The UK has become a world leader in pessimism about the future quality of its health care. A 2016 Ipsos MORI poll of 18,000 people in 23 countries found that British people were the least optimistic when asked about the quality of health care that they or their family would have access to over the next few years. Only 8% of people in the UK thought it would get better; 47% thought it would get worse, making people in the UK more pessimistic than those in 22 other countries, including Spain, Italy, France and Germany.

This worry is understandable. Public perceptions are likely to have been shaped by the intense media coverage of the human and financial pressures on the NHS in recent months and years. Paradoxically, a large majority of patients using care tend to be very satisfied, so how justified is this anxiety about the quality of NHS care in the future?

To help inform the debate ahead of the June 2017 general election, the Health Foundation is publishing three briefings on NHS and social care finances, the quality of care provided by the NHS, and the NHS and social care workforce. In the first briefing, we showed that funding in England since 2010 has not risen as quickly as the pressures on the NHS, which have been caused by having to meet the health care needs of a growing population, and the rising costs of staff, drugs and other essentials.

So what has happened to the quality of services over this period? Has it started to falter under the weight of the gap between static funding and rising pressures? In this second briefing, we give a very high level snapshot of how the quality of some NHS services has changed over the past few years in England.

This briefing examines some aspects of the quality of care for a small selection of major conditions where we could find enough reliable data to tell the story of change over time. It is largely limited to England but includes UK comparisons with the performance of health systems in other countries. Where possible, we have used metrics from national clinical audits, themselves based on guidance by the National Institute for Health and Care Excellence (NICE), together with international comparisons published by the OECD.

The four aspects of quality covered in this briefing are all either leading causes of ill health or high profile dimensions of NHS performance.

• Waiting times for hospital treatment: we have included urgent and emergency care, and other more routine hospital treatment and procedures.
• Care for patients with diabetes: this is a complex lifelong condition that can cause a range of complications and is estimated to affect around 3.8 million people over 16 years of age in England.
• Psychological therapy for common mental health conditions: we have included data on access to evidence-based psychological therapies for conditions such as depression and anxiety, which affect around 6.1 million people in England at any one time.
• Speed and use of the most effective best-practice treatments: we have looked at indicators for two cardiovascular diseases and two common cancers. In 2015/16, around 194,000 hospital visits were caused by heart attacks in the UK and around 240,000 visits were caused by stroke. 46,083 new diagnoses of breast cancer and 34,729 new diagnoses of bowel cancer were registered in England in 2015 which, together with prostate and lung cancer, accounted for just over half of all new cancers diagnosed in 2015.

The data on waiting times tell a clear story of rising pressure: NHS staff have worked hard to treat more patients within target times, but demand has grown more quickly than supply and hospitals have struggled to meet their targets. Although there are limited data on waiting times beyond the ambulance service and acute hospitals, the situation is equally challenging elsewhere in the health system. General practice is under increasing pressure linked to increased workload, for example, and more patients report difficulty making an appointment.

But what happens once patients are through the door of a service, with a diagnosis of a particular condition? This and the next section look at six leading causes of ill health in England where we could find data that allow for comparison across time. We cover longer term illnesses primarily managed through general practice and other NHS services based in the community (diabetes and common mental health conditions), and sudden or life-threatening illnesses that need high quality care from the ambulance service and acute hospitals (stroke, heart attack, and breast and bowel cancer).

Care for patients with diabetes

NICE recommends eight care processes for people living with diabetes, including tests for blood pressure, cholesterol, blood sugar and kidney function. The NHS has made substantial improvements in diabetes care, but still has a long way to go: only 36.7% of patients received all of the recommended care processes in 2007 compared with 52.6% in 2016. This represents a reduction from 60.6% in 2010, although participation in the National Diabetes Audit, which measures the effectiveness of diabetes care against NICE guidelines in England and Wales, has increased and the total number of patients who received all care processes in 2016 was nearly as high as it was in 2010.

