and reward exceptional contributions to
quality improvement, which was often
The advice was accepted in full by the ACCEA
not regarded as a proper science.
for the 2009/10 awards scheme, through
guidance published in August 2009. We will be
considering how the 2010/11 scheme could be
further improved at a future meeting.
12
www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_101553
31
A core model for clinical service We discussed the core model at our December
accreditation 2009 meeting and agreed with the Academy’s
proposals. The model includes eight key
In June 2009, Lord Darzi published High Quality principles that should underpin clinical service
Care for All: Our journey so far,13 an update on accreditation.
actions following the NHS Next Stage Review.
This highlighted the need for clinicians to be Core principles of service accreditation
aspiring to excellence, and what role service
accreditation can play in improving quality. The model, agreed by the NQB, is focused
on eight key principles. Schemes should:
Service accreditation complements the existing
• be inclusive of the range of interests
regulatory framework. Whereas, from April

in the clinical service that is the focus
2010, the Care Quality Commission will

of accreditation;
�
regulate the essential levels of quality and
safety through the new system of registration, • have a patient focus;
accreditation offers an opportunity to
• have methodological rigour and draw on
involve clinical teams in aspiring towards and
the evidence base in the development of
demonstrating excellence in clinical services.
standards and in the processes used to
There are numerous existing accreditation
assess levels of performance;
schemes run by Royal Colleges and independent
organisations. However, there has been no • be about excellence and show a
coherent or comprehensive approach to commitment to quality improvement;

�
recognising those leading teams which are
• have sound governance;
providing excellent standards of care.
• be subject to evaluation and external
We recognised that our unique composition quality assurance;

�
and overview of the system makes us ideally
• be aligned with the system that regulates
placed to bring these different schemes
and performance manages healthcare
together through the development of a core
and be recognised as being part of
model of professionally led service accreditation
that system (in particular, they should
used throughout the NHS. Individual services
be based on NICE quality standards
or Royal Colleges will then be able build upon
and contribute information to support
and develop this core model, thereby providing
registration by the CQC); and
a framework for aligning accreditation schemes.
• demonstrate value for money.
The Academy of Medical Royal Colleges,
representing all medical Royal Colleges, has
been leading on this work, asking the Healthcare
Quality Improvement Partnership (HQIP) to take
forward the development of the core model.
13
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_101670
32
We see accreditation schemes as very

much part of the NHS system for quality
improvement. In particular, accreditation
schemes should:
• feed into trusts’ returns to regulators;
• inform and feed into a trust’s Quality
Account; and
• support the implementation of the relevant
NICE quality standard(s), which are developed
and draw on the quality standards in
determining what ‘excellent’ looks like for
that service.
The practical implications of the core model are

currently being considered, along with further
consultation with stakeholders. Following this,
we will consider the model again, particularly
to ensure that it is aligned with the national
systems for regulation and performance
management.
33
Chapter 5
International healthcare comparisons
for quality improvement
the last year to move the NHS towards this

ambition. This chapter focuses on how the
quality of care in the UK compares with
healthcare systems around the world, and
how we are learning from other countries
using international comparisons. Our role
is to oversee and advise on work led by the
Department of Health.
Our commitment to learning from the best is

reflected in our membership; we are privileged to
have Don Berwick, President and Chief Executive
of the world-renowned Institute of Healthcare
Improvement, as a special adviser to the NQB.
Over the past year, he has provided invaluable
insights into how we are approaching our work,
benefiting us with his experience in improving
“I know that patients, staff and the public all
quality across the world.
want an NHS that is as good as any healthcare
system in the world. Meeting this aspiration
will require us to understand how we perform Why use international comparisons?
compared to other advanced healthcare
By comparing ourselves with other countries, we
systems. So we will work together with other
can identify particular areas where, internationally,
Organisation for Economic Co-operation and
we are underperforming. We can then examine
Development (OECD) countries and with the
how different countries have approached similar
best academic institutions in the world and
issues, learn from their solutions, and improve
draw on our new national quality framework to
care in the NHS. The use of international
agree some internationally agreed measures.”
comparisons is an important tool for quality
High Quality Care for All, 2008
improvement. There are already powerful
As a Board, we have a shared commitment to examples of how international comparisons
make the NHS world-class. Previous chapters have been used to directly improve patient care
have detailed the work we have led on over (see examples 1 and 2 in the boxes opposite).
34
�
Like any quality improvement tool, international

Example 1
comparisons must be used carefully to get the
most from them. Meaningful learning from
The EUROCARE comparisons of cancer
international comparisons requires valid, reliable
survival revealed lower cancer survival rates
and sustainable international comparative data.
in England compared with some other
Developing appropriate healthcare quality
western countries. Highlighting this disparity
indicators, collecting and submitting data, and
influenced the NHS Cancer Plan (2000) and
interpreting the results is a complex process.
the Cancer Reform Strategy (2007), which
Face-value comparisons may not always
have led to changes in practice to improve
reflect the true situation, or reveal the
survival rates. The Cancer Reform Strategy
reasons for disparities. Detailed investigation
set up the National Awareness and Early
is always required before international
Diagnosis Initiative (NAEDI), which promotes
comparisons can be used meaningfully to
greater awareness of cancer symptoms,
drive improvement in healthcare quality.
earlier presentation and earlier diagnosis
as a means of improving survival rates. It is
“While international comparisons may thought that earlier diagnosis might be one
provide an important benchmark for national of the key reasons for better cancer survival
progress, it will be important to consider a rates in some comparable countries.
range of indicators to capture the different
aspects of a given aspect of healthcare in
order to allow a meaningful interpretation Example 2
of observed phenomena.”
Ellen Nolte (RAND Europe Literature Review) When international comparisons in 2007
revealed comparatively lower kidney
In addition, we must try not to ask international transplantation rates in England, the
comparisons to do too much. There is always Department of Health established an Organ
a temptation to produce league tables of Donation Taskforce to find out why. By
different healthcare systems, with this having identifying the countries with high and
being attempted unsuccessfully by several increasing rates, the taskforce was able to
organisations. Following criticism of and learn how these countries had achieved
controversy over such an attempt in 2000, the improvements. Its recommendations
World Health Organization (WHO) has decided were published and are currently being
not to publish health system rankings, and is not implemented, including the appointment of
anticipated to do so in the future. It has simply a Transplantation National Clinical Director.
not proved possible to create a satisfactory way
to compare entire complex healthcare systems.
As such, and following the advice of international

