Welcoming NHS Improvement

The status quo of NHS  data collection could be described as “Collect it all yourself; trust no-one else”. This is clearly unsustainable: care.data may have been the straw that almost broke the camel’s back; the Prime Minister’s Challenge Fund just tossed some steel girders on top. Poor camel.

With the merger of the NHS Trust Development Authority (TDA) and Monitor under a new name, “NHS Improvement”, there may be an opportunity to begin to address some serious data shortcomings – and some persistent category errors. Monitor was supposed to act as a Government “stick”; the TDA was supposed to be an NHS “carrot” – but, as with so many bureaucracies, the left hand seemed not to know what the right hand was doing, so the stick ruled and very little productive got done.

From documents medConfidential has seen, Monitor’s approach to data seems to have adopted care.data as a handbook, rather than recognising the scheme for the “fiasco” it has so clearly become. Problems that emerged with the “pioneer” in Southend could have been as much down to flawed advice propagated by Monitor as it was the result of NHS England’s inadequate and inaccurate guidance.

We had expected the Government to have responded to its “Accredited Safe Havens” consultation from last summer by now. That it hasn’t speaks volumes. That some of the “pioneers” and “vanguards” reflect a backward-looking data worldview still prevalent in parts of DH gives cause for concern. It’s clearly not just care.data that’s infecting the thinking, and in real danger of further damaging patient – and professional – trust.

In the forthcoming consultation on the powers and remit of the National Data Guardian, we hope the Department gathers views on NDG having to be consulted on every use of NHS England’s and other statutory bodies’ powers to require data. While NHS Improvement should certainly not be given powers to require data (HSCIC doesn’t have such powers either), it could be a place where conversations can be had between the various stakeholders – care providers, commissioners and the Department of Health – about the statistics required to firstly measure, and then “improve” a particular area.

This should not be about measuring only what it is you want to manage, but be about measuring the things that matter. Not least because, as has been repeatedly been shown, simple measures can lead to detrimental care when ‘gamed’ by those in the system.

Learning the lessons of care.data – though some are still lagging behind – such datasets must always and exclusively be aggregated datasets; published statistics where not only the figures but the methodology are published for all to read. (Some datasets where the detail contains small numbers may need to remain unpublished, available only in a tightly-controlled safe setting.) The public must be able to see, and debate, the specification of any dataset that will be used for strategic decision making.

While the research process involved in the design and testing of these datasets may need access to consented individual-level data, such as should be possible with data in the new Secure Data Facility, the use of aggregated counts as the basis for decisions, rather than individual-level detail would remove many of the problems NHS England still claims will befall GP practices where 12% or more of the patients have already opted out of its ill-conceived, zombie data grab.

NHS Improvement could be a good place for these conversations to take place, if it steps up several gears. NHS England could even have a seat at the table – so long as NHS Improvement convenes and manages the process of defining these new aggregated measurement datasets, of which, given the dearth of them, there will probably need to be a fair few.

The process could be designed to ensure that care providers can have measures they feel accurately reflect good care, NHS England gets the evidence base it needs to justify decisions, and HSCIC can focus on the vital implementation issues – such as feasibility, assurance and process.

Preventing a repeat of the Prime Minister’s Challenge Fund debacle would appear to require such a venue; NHS England has proved itself institutionally incapable of being a trusted broker, and HSCIC has other roles. A correctly constituted NHS Improvement, appropriately staffed and resourced, could provide a venue to help ensure the outcome: “High quality care for all, now and for future generations”.

It could also help with another problem

In much the same way as the DWP requires health assessments by its own staff, rather than trusting the assessments of NHS care providers, and the way HMRC trusts nothing it didn’t confirm itself, an underlying cause of many problems in the NHS is quite easy to define: NHS bodies simply don’t trust other NHS bodies.

This is why bean counters in a CCG want detailed medical records of all “high cost” patients. Or indeed believe, in spite of Caldicott2, they should have access to individual-level medical records.

Multiple interlocking but discrete datasets, properly designed and produced as above, can show up the various “tricks” that get used to move people out of one column into another – “massaging” the figures – a practice that certainly should be measured. And acted upon by someone independent.

If an NHS organisation believes statistics being provided are fraudulent, then that’s a question for NHS Protect, rather than CCGs thinking they can investigate themselves. Integrity on process can be provided by HSCIC working on collation and process (SUS and GPES already do this for hospitals and GPs).

For NHS Improvement, ask the patients?

Though it has positive potential, NHS Improvement also has the potential to become yet another arcane and somewhat obscure NHS body. Yet one of the groups who understand a great deal about what might provide disproportionate improvements within the NHS are that chronically underrepresented group who use it every day; patients.

While NHS England continues to have its own political priorities and funding considerations, when HSCIC is telling patients what did actually happen to their data, patients can (also) feed back to NHS Improvement what they believe should have happened – a genuine partnership in improvement.