Monitoring quality of care: the Better Metrics Project

First published February 2007, updated November 2021

Key points: 

• Existing performance indicators are largely unhelpful to clinicians wishing to monitor their services for older people.
• Better Metrics is a project supported by the Healthcare Commission that is developing new indicators with greater practicability and relevance for clinicians.
• The proposed metrics specific to older people’s services are described with an opportunity for comments and improvements by the reader.

In our modern, devolved heath service we have become familiar with the vocabulary of targets, performance indicators and standards as mechanisms to monitor the quantity, quality and efficiency of health care delivery. Most of these measures originate as high level policy and are transmitted by documents such as the National Service Frameworks (NSFs) and central planning statements.

There is therefore limited opportunity for engagement with — or ownership by — front line clinicians. This results, for example, in local clinicians not being aware of what targets are being measured, or why. Even the components of publicly visible standards, such as the previous star rating measures, remained unfamiliar to most clinicians so they were unlikely to use them as part of their service quality improvement initiatives.

One explanation of this lack of clinician engagement in existing performance measures is that they have not been sufficiently relevant to clinicians’ day-to-day practice or the patients they were treating. To address this, a project has been established to develop more clinically relevant measures of performance. This project is called Better Metrics — the word metrics chosen to avoid confusion with other terms such as targets, indicators, standards or benchmarks. The aim has been that the proposed metrics could be used for any of these purposes. The publication National Standards, Local Action; Health and Social Standards and Planning Framework 2005–2006 to 2007–2008 describes the current performance measures for the NHS. The national targets set were purposely fewer than in the previous planning round and there was an expectation, therefore, that primary care trusts (PCTs) would have headroom to set additional local targets. 

When the Better Metrics Project was launched, it was hoped that the suggested metrics could assist in the process of setting local PCT targets. Better Metrics is available on the Healthcare Commission website. It currently has nine chapters that encompass various clinical areas, mostly those covered by the NSF, and there are four other chapters covering public health, patient experience, research and development, and primary care.

Better Metrics for older people

It is now generally acknowledged that the needs of older people should be central to the development and organisation of health and social care services, on the basis that they are the majority users of such services. This is being made explicit within the NSF for Older People — a 10-year programme of action aimed at developing high quality, integrated health and social care services for older people. However, many other programmes of work are highly relevant to the needs of older people and this is reflected in several sections of the Better Metrics Project. For example, coronary heart disease and stroke, urgent care, diabetes, mental health and long term conditions — are all highly pertinent to older people. This is partly a direct implication of the rising condition prevalence rates that come with increasing age. These mean older people are a major user of such services and, further to this, if these services are sympathetic to the often complex needs of older people, all other service users will benefit. Therefore, a chapter specific to older people has been developed to reflect the health and social care responses that are of special value to older people. The metrics specifically developed for older people are listed in Table 1. It is acknowledged that some may prove difficult to collect.

Population health and wellbeing

In healthcare settings, particularly in secondary care, there is a pervasive tendency to view all older people as infirm, frail and to have chronic health problems. This group, although the largest consumer of health and social care, are not representative of the older population as a whole. The large majority of older people are healthy, active and socially engaged. Indeed, older people have a major influence on the content of the NSF and want it to reflect their own priority of maintaining independence. Hence, two metrics have been incorporated that aim to examine population health and well being, and thereby act as a stimulus to keep our health and social services mindful of the key ambition of older people — to maintain their active and independent lifestyles.

Better assessment and care

It is now well recognised that older people can have several conditions of varying severity, so it can be complex to unravel and identify the critical components in order to form a personalised intervention plan. The process of doing this is called assessment and it has been central to good practice since the inception of special services for older people. There is reliable evidence the process is effective in improving the outcomes for older people. However, we have abundant evidence that assessment is not always well done or well co-ordinated between professionals or agencies. For this reason the second theme in the Better Metrics Project in respect of older people is ‘better assessment and care’. There is no doubt our continuing drive to improve the consistency and quality of assessment for older people at all levels and services within health and social care will translate into large improvements in health experience and outcomes for this major population group in our society. 

However, assessment alone without explicit links to intervention(s) is not associated with any health gain. Thus, we have linked assessment to drug reviews (excess medication is associated with considerable morbidity in older people) and to interventions to reduce falls risk. Death becomes increasingly inevitable with advancing age but end-of-life care is not universally well organised. Hence, a metric to promote recognised end-of-life care pathway has been included.

Proposed new metrics

We are aware that the coverage within the older people chapter in ‘Better Metrics’ is less than comprehensive. We are now proposing extending the coverage to two new areas (Table 2).

The first is aimed at improving care for older people in A&E departments. There are over three million A&E attendances in England each year (20 per cent of all A&E attendances) by older people. We wish to drive up the quality of assessment of older people in A&E in line with the expectations described in the NSF. As a focus for the proposed metrics we have taken healthcare topics of falls, confusion and hip fracture as common conditions through which older people present to the A&E department.

Second, the recent national audit of continence has shown that considerably more work needs to be done to improve the assessment and management of continence in older people. Two suggested metrics have therefore been selected to address this topic.

Next steps

The Healthcare Commission is already making use of some of the Better Metrics for its core standard assessment, improvement reviews and developmental standards assessment. Your views of the utility of the proposed metrics for older people would be welcome. Could they be adopted in your local health and social care community to help drive up standards of care for older people? How willing would you be to collect the data? What are your views on the proposed new metrics (Table 2)? 

Finally, what are other critical gaps in the metric coverage — and how would you like us to address them? We would be grateful for your views on these issues. Emails to further the discussion are welcome at: [email protected]