experts, we do not advocate attempts to rank
countries’ healthcare systems. Instead, the use
of international comparisons must be far more
nuanced, selecting specific areas to compare
performance and share learning.
35
How does the UK compare with Inhospital case fatality rates within

30 days after admission for
other countries? ischemic stroke, 2007
The OECD publishes a biennial report, Health United Kingdom 9.0

17.4
Canada 7.6
at a Glance,using data provided by its member Slovak Republic 7.5
12.9
11.6
states. The report uses indicators to compare Ireland 6.6
12.1
health systems and their performance across a Spain 6.5
11.4
6.3
New Zealand
number of key dimensions, including healthcare Czech Rupublic 6.2
10.7
10.8
quality. Like the WHO, the OECD does not Netherlands (2005) 5.9
9.4
publish overall rankings of systems, but focuses Luxembourg (2006)

5.0
5.6
10.5
OECD
on specific areas of care. United States (2006) 4.2
9.0
6.0
Sweden 3.9
8.4
The Quality of Care Indicators in the Health at Germany 3.8

7.7
Austria (2006) 3.7
a Glance report provide the best international Italy (2006) 3.7
7.0
7.3
comparisons on quality of care available. As Norway 3.3
7.4
3.2
with all comparisons of this kind, however, Finland
3.1
5.9
Denmark
the figures presented in this chapter should be Korea 2.4
3.6
5.3
Agesex standardised rates
seen as raising questions about the quality of Iceland 2.3
5.8
Crude rates
care in different countries rather than providing 0 5 10 15 20

Rates per 100 patients
definitive answers or normative judgements.
Full analysis of the UK’s performance can be Inhospital case fatality rates within

30 days after admission for
found in the recently published 2009 OECD hemorrhagic stroke, 2007
report,14 which is summarised in Annex 1.
In comparison with other OECD countries, Luxembourg (2006) 30.3
32.6
the UK does not stand out as consistently over Slovak Republic 29.3
29.5
United Kingdom 26.3
or underperforming. However, the UK does United States (2006) 25.5
32.1
26.0
stand out in some areas as highlighted in the Netherlands (2005) 25.2
31.0
following graphs. Spain 24.2
28.2
Czech Republic 24.0
27.3
New Zealnd 23.8
26.8
Stroke care Canada 23.2
27.3
19.8
OECD 23.5
19.8
Iceland
The data indicates that the UK underperforms 19.4
29.2
Ireland 22.5
internationally on stroke care, with the highest Italy (2006) 17.2
20.8
reported in-hospital 30-day case fatality rate for Denmark 16.7
21.3
14.5
Germany
ischemic stroke. The standardised rate is 80% Norway 13.7
19.7
19.9
higher than the OECD average. The UK also Sweden 12.8
17.2
reports a high in-hospital 30-day case fatality Korea 11.0