The NHS has also made progress in achieving all three NICE-recommended treatment goals for people with diabetes – controlling blood sugar levels, and reducing blood pressure and cholesterol – to avoid complications such as heart attack, kidney failure and damage to eyesight. In 2016, all three goals were met for 18.1% of people with type 1 diabetes (up from 16.5% in 2011). 40.2% of people with type 2 diabetes met the treatment goals (up from 35.1% in 2011) in 2016, but this was a reduction from a peak of 41.4% in 2014. The greatest improvement has been observed in achieving the blood pressure goal, but progress has leveled off since 2014.

A 2014 study comparing 30 European countries ranked the UK fourth for the quality of diabetes care, behind only Sweden, the Netherlands and Denmark. Figure 6 also shows that the UK was better than the average for OECD countries in 2013, both in terms of hospital admissions for people with diabetes (though this may simply reflect differences in how care is delivered) and for rates of amputations due to complications.

Figure 6: Diabetes care, age-standardised rates per 100,000 population, OCED average vs UK, 2013

Source: OECD, 2015

The number of people developing type 2 diabetes has grown and the percentage of people in hospital who have diabetes increased from 15% in 2011 to 17% in 2016. Regardless of the reason for admission to hospital, people with diabetes need high levels of care. The need for more hospital staff who specialise in diabetes has consistently been highlighted as an issue for the past six years, with fewer than one in 10 patients under a diabetes consultant while in hospital and more than a quarter of sites with no diabetic specialist inpatient nurses.

Despite an increasing workload, there have still been improvements in care, but nearly two in five inpatients admitted with diabetes experienced medication errors (38% in 2016, 32.4% in 2009/10), from either an incorrect prescription or incorrect management of medicine. In 2016, around one in 25 people with type 1 diabetes developed in-hospital diabetic ketoacidosis due to under-treatment with insulin.

Psychological therapy for common mental health conditions

One in four adults in the UK experiences a mental health problem in any given year, at an estimated cost to the economy of £105 billion per year. But mental health services have often received lower funding relative to need, struggled to offer sufficient access to services and tended to focus on containment rather than recovery. Despite improvements, these issues remain – particularly for people with severe mental illness, and for children and young people with mental health conditions. (We will be publishing further analysis on mental health services separately.)

In this briefing, we focus on access to psychological therapies for people with common mental health conditions, including depression and anxiety, which affect up to 15% of the population at any one time. Medication remains an appropriate and effective option for treating these conditions: 61 million antidepressant drugs were prescribed and dispensed in England in 2015, more than double the number in 2005. But many people prefer psychological interventions and the Improving Access to Psychological Therapies (IAPT) programme, launched in 2008, aims to improve access to a range of evidence-based psychological therapies.

Figure 7: Numbers of people referred to IAPT services, finishing a course of treatment and recovery rate, 2011/12 to 2016/17

Source: NHS Digital, 2017

The NHS has consistently met its target of at least 75% of people starting psychological therapy within six weeks of referral to IAPT services, with at least 95% starting within 18 weeks. But these targets have been criticised for allowing people to wait months too long.

Figure 7 shows that the number of people being referred to IAPT services and the number of people completing treatment has increased over time. Over a million people were referred to IAPT services in the first nine months of 2016/17, an increase of nearly 400,000 from the same period five years ago. The number of people completing treatment has also increased substantially with nearly 430,000 people completing a course of therapy in the first nine months of 2016/17, almost double the number in the same period five years ago.

As well as increasing access to psychological therapies, the quality of IAPT services has also improved. The percentage of people who completed a course of treatment and were assessed as no longer being above the clinical threshold for anxiety and depression has increased over time, and early data suggest the 50% target for recovery rates was met for the first time in January 2017. There is still a long way to go: the NHS estimates that three in four people needing help get no support at all.

Stroke

Stroke – where a blockage cuts off the blood supply to the brain, or a blood vessel bursts within or on the surface of the brain – is a major cause of death and disability.

About 85% of patients leave hospital alive after a stroke, with about a third of those returning home. Close to 10% are discharged to a care home, of whom 65% are being sent to a home for the first time and about 80% are expected to become permanent residents. The proportion of people who become permanent residents in care homes is an important measure – at 7% in 2016, it has decreased from about 10–15% in 2013.

