The day before I had been reading about quality measures – “Metrics for quality must be acceptable to clinicians, collectable from management systems and understandable by the public. A simple triad that’s hard to reconcile” was the conclusion of Sir Liam Donaldson and Lord Darzi in their viewpoint article about quality measures comparing the US healthcare system to the NHS as it undergoes fundamental redesign to its structures and accountability mechanisms. Well, far be it from me to take issue with my esteemed erstwhile colleagues at the Department of Health but these diabetic kidney disease quality measures are I think clinically credible, have been pulled from routine management systems and make sense to our public and patients – perhaps one of the exceptions that proves the rule.
Our former Chief Medical Officer and Minister of State for Health argued that no matter how often the language of quality and safety is spoken by those running the system, the true lingua franca of healthcare in the United Kingdom is financial. They point to a perceived fundamental difference in the values of clinicians and patients on the one side and healthcare planners on the other. Often the absence of powerful data on quality of care, data that is universally believed and trusted further deepens this rife between managerial and clinical cultures. Donaldson and Darzi argue cogently for a clinical culture of valuing collecting and working with quality data as a credible scientific endeavour on a par with clinical and molecular research in everyway. Well the future is here, but unevenly distributed!!!
If we are going to live up the rhetoric of “quality is the only organising principal of the NHS” as a credible scientific endeavour, we need to embrace clinical audit and quality improvement as a core component of good clinical practice. Rather than an activity that is tolerated because, management requires it. We have the audit data now we need the quality improvement. Renal replacement therapy is more common that retinopathy or amputation (major or minor ) and CKD is by far and away the most frequent and worrying vascular complication of diabetes affecting 20 times more people than those that have ischaemic heart disease. However, the point is not kidney disease is numerically larger than all the other complications put together rather it is these complications occur together – they are the same disease process - blood vessel injury and most importantly of all CKD is an early marker that we can both prevent and treat. The revised general practice contract with the addition of local quality improvement focused on particular disease pathways commissioned by the NHS commissioning board through the Quality and Outcomes Framework provides a systematic mechanism for getting this right and avoiding these unnecessary heart breaking kidney complications of diabetes. We should not go on missing these opportunities.
These qualities metric make sense to clinicians, patients and careers, managers and trust boards. It is time for action.