11.3
10.8
Austria (2006) 13.1 Agesex standardised rates
rate for hemorrhagic stroke. It should be noted Finland 9.5 Crude rates
11.1
that the figures presented pre-date the launch
of the Department of Health’s Stroke Strategy Rates per 100 patients
in December 2007. Source: OECD 2009
14
www.oecd.org/document/11/0,3343,en_2649_33929_16502667_1_1_1,00.html
36
Mental health
The data indicates that the UK performs and bipolar disorder; for both conditions,
particularly well on unplanned hospital UK re-admissions are less than half the
re-admissions for patients with schizophrenia OECD average.
Unplanned schizophrenia readmissions to the same hospital, 2007
32.2
31.9 Finland
31.8
27.0 Sweden
28.2
25.9
23.2 Denmark
25.3
20.6
22.6 Norway
24.7
20.3
21.4 Ireland
19.2
23.1
18.1 OECD (12)
18.2
18.0
17.7 Belgium (2006)
16.7
18.7
16.5 New Zealand
15.9
17.2
16.4 Canada (2005)
17.6
15.1
14.8 Italy (2006)
13.3
16.3
10.9 Spain
10.4
11.5
8.5 United Kingdom
8.8
8.2
Female
6.3 Slovak Rep. (2006)
5.7
6.9 Male
40 30 20 10 0 0 10 20 30 40
Agesex standardised rates per 100 patients Age standardised rates per 100 patients
Source: OECD 2009
Unplanned bipolar disorder readmissions to the same hospital, 2007
36.9
33.9 Finland 30.5
28.3
25.1 Sweden 22.0
26.6
23.2 Ireland 19.4
18.0
19.4 Denmark 20.4
17.7
18.4 Norway 19.1
16.8
17.8 New Zealand 19.3
17.5
16.8 OECD (12) 16.1
16.7
15.4 Canada (2005) 14.1
14.7
13.6 Belgium (2006) 12.5
11.1
11.1 Spain 11.2
10.6
10.9 Italy (2006) 11.1
7.0
6.7 United Kingdom 6.4
5.6 Female
6.2 Slovak Rep. (2006) 6.8 Male
40 30 20 10 0 0 10 20 30 40
Agesex standardised rates per 100 patients Age standardised rates per 100 patients
Source: OECD 2009
37
Hypertension and congestive heart failure
Data indicates that the UK has the lowest data. In terms of congestive heart failure
standardised avoidable admission rate for only Korea reported lower rates for avoidable
hypertension of all the countries that supplied admissions.
Hypertension admission rates, population aged 15 and over, 2007
Austria (2006) 396
Poland (2006) 261
Germany 213
Korea 191
Finland 107
Denmark 85
OECD 84
Norway 70
Sweden 61
Italy (2006) 59
Switzerland (2006) 55
Japan (2005) 54
United States (2006) 49
Ireland 42
Belgium (2006) 21
Netherlands (2005) 19
Portugal 17
New Zealand 16
Iceland 15
Canada 15
Spain 13
United Kingdom 11
0 200 400
Agesex standardised rates per 100,000 population
Source: OECD 2009
CongestiveCHF admission rates, population aged 15 and over, 2007
heart failure admission rates, population aged 15 and over, 2007
Females Males
474 Poland (2006) 395
575
441 United States (2006) 395
501
352 Germany 307
408
331 Austria (2006) 274
408
258
308 Italy (2006) 377
306 Finland 264
363
289 Sweden 214
399
209
276 France 371
234 OECD 193
280
234 Spain 213
257
167
206 New Zealand 261
129
202 Iceland 317
149
192 Ireland 256
148
188 Norway 242
158
176 Portugal 199
171 Netherlands (2005) 142
211
137
169 Belgium (2006) 216
114
165 Denmark 235
120
155 Switzerland (2006) 206
119
146 Canada 184
117
134 Japan (2005) 153
96
117 United Kingdom 147
110 122
Korea 88
600 400 200 0 0 200 400 600
Agesex standardised rates per 100,000 population Age standardised rates per 100,000 population
Source: OECD 2009
38
What did we focus on in 2009? England to have services and outcomes which
are world class. The review aims to gain a better
In 2009 we advised the Department of understanding of the reported differences in
Health on how to establish the foundations outcomes for cancer between England and
of a successful programme of international other comparable healthcare systems that have
comparisons work. The Department also drew agreed to join the partnership as a basis for
upon a panel of international experts through further action in England to improve outcomes
a workshop hosted by Lord Darzi and Sir David for cancer patients.
Nicholson (membership is set out in Annex 2).
Four cancers (breast, colorectal, lung and
We approved a set of principles to guide the ovary) and five programme modules have
international comparisons work, including been identified as a focus. The first module of
the following: the programme – core benchmarking – has
already begun and is looking at root causes
• Detailed learning for quality improving is best
of differences in survival rates among the
achieved by comparing a limited number of
participating countries. We are pleased to
countries, or by focusing on a theme.
see that a number of countries are interested
• Producing an overall health system ranking in joining the benchmarking partnership –
is statistically unsound and does not offer Australia (New South Wales and Victoria),
valuable learning opportunities for quality Norway, Sweden, Canada (Alberta, British
improvement. However, individual indicators Columbia, Manitoba, Ontario), Denmark
in some cases (e.g. renal transplant rates) can and Wales.
be meaningfully ranked.
We were also pleased that the Department
• The quality of England’s data submissions for
of Health fully contributed data to the OECD
international comparisons needs to improve
Health at a Glance project, enabling the
in order to increase the validity of baseline
comparisons in this chapter to be drawn.
comparative data.
• Comparing healthcare quality between the How are we progressing in 2010?
four countries of the United Kingdom offers
important learning opportunities. We are confident that the foundations for an
effective international comparisons programme
• The best source for comparison data is
are starting to take shape. In 2010, we have
to be found through work with existing
advised the Department to continue this work
international quality comparison groups
of building foundations by focusing on three
(e.g. OECD, Commonwealth Fund, Nordic
key areas:
Group) in liaison with academics and experts.
• Improving international participation
We were pleased to see the Department of In addition to ensuring the UK continues
Health is taking forward a major international to contribute data to the OECD, we will
thematic review on cancer. Although England’s be overseeing full participation of the UK
cancer survival rates are improving, we believe in key international projects to develop
that understanding the reasons for comparable quality indicators. This will ensure that the
countries’ higher survival rates will help enable UK develops a position of leadership in
39
international healthcare quality comparisons. • Exploring new opportunities of learning

The UK is also exploring how best to pursue from international comparisons
useful bilateral relations with other countries, We will encourage the Department of Health
and how it can effectively engage with the to think creatively about what more we can
Nordic Group and the Commonwealth Fund. do to learn from other countries. To begin, we
would like to consider how best to expand
• Developing the thematic review
bilateral relations with other countries, how
programme
we can best analyse intra-UK data (building
We will monitor the progress of the cancer
on the Health Foundation’s work in this area),
thematic review and consider new topics
and how we can support individual NHS
for review, building on our prioritisation
organisations to make contact and learn from
processes.
their peers internationally.
In addition, given the UK’s relatively poor
In our annual report next year, we will give an
results for stroke care in Health at a Glance
update on progress in these areas of work, and
2009, we recommend that an international
seek to present further data as to how the UK is
thematic review on stroke care in England
performing internationally.
be performed. We were pleased to see the
recent report by the National Audit Office,
which noted significant progress in improving
stroke care.15 However, to help further
improvement, the review will:
– examine the apparent differences between
countries in stroke survival to establish
whether these reflect real differences in the
quality of care;
– learn from the best performing countries
about how they deliver their stroke care
now and how they plan to further develop
their stroke care in the future;
– consider to what extent the issues
highlighted in the report are already being
addressed by the stroke strategy; and
– recommend any further action that could be
taken to ensure that stroke care outcomes
in England are brought up to the standard
of the best performing countries.
15
Progress in improving stroke care, National Audit Office, 3 February 2010.
Available at www.nao.org.uk/publications/0910/stroke.aspx
40
41
�
Chapter 6
The continuing quality
challenge
of care for patients. Lord Darzi’s report

