The social context
There is increasing demand for healthcare and people want more involvement and choice in their care. This is driven by an ageing population, more long term illness, higher levels of multimorbidity and consumerism.
- One in six people today are aged 65 years or over and by 2020 this will reach one in four of the population. On average, people in this age group consume five times the national average of health resources. At an individual level, care at the end of life constitutes about three-quarters of all healthcare consumed over a lifespan.
- Long term conditions are major causes of disability and death, and those people affected consume the majority of healthcare resources in developed countries. This is compounded by multimorbidity which is evident even in younger age groups but increases with age.
- At the same time, people want more choice and greater control of health services, rightly as they are paying for them.
The political context
- Much of the political momentum for change over the last 20 years has derived from well-publicised health scandals. In the UK, Bristol, Alder Hey, Shipman, Mid Staffordshire, are names are engraved on the collective consciousness of the public and professionals alike. Each in turn was followed by major inquiries. The Kennedy report examined the events surrounding the death of over 30 babies after paediatric heart surgery at the Bristol Royal Infirmary. Its recommendations drove major changes in the way medical practice is overseen (Kennedy 2001).
- The term ‘clinical governance’ was used to denote a range of activities required to improve the quality of health services together with accountability for their delivery. Central among these were the need for all NHS organisations to develop processes for continuously monitoring and improving quality and to develop systems of accountability to ensure these were in place. Components of clinical governance include evidence-based practice, clinical audit, risk management, mechanisms to monitor the outcomes of care, lifelong learning, and systems for managing poor performance. In addition, the term combines an emphasis on improving care for individual patients with QI targeted at whole populations.
The scientific context
- Medical scientific knowledge and the evidence for what works, its costs and safety are increasing at an exponential rate. Our ability to deliver safe, effective healthcare is struggling to keep up with the rapid advances in science and medical treatments.
- Practitioners have to rely on the translation of evidence to systematic reviews and guidance rather than necessarily having time to access primary sources of research. Archie Cochrane, who first extolled the importance of the randomised controlled trial, is often regarded as the father of evidence-based healthcare and the Cochrane Centre, now coordinates the production and publication of high-quality systematic reviews.
- The translation of guidance into routine practice is one of the greatest challenges for healthcare – the so-called ‘second translation gap’. QI provides a means to bridge this gap and so the science of QI is now as essential to good practice as the anatomy, biochemistry and physiology that doctors and other health workers learn in their undergraduate training.