High quality care for people with stroke involves rapid diagnosis and specialist hospital treatment, as well as early assessment by therapists to provide essential care and begin rehabilitation. The Sentinel Stroke National Audit Programme grades NHS stroke services in England, Northern Ireland and Wales on how well they perform on delivering all these different aspects of care. Figure 8 shows that in England, Northern Ireland and Wales, the NHS made substantial progress in improving care from 2013 to 2016, with more clinical teams achieving a grade of ‘first-class’ or ‘good or excellent in many respects’, and a decrease in services where substantial improvement is needed.

Figure 8: Percentage of patients receiving stroke services that meet quality standards in England, Northern Ireland and Wales, July–September 2013 and August–November 2016

Source: Sentinel Stroke National Audit Programme, 2017

The latest data, from August to November 2016, suggest that 93.7% of patients who have had a stroke have a brain scan within 12 hours of arrival at hospital and 50.7% within 60 minutes. Over 88% of patients who have had a stroke and can be treated with ‘clot-busting’ drugs receive this treatment, two-thirds within one hour of arrival at hospital. 58.5% of patients are admitted to a specialist stroke unit within four hours of arrival at hospital, with over 80% seen by a stroke specialist within 24 hours.

Approximately 90% of patients see stroke specialist nurses, occupational therapists, physiotherapists and speech and language therapists within 72 hours, who provide essential care and help improve outcomes – for example, they reduce the chances of patients becoming ill with pneumonia by making early swallow assessments.

However, many patients are not receiving the amount of therapy they need – particularly speech and language therapy, which is rarely available seven days a week. Fewer than a third of patients received a six-month follow-up assessment and, in a 2016 survey by the Stroke Association, over 45% of stroke survivors reported feeling abandoned after leaving hospital.

Figure 9 shows that the UK lagged behind OECD countries for stroke mortality in 2008: 17 per 100 people died within 30 days of hospital admission for ischaemic stroke in the UK, compared with an average of 12 per 100 people in OECD countries. But advances in the treatment of stroke have led to a substantial reduction in deaths, and Figure 9 shows that the UK had made rapid improvement to virtually close the gap by 2013.

Figure 9: Mortality following admission to hospital for stroke and acute myocardial infarction, OECD average vs UK

Source: OECD, 2015

Heart attack

Heart attack, also a major cause of death, is caused by the blood supply to the heart being suddenly interrupted.

For the most serious form of heart attack, primary percutaneous coronary intervention (PCI) has been established as the best treatment to re-open blocked heart vessels that cause heart attack. In 2015, 99% of patients in England who could benefit were treated with PCI.

In 2015, 88.6% of all patients in England and Wales were treated with PCI within 90 minutes of arriving at hospital, up from 52% in 2005. This was a slight deterioration from 92% in 2014, but it is unclear if this is normal variation or the start of a downturn in quality. The time from the 999 call to treatment gives an indication of the quality of care provided by the ambulance service and in hospital, as well as the transition between the two. 77% of patients were treated within 150 minutes of a 999 call in 2015, a decrease since 2014 (82%). 90% of patients were discharged from hospital with the appropriate medication.

Heart attack mortality in 2008 was worse in the UK than in OECD countries: 12.0 per 100 people died within 30 days of hospital admission for heart attack in the UK, compared with an average of 11.0 per 100 people in OECD countries. Performance has improved and, although progress has since levelled off, Figure 9 shows that the UK overtook the OECD average by 2013, when 9.1 per 100 people died within 30 days compared with an average of 9.5 per 100 people in OECD countries.

Cancer

In the 2015 National Cancer Patient Experience Survey, participants were asked to rate the overall quality of their care on a scale from zero (very poor) to 10 (very good) and gave an average rating of 8.7, with 94% rating their care as seven or higher.