Our journey so far, published in June 2009,
set out some of the progress being made.16
Since then, the true scale of the financial

challenges facing the NHS has become
apparent. These challenges should not dilute
the NHS’s focus on quality, but rather should
strengthen it – they make the Next Stage
Review ambition of high quality care for all
more, not less, relevant.
The NHS must continue to drive quality

improvement in patient care, as the
demands on resources increase and its
budget remains broadly constant. The
It is now 18 months since High Quality Care for Department of Health’s NHS 2010–2015: from
All was published. While the vision it set out for good to great, published in December 2009,
quality was compelling, it was also ambitious, set out how the NHS needs to become more
and the changes needed at every level of the productive, while maintaining the drive for
system to truly make quality the organising quality improvement.17
principle of the NHS were always going to take
time to become a reality. This change in financial climate presents a
challenge that requires everyone to be more
Yet over this period, there has already been innovative and efficient in the way we pursue
good evidence of strong progress being made quality. How to maintain and improve quality
right across the country, and a real sense that within constrained resources becomes an even
the pursuit of quality is inspiring both clinicians more important question. This challenge offers
and managers to make the changes needed to the NHS an opportunity to take some of the
improve the safety, effectiveness and experience difficult decisions that will lead to improved
16
High Quality Care for All: Our journey so far, Department of Health, 30 June 2009. Available at www.dh.gov.uk/en/
Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_101670
17
NHS 2010–2015: from good to great. Preventative, people-centred, productive, Department of Health, 10 December 2009.
Available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_109876
42
�
quality and productivity – the system needs to The visits to each region took place during
support providers and commissioners in taking the summer of 2009. This was an interesting
those decisions and maintaining their focus on time as, during the course of the visits, the
improving the quality of care for patients. potential implications of the financial downturn
on public spending became clearer. During the
Quality tour of England course of their visits, Sir Ian and Sir Bruce saw
no evidence that this expectation was having
In early 2009, Sir David Nicholson, the Chief a negative impact on the drive to improve
Executive of the NHS and Chair of the NQB, quality in the NHS. In fact, they saw this
asked Professor Sir Bruce Keogh (NHS Medical emerging context as helping to connect the
Director and NQB member) and Sir Ian Carruthers quality, innovation, productivity and prevention
(Chief Executive, NHS South West) to look at agendas in a very real way.
the progress being made across the NHS in
improving the quality of health and healthcare, Encouragingly, Sir Ian and Sir Bruce found that
with a view to reporting back to the NQB. there had been a sizeable shift in the attitude
They visited every region in England, meeting of managers and clinicians towards working
front-line staff and senior leaders from the NHS together to improve the quality of care. They
in a range of care settings, as well as some saw managers working with clinicians to help
patient and partner representatives. them do what they thought was right for
patients – something that must be nurtured as
Sir Ian and Sir Bruce reported back to us at work to improve quality and meet the financial
our September meeting on the particular challenge progresses.
lessons we should draw from their tour, and
on the progress being made on the ground. We We heard how their meetings with front-line
wanted to include several of these headlines in staff and clinicians showed that the definition
our first annual report, as these have helped us of quality described in the Next Stage Review
shape our forward work programme and will – safety, effectiveness and patient experience
be informing our thinking throughout 2010. – intuitively appeals to staff in the NHS: not
only is it simple to understand when discussing
individual patient interactions, it is also enabling
“The momentum generated from the
a new and different approach to measurement
engagement process that underpinned
to better inform decision making.
the Next Stage Review has remained very
evident, with locally driven change being
Overall, they described an emerging picture
enthusiastically embraced in almost every
where quality is becoming the main focus of
part of the system. Allowing front-line
activity at every level of the NHS, and this was
clinicians and staff to set the ambitions
illustrated by some of the outstanding examples
they want to achieve for patients and to be
of good practice they had seen. However, they
fully engaged in the implementation of the
were clear that the adoption and diffusion of
changes necessary to meet those ambitions
good practice present the principle challenge
clearly has the potential to transform the
for the NHS in the future.
way the NHS works on a scale which would
previously not have been possible.”
Sir Ian Carruthers in his report to the NQB at
its September meeting
43
It is within this context that we highlight • Strong commissioners, empowered

