Measuring the quality of healthcare: Q+A with Iona Heath

Following the launch of a new series, ‘The Many Meanings of ‘Quality’ in Healthcare: Interdisciplinary Perspectives’, I asked Iona Heath, a contributing author, for her views on quality of healthcare, the current challenges we are facing in this area, and what changes need to be made to overcome them.

How do you think this collection of papers and the conference on which it was based contributes to current debates around the ‘quality’ of healthcare?

Above all the collection shows the breadth and complexity of notions of quality in healthcare. In addition it demonstrates the extent to which individual professional aspirations to provide good quality care can be distorted and even undermined by the imposition of excessively simplistic ‘quality’ measures.

How does quality in social care impact quality in healthcare and vice versa?

Healthcare and social care are inevitably interdependent because of the extent to which social context determines health status, and because of the potential for illness and disease to impair social functioning.

In this way, for example, providing high quality healthcare to people and families who are homeless will always be challenging. It is not possible to be healthy if one is obliged to live on the street or in inadequate or squalid conditions.

In the field of general practice, what are the key challenges that arise in trying to maintain high standards of quality care in day-to-day practice?

Here the most important constraint consists in the limitations of time and the pressure of patient numbers. Government and policy-makers are demanding that the population is subjected to ever greater levels of surveillance in relation to perceived risks to individual health. This means that many more people who feel perfectly well are seeking appointments, and every new policy initiative has opportunity costs in terms of the time available in general practice.

Time spent pursuing the well is time taken away from the already sick and suffering. This would be acceptable, perhaps, if preventive interventions produced large benefits and minimal harms but we have increasing evidence that the opposite is the case.

And again in general practice, what are the challenges in accurately measuring standards of quality in a meaningful way?

From my perspective (now increasingly as a patient) the key determinants of quality of care in general practice are the capacity and commitment of the doctor to listen carefully to the patient and to think deeply about their predicament and the extent to which it might be helped or harmed by biomedical science.

We have no ways of measuring the quality of listening and thinking and we would probably make matters even worse if we tried to develop them.

How have you seen the quality of care for patients change during your career? What has driven these changes?

High quality care will never be secured by ticking boxes.

I fear that, while some of the worst care has disappeared, the very best has also been constrained. Notions of quality have shifted from the broadly descriptive to the narrowly mathematical.

The ease with which computers enable us to collect quantitative data, has meant that the measurable has been rendered ever more important in the assessment of quality. This is at the expense of things that are difficult or impossible to measure, such as the moral commitment of the practitioner to the individual patient, and the depth of listening and thinking.

High quality care will never be secured by ticking boxes and eventually we will have to return to a respect for the virtue ethics of professionalism and a much broader descriptive understanding of quality in healthcare.

With growing demands across the NHS, what changes do you think need to be implemented to ensure quality of care is maintained?

To quote the Dutch philosopher Annemarie Mol:

“Instead of either pushing professionals back into their cage, or allowing them to do whatever they like, it is better to open up and share the crucial substantive questions publicly. How to live well, what to die from, and how, thus, to shape good care?”

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