Breast cancer is the third most common cause of cancer death in the UK, with around 11,400 deaths in 2014. The UK performs very well on breast cancer screening, with an average of 75.9% of women aged 50–69 screened in 2013 compared with the OECD average of 60.3%. Survival for people with breast cancer in the UK is improving over time, as with most cancers. One-year survival rates improved by 14% between 1971 and 2010, from 82% to 96%, while five-year survival rates improved from 53% in 1971 to 87% in 2010. The latest available international comparisons of five-year survival rates suggest the UK remains worse than the average for OECD countries. But Figure 10 suggests the UK has gained some ground in the past decade, with a 7.6% improvement in rates between 1998–2003 and 2008–2013, compared with a 5.5% improvement in the average for OECD countries over the same period. Breast cancer mortality rates have decreased by 32% in women in the UK since the early 1970s, but despite this they are currently the 14th highest in Europe.

Figure 10: Breast and bowel cancer five-year relative survival rates, OECD average vs UK

Source: OECD, 2015

With around 40,000 new cases registered every year, bowel cancer is one of the most common cancers in the UK and the second most common cause of cancer death. Around half (57.9%) of people in England who are invited for bowel cancer screening are screened with a definitive usable result within six months of invitation, although uptake rates vary between different parts of the country. There have also been marked improvements in the quality of care delivered by the NHS for patients with bowel cancer. Shorter stays in hospital following major bowel surgery indicate improvements in terms of other treatments like chemotherapy, better decisions on who would benefit from surgery, and advances in care of people after operations. Median time in hospital following major surgery for bowel cancer has almost halved from 13 days in 2004 to seven days in 2015, although the ambition is to reduce this further to five days. It is difficult to compare bowel cancer mortality over time due to changes in how data have been collected, but there is a general trend of improvement, with 90-day mortality following major surgery declining steadily from 5.4% in 2010 to 3.8% in 2015.

Figure 10 shows that the UK’s five-year survival rate for bowel cancer remained below the average for OECD countries in 2008–13. While the UK was above the average for OECD countries for age-standardised mortality rates for bowel cancer in 2003–13, it remained behind France, Australia, Switzerland, Germany and Spain. The UK mortality rate for bowel cancer in 2012 was the tenth lowest in Europe, with five-year survival in men (51%) and women (52%) in England below the average rates for Europe (both 56%).

This briefing began by asking whether public anxiety about the quality of health care in the future was justified based on the experience of the past few years.

If quality was solely about getting speedy access to treatment, then there is reason to be concerned. We have shown in this briefing that the NHS in England has treated more people each year but struggled to meet key waiting time targets for a range of services in the past two years, including ambulance response times, treatment in hospital A&E departments, and the time from GP referral to consultant treatment for planned conditions, including suspected cancer.

This is concerning on two levels. For the person left in pain because their operation is delayed or they are waiting on a trolley, knowing that they are in a minority and that most other people are still treated quickly is cold comfort. But it is concerning on another level. If deteriorating waiting times are a symptom of a shortfall in funding colliding with rising needs, does it mean that other dimensions of quality are deteriorating too?

In this briefing we attempted to assess some of the other dimensions of quality in addition to waiting times. We chose to look at aspects of care for a selection of common acute and chronic serious illnesses, including heart attack, stroke and diabetes, where the data allowed for comparison across time. The picture here is more mixed. There have been real achievements. For example, in the past decade there have been strong improvements in the quality of care for heart attack and stroke, progress that has been recognised internationally. For breast and bowel cancer, and diabetes, there has also been improvement, but for these cancers the NHS is still lagging behind some comparable countries in terms of survival rates.

The one dimension of mental health we looked at, the IAPT programme, shows progress is possible, but it is still only a small step in bridging the gap between mental health needs and the services available.

It has proved difficult to know what has happened to quality more generally. This is partly a scale and complexity problem: we have looked at national averages, but there are persistent inequalities between areas and different groups. But it is also a time-period problem. Assessing whether the improvements we have seen have continued or tailed off, for even a limited set of quality indicators for a limited set of conditions, has proved to be like a book missing its last chapter. Many of the data reports have a time-lag, in some cases by two to three years.

In March 2017, the CQC found that there were examples of high quality care in many hospitals across England, but that all hospitals were facing ‘steadily increasing demand for their services at a time when they are also expected to make unprecedented efficiency savings’. It pointed out a correlation between hospital trust deficits and the ratings of the quality of care: trusts with larger deficits tended to have lower ratings.