several characteristics that Sir Ian and by data, leading the way – world-class
Sir Bruce found: commissioning was taking place where there
was a relentless focus on patient pathways,
• Strong local leadership – leadership is the
clear expectations around delivery that were
linchpin for successful improvement in quality.
data-driven, and mature relationships at a
Creating the conditions where managers and
leadership level within a health and social
clinicians from within organisations and across
care community. However, this was not the
different organisations are given the tools and
norm, and commissioners need to look across
the empowerment to work closely together
the NHS for support in developing better
around the patient pathway is central to
commissioning strategies.
improving quality. Successful examples of high
quality services that they saw had, without
These characteristics should act as a challenge
exception, been led jointly by clinicians,
to us as the NQB in leading for quality
managers and support staff.
and as signposts for NHS organisations in
• A strong, data-driven evidence base – terms of what needs to be in place to really
there is an increasing understanding that deliver quality, within a constrained financial
effective measurement of improvement, as environment in 2010 and beyond.
well as outcomes, patient experience and
productivity, is what provides the ultimate Conclusion
case for locally driven change. Where quality
had demonstrably been improved, it was We exist as a Board to provide strategic
often because it was against a reliable oversight and leadership for quality. Over the
evidence base with a clear methodology. past year, we have worked to try to improve
quality in the NHS, as this report shows.
• A systematic understanding of the
patient experience and patient views –
The financial context of our work has changed,
those teams that were pushing ahead with
yet our aim has not, and will not. In fact, the
quality improvements had often devised new
challenge of how to improve quality and increase
ways of understanding, in real time, how
productivity does not represent a change in
their patients felt about a range of indicators
direction; rather, it makes the drive for quality
relating to their care.
and the NQB’s role even more important.
• Innovative ways of working – there were
very localised examples of truly innovative The policies we have overseen have been
work leading change right across the system. mindful of the need to increase productivity.
However, these were not widespread. For example, when we make prioritisation
There was a need and a desire for greater decisions, we have decided to consider a range
systemisation of innovation and there is of data relating to cost and the potential to
a strong case for a more central focus on reduce costs. We have advised that NICE quality
improvement. standards need to be financially achievable,
defining high quality, cost-effective care that
can be implemented within tighter budgets.
44
For 2010, the challenge of improving quality

and productivity will underpin everything we
do. Our forward work programme has been
planned on this basis, and includes work such
as supporting provider boards in making what
will be extremely difficult decisions in relation to
delivering efficiencies while maintaining quality.
We are pleased with the progress made

in 2009, yet recognise that 2010 will be a
challenging year. We welcome your views
on the NQB’s achievements over the past
year and encourage you to email us at
nationalqualityboard@dh.gsi.gov.uk.
We commend this report to the Secretary of

State for Health and to the NHS.
45
Annex 1
Summary of OECD Health at a Glance
�
2009 Quality of Care Indicators
The table below summarises how the UK performed against the Quality of Care
Indicators included in the Organisation for Economic Co-operation and Development (OECD)
Health at a Glance report 2009.
Indicator UK position
At or Better Worse At or
near the than than near the
best18 average average worst19
CArE FOr CHrONIC CONDITIONS
Avoidable admissions: respiratory diseases
Asthma admission rates, population aged 15 and over,
4
2007
Chronic obstructive pulmonary disease (COPD) 4
admission rates, population aged 15 and over, 2007
Avoidable admissions: diabetes complications
Diabetes lower extremity amputation rates, population
4
aged 15 and over, 2007
Diabetes acute complications admission rates,
4
population aged 15 and over, 2007
Avoidable admissions: congestive heart failure (CHF), hypertension
CHF admission rates, population aged 15 and over, 2007 4
Hypertension admission rates, population aged 15 and
4
over, 2007
ACUTE CArE FOr CHrONIC CONDITIONS
In-hospital mortality following acute myocardial infarction (AMI)
In-hospital case fatality rates within 30 days after
4
admission for AMI, 2007
In-hospital mortality following stroke
4
admission for ischemic stroke, 2007
4
admission for hemorrhagic stroke, 2007
18
In the ‘best’ three countries.
19
In the ‘worst’ three countries.
46
Indicator UK position
At or Better Worse At or
near the than than near the
best18 average average worst19
CArE FOr MENTAl DISOrDErS
Unplanned hospital re-admissions for mental disorders (AMI)
Unplanned schizophrenia re-admissions to the same
4
hospital, 2007
Unplanned bipolar disorder re-admissions to the same
4
hospital, 2007
CANCEr CArE
Screening, survival and mortality for cervical cancer
Cervical cancer screening, percentage of women
4
screened aged 20–69, 2000–06 (or nearest year)
Cervical cancer five-year relative survival rate, 1997–
4
2002 and 2002–07 (or nearest period)
Cervical cancer mortality, females, 1995–2005 (or
4
nearest year)
Screening, survival and mortality for breast cancer
Mammography screening, percentage of women aged
50–69 screened, 2000–06 4
(or nearest year available)
Breast cancer five-year relative survival rate, 1997–
4
2002 and 2002–07 (or nearest year available)
Breast cancer mortality, females, 1995–2005 (or
4
nearest year available)
Survival and mortality for colorectal cancer
Colorectal cancer, five-year relative survival rate, total
4
and male/female, latest period
Colorectal cancer mortality, 1995–2005 (or nearest year) 4
CArE FOr COMMUNICABlE DISEASES
Childhood vaccination programmes
Vaccination rates for pertussis, children aged 2, 2007
4
(or latest year available)
Vaccination rates for measles, children aged 2, 2007
4
(or latest year available)
Influenza vaccination for elderly people
Influenza vaccination coverage, population aged 65 and
4
over, 2007 (or latest year available)
47
The Quality of Care Indicators in the OECD’s The UK is above the OECD average for COPD
Health at a Glance 2009 report provide the best admission rates, with 236 per 100,000
available international comparisons on quality population in 2007 compared with an OECD
of care. However, as with all comparisons of average of 201 per 100,000. The performance
this kind, the UK positions presented in this of other countries ranged from 384 (Ireland) to
table should be seen as raising questions about 33 (Japan) admissions per 100,000 population.
the quality of care in different countries rather
than providing definitive answers or normative Diabetes
judgements.
Health at a Glance presents figures for
A more detailed commentary on the OECD’s avoidable hospital admission rates for diabetes
results for each of the indicators is included below. acute complications and lower extremity
amputation, defined as the number of hospital
Asthma and chronic obstructive admissions of people aged 15 years and over
pulmonary disease (COPD) per 100,000 population. Admissions for acute
diabetic complications and lower extremity
Health at a Glance presents figures for amputations are considered to be suitable
avoidable asthma and COPD admission rates, quality measures for the quality of diabetes
defined as the number of hospital admissions treatment in primary care as these can be
of people aged 15 years and over per 100,000 effectively avoided with appropriate diet,
population. Treatment for asthma with anti- exercise and drug treatment.
inflammatory agents and bronchodilators
in the primary care setting is largely able to The data indicates that the UK performs well
prevent exacerbations and, when they do on lower extremity amputation rates with
occur, most exacerbations can be handled 9 admissions per 100,000 population in 2007
without any need for hospitalisation, hence compared with an OECD average of 15.
high hospital admission rates are an indication The performance of other countries ranged
of possible poor quality of care. As much of from 36 (USA) to 7 (Austria) admissions per
the responsibility for managing COPD lies with 100,000 population.
primary care providers, hospital admission rates
are a measure of the quality of primary care. The data indicates that the UK performs poorly
on diabetes acute complications rates with
The data indicates that the UK performs poorly 32 admissions per 100,000 of population in
on asthma hospital admission rates with 2007 compared with an OECD average of 21.
75 admissions per 100,000 of population in The performance of other countries ranged
2007 compared with an OECD average of from 57 (USA) to 1 (New Zealand) admissions
51 per 100,000. The performance of other per 100,000 population.
countries ranged from 120 (USA) to 17 (Italy)
admissions per 100,000 population.
48
Congestive heart failure (CHF) track patients in and out of hospital, across
and hypertension hospitals or even within the same hospital
because they do not currently have the use of a
Health at a Glance presents figures for unique patient identifier. Therefore, this indicator
avoidable CHF admission rates and avoidable is based on unique hospital admissions and
hypertension admission rates. Admissions with restricted to mortality within the same hospital.
a primary diagnosis of hypertension typically Thus, differences in practices in admitting,
indicate hypertensive crises, characterised by discharging and transferring patients may
very high blood pressure and with high risk of influence the findings. In particular, countries
acute complications such as heart failure or with a good ambulance service may increase
hemorrhagic stroke. As such, exacerbations can the in-hospital mortality rate as more patients
usually be controlled with proper outpatient reach the hospital alive, but cannot ultimately
treatment; hospital admissions are avoidable and be stabilised and die soon after admission.
are an indicator for the quality of primary care.
The UK reported an age–sex standardised
The data indicates that the UK performs very in-hospital 30-day mortality rate for AMI of
well on CHF with 117 admissions per 100,000 6.3% in 2007, higher than the OECD average
population in 2007 compared with an OECD of 4.9%. The standardised rates ranged from
average of 234. The performance of other 8.1% (Korea) to 2.1% (Iceland).
countries ranged from 474 (Poland) to 110
(Korea) admissions per 100,000 population. It should be noted that the standardisation
Only Korea reports a standardised rate better method chosen has a large impact on the
than the UK. figures for all countries. The figures are a good
relative measure and are useful for making
The UK reports the best performance of the comparisons between countries; however, they
countries that reported results on hypertension are not a good measure of the actual mortality
with 11 admissions per 100,000 of population within each country. The standardised figures
in 2007 compared with an OECD average should not be quoted as mortality rates, but
of 84. The highest reported admission rate used only for comparisons.
was 396 admissions per 100,000 population
in Austria. Stroke
Acute myocardial infarction (AMI) Health at a Glance presents figures for the
in-hospital case fatality rate within 30 days after
Health at a Glance presents figures for the in- admission for ischemic stroke and hemorrhagic
hospital case fatality rate within 30 days after stroke. The in-hospital case fatality rate
admission for acute myocardial infarction. following ischemic and hemorrhagic stroke
The in-hospital case fatality rate following is defined as the number of people who die
acute AMI is defined as the number of people within 30 days of being admitted to hospital.
who die within 30 days of being admitted Ideally, these rates would be based on each
to hospital with an AMI. Ideally, these rates individual patient being tracked after admission.
would be based on each individual patient However, not all countries have the ability to
tracked through the system after admission. track patients in and out of hospital, across
However, not all countries have the ability to hospitals or even within the same hospital
49
because they do not currently have the use It should also be noted that the figures
of a unique patient identifier. Therefore, this presented in this report are for 2007, before the
indicator is based on unique hospital admissions national stroke strategy began implementation.
and restricted to mortality within the same One of the drivers for developing the strategy
hospital. Thus, differences in practices in was to address the fact that England is
admitting, discharging and transferring patients experiencing significantly worse outcomes than
may influence the findings. In particular, other countries.
countries with a good ambulance service may
increase the in-hospital mortality rate as more Mental health
patients reach the hospital alive, but cannot
ultimately be stabilised and die soon after Health at a Glance presents figures for
admission. unplanned schizophrenia and bipolar disorder
re-admissions to the same hospital. The
The UK reported a standardised in-hospital indicator is defined as the number of unplanned
30-day mortality rate for ischemic stroke of re-admissions per 100 patients with a diagnosis
9.0% in 2007; this is the highest rate of all the of schizophrenia or bipolar disorder per year. A
countries that submitted valid figures to the re-admission is considered unplanned when the
report. The OECD average is 5.0%. patient is admitted for any mental disorder to
the same hospital within 30 days of discharge.
The UK reported a standardised in-hospital Same-day admissions (less than 24 hours) are
30-day mortality rate for hemorrhagic stroke of excluded. Unplanned hospital re-admission
26.3% in 2007; this is much higher than the rates are commonly used as an indicator for
OECD average of 19.8%. insufficient care co-ordination following an
inpatient stay for psychiatric disorders. 30-day
It should be noted that the standardisation hospital re-admission rates are part of mental
method chosen has a large impact on the health performance monitoring systems in
figures for all countries. The figures are a good many countries, such as the Care Quality
relative measure and are useful for making Commission in the UK, the Canadian mental
comparisons between countries; however, they health annual report, and the Joint Commission
are not a good measure of the actual mortality and the National Mental Health Performance
within each country. The standardised figures Monitoring System in the United States.
should not be quoted as mortality rates, but
used only for comparisons. The data indicates that the UK performs very
well on schizophrenia, with readmission rates
Compared with the figures presented in of 8.5% in 2007, compared with an OECD
the previous report (published in 2007), average of 18.1%. The performance of other
these figures appear to show that the UK’s countries ranged from 31.9% (Finland) to 6.3%
performance on stroke has fallen dramatically (Slovak Republic).
compared with the rest of the OECD. However,
the figures in the 2007 report were incorrect The data indicates that the UK performs very
and should not be taken as a valid assessment well on bipolar disorder, with readmission rates
of the UK’s performance. of 6.7% in 2007, compared with an OECD
average of 16.8%. The performance of other
countries ranged from 33.9% (Finland) to 6.2%
(Slovak Republic).
50
Cancer that the lesions that do progress into invasive

cancer are, on average, at a more advanced
Health at a Glance presents figures for cervical, stage. Effective cervical screening therefore not
breast and colorectal cancer. For cervical and only reduces the incidence of invasive cancer
breast cancer, figures on screening, five-year (detection and complete removal of pre-invasive
survival and mortality are presented. For disease), but also leads to a reduction in the
colorectal cancer, figures on five-year survival reported survival rate because the invasive
and mortality are presented. cancers that do escape screening tend to be the
more rapidly growing ones. The cervical cancer
The survival rates state the first year of screening programme was reactivated in 1988.
diagnosis and the last year of follow-up
included in five-year survival figures (e.g. Breast cancer
1997–2002). The UK data are for patients
diagnosed during 1996-99 and followed up to The UK has an above average breast cancer
2002 (labelled ‘1997–2002’), and for patients screening rate of 70.7%, compared with an
diagnosed during 2000–02 and followed up OECD average of 62.2%. Five-year survival is
to 2007 (‘2002–07’). The period of incidence just below average at 78.5%, compared with
used varies by country and this may affect the an OECD average of 81.2%. The mortality rate
comparability of the survival estimates. of 25.8 per 100,000 females in 2005 is high
compared with an OECD average of 20.8.
Cervical cancer
Screening uptake in the UK is high. Some of
The UK has a high cervical cancer screening rate the OECD countries do not have mass screening
of 79.4%, compared with an OECD average programmes and the data are based on survey
of 64.0%. Five-year survival is low, at 59.4%, returns. Five-year survival (for women of all
compared with an OECD average of 65.7%. ages combined) in the UK is somewhat lower
The mortality rate of 2.4 per 100,000 females is than the OECD average. The OECD average
low compared with an OECD average of 3.0. is somewhat lower than it would otherwise
have been, however, because recent survival
Cervical cancer survival rates in the UK are fairly data were not available for France or Japan;
stable and among the lowest among OECD both countries report higher survival than in
countries for which data are reported. Incidence the UK. Estimated annual incidence in the UK
rates of invasive cervical cancer declined by in 2002 was 87.2 per 100,000, similar to that
50% between 1990 and 2002 – from 15.7 per in Sweden (87.8) and higher than in Ireland
100,000 in 1990 to 10.3 in 1996 and 8.4 in (74.9) (world standardised rates). UK breast
2002 (European age standardisation). Mortality cancer mortality in 2005 was higher than in
rates have also dropped sharply since the late Sweden (20.3) and lower than in Ireland (28.4).
1980s, and were well below the OECD average The patterns of survival and mortality between
for 2005 (2.4 per 10,000 compared with 3.0). Sweden, Ireland and the UK are coherent –
This pattern is likely to be due to improved survival is slightly higher and mortality slightly
screening, with the removal of both pre-invasive lower in the UK than in Ireland. By contrast,
disease (more than 80% of cervical cancers incidence is similar in the UK and Sweden,
are now detected at this stage) and the more but survival is lower and mortality higher in
slow-growing invasive cancers. This means the UK than in Sweden. Survival in the UK has
51
nevertheless improved rapidly and mortality The UK reported pertussis vaccination rates
rates have declined steadily and substantially close to the OECD average, with 94.0% of
since the early 1990s, even though incidence children aged 2 being vaccinated, compared
rates have increased over the same period. with an OECD average of 93.5%. The
performance of other countries ranged from
Colorectal cancer 99.9% (Hungary) to 75.0% (Denmark).
The UK has a below average five-year survival The UK reported low measles vaccination rates,
rate for colorectal cancer of 51.6%, compared with 86.2% of children aged 2 being vaccinated,
with an OECD average of 57.3%. The mortality compared with an OECD average of 92.2%.
rate of 17.6 per 100,000 of population is below The performance of other countries ranged
the OECD average of 19.0 in 2005. from 99.9% (Hungary) to 79.0% (Austria).
Five-year survival for patients diagnosed with The UK did not provide figures on vaccination
colorectal cancer in the UK during 2000–02 and for hepatitis B; however, the incidence of
followed up to 2007 was 2.8% higher than for hepatitis in the general population was lower
patients diagnosed in 1996–99. The distribution than average, with 2.3 new cases per 100,000
of mortality in OECD countries does not of population, compared with an OECD
always reflect the distribution of incidence (not average of 2.5 in 2007. The performance of
included in the OECD report) and survival. Thus, other countries ranged from 10.6 (Iceland) to
survival is higher than the OECD average in the 0.1 (Japan) cases per 100,000 population.
Netherlands and New Zealand, even though
mortality is above the OECD average, whereas The UK reported very high influenza vaccination
both mortality and survival in the UK are below rates, with 73.5% of those aged 65 and over
the OECD average. These patterns are difficult being vaccinated compared with an OECD
to interpret because not all the countries are average of 55.9%. The performance of other
included in both series (12 for survival; 29 for countries ranged from 77.5% in Australia, to
mortality). The increase in survival in the UK 23.7% in the Czech Republic.
is nevertheless consistent with the declining
mortality, a pattern seen in most countries.
Vaccination rates
Health at a Glance presents figures for

vaccination rates for pertussis and measles.
The report presents figures on hepatitis B in
children aged two, as well as incidence of
hepatitis B in the total population. The UK did
not provide figures on hepatitis B vaccination,
but did provide incidence figures. The influenza
vaccination rate is reported for the population
aged 65 and over.
52
Annex 2
Expert Advisory Group on International
Healthcare Quality Comparisons
Mike Farrar (Chairman) – Chief Executive of Veena raleigh – Reader in Epidemiology and
NHS North West Public Health, University of Surrey
Professor the lord Darzi of Denham – robin Osborn – Vice President and Director
Former Parliamentary Under Secretary of State of The Commonwealth Fund’s International
Program in Health Policy and Practice
David Nicholson – NHS Chief Executive
Elizabeth McGlynn – Associate Director of
Bruce Keogh – NHS Medical Director RAND Health and Distinguished Chair in Health
Care Quality
Sheila leatherman – Research Professor at
the School of Public Health, University of North Susan law – Health services researcher and
Carolina and Visiting Professor at the London manager, Canada
School of Economics
Jeremy Veillard – Regional Adviser for Health
Martin McKee – Professor of European Policy and Equity for WHO Regional Office
Public Health, London School of Hygiene and for Europe
Tropical Medicine
Niek Klazinga – Project Leader of OECD’s
Peter Smith – Professor of Economics and Health Care Quality Indicator Programme and
Director of the Centre for Health Economics, Professor of Social Medicine, Academic Medical
University of York Centre/University of Amsterdam
Nick Black – Professor of Health Services Jan Mainz – Chairman of the Nordic Minister
Research, London School of Hygiene and Council Indicator Project and the Danish
Tropical Medicine representative at the OECD Health Care Quality
Indicator Project
John Appleby – Chief Economist at The King’s
Fund and Visiting Professor at the Department
of Economics at City University
53
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Annual Report

quality has meant different things to

Through Lord Darzi’s Next Stage Review,

The review has also given us a definition

The NQB provides us with the opportunity to Generating meaningful international

it clear that the whole system should share

High Quality Care for All set out a vision for an

The members 2009

NHS Medical Director Chair of NICE

Chief Nursing Officer Executive Chair of Monitor

Chief Medical Officer Chair of the National

Sir John Oldham

Professor Hilary Scholefield

Don Brereton, Chair, Carers UK

A unique body, a unique opportunity • advising the Secretary of State on clinical

About this first annual report

This first report combines a description of our

This first chapterhas described how the NQB

The next three chapters focus on how we have

Chapter 5then looks at how and what we

Chapter 6concludes by setting out some of

the previous Secretary of State for Health into

Building on this work, in 2010 we plan to take

Our terms of reference were: Review of Early Warning Systems

potentially serious failings in patient care

ensuring that patients receive high quality

System Alignment Sub-group System Alignment Sub-group

External members NQB members (or representatives)

Developing a quality information Quality Information Strategy Sub-group

Supporting provider boards in their organisations. As part of this, the work

We therefore plan to take forward a piece of

To determine future priorities for quality

The methodology we have developed will

The prioritisation methodology

Our starting point for this piece of work was

Our recommendation, which the Secretary of

• the largest improvements will have to be made

The new MRSA Objective was published in the

Bringing clarity to quality – NICE

To address this confusion and bring greater

We have been involved in the development of We are committed to providing transparent

Measuring for Quality Improvement Indicators for Quality Improvement

To support the development of IQI we asked

It will ensure that key indicator gaps are

keY DeVeLoPMentS the quality of local

Quality Accounts advised the Department of Health to build

Clinical Excellence Awards NQB’s advice to the ACCEA on

regulatory framework. Whereas, from April

2010, the Care Quality Commission will

coherent or comprehensive approach to commitment to quality improvement;

We recognised that our unique composition quality assurance;

We see accreditation schemes as very

The practical implications of the core model are

for quality improvement

the last year to move the NHS towards this

Our commitment to learning from the best is

Like any quality improvement tool, international

As such, and following the advice of international

How does the UK compare with In­hospital case fatality rates within

The OECD publishes a biennial report, Health United Kingdom 9.0

publish overall rankings of systems, but focuses Luxembourg (2006)

The Quality of Care Indicators in the Health at Germany 3.8

How does the UK compare with Inhospital case fatality rates within

Full analysis of the UK’s performance can be Inhospital case fatality rates within