R.I.P. the European Society for Quality in Healthcare
by David Somekh
Twenty years ago to this month a group of twelve leaders of European national healthcare quality societies met at the ISQuA (International Society for Quality Assurance in health) conference in Budapest. The meeting was convened by Charles Shaw, who at that time was the ISQuA President. At the meeting, the group agreed to form a confederation of quality societies which soon after became ESQH, registered as a Charity in Ireland, the first President of ESQH being Stiofan de Burca, the CEO of the Irish Mid-West regional health board.
Now we’re about to wind up ESQH and absorb the brand under the EHFF umbrella. Why? There are several layers to the answer, but we hope that the most interesting answer relates to what seems to have happened in the arena of healthcare quality in the last twenty years. This brief account will attempt to set the scene, but then we plan to ask a number of expert individuals who have shared the same journey for their perspective on where we’ve come from and where we are now.
One remark that I personally remember clearly from that November afternoon in 1998, in a conference room overlooking the Chain bridge that spans the Danube between Buda and Pest, was that we didn’t want to create a ‘hot-air’ society. In other words, not to be a talk-shop but a group that actually did things.
Did we succeed? For the first ten or fifteen years we certainly did. ESQH began holding six monthly meetings built round specific quality topics, each one held in a different European city. Then in 2003 events within the European Commission gave us the chance of a breakthrough. The Council of Ministers set in train a high level reflection process on health (HLRP) part of which involved taking evidence on cross-border care. In doing so the Commission realised that in order to manage cross-border care they needed tools to measure the quality of treatment in another country and therefore needed advice from experts in that field.
This was ESQH’s opportunity to become involved with health policy directly with the Commission, rather than at only a national level, and we were able to benefit from this connection for the next ten years.
With encouragement from the then head of unit at DG-SANCO, Bernard Merkel, ESQH wrote and submitted a bid for their first health programme project, subsequently named ‘Simpatie’ which was a collaboration, led by the Dutch Quality Institute (CBO) (where our current Chair, Marius Buiting was at that time, head of knowledge management) mapping the implementation of Patient Safety strategies across EU member states and describing a patient safety quality tool-box (the website is now defunct, but the interim report can still be found: http://ec.europa.eu/health/ph_projects/2004/action1/docs/action1_2004_inter_19_en.pdf ).
With the success of Simpatie, a follow-on project, EuNetPas (2007) was fundedby the Commission and led to the Joint Action on Patient Safety and Quality (PaSQ: 2012-2015). What is interesting about this development is that the Member State engagement in these activities steadily grew, but the involvement of NGOs steadily diminished over time, they were pushed out.
Thanks to the efforts of the then Chief Medical Officer of England, Sir Liam Donaldson and his Danish opposite number, patient safety had already by 2003 come on to the international agenda, but what was most interesting was that in 2004, when the Simpatie project took off, the rotating Presidency of the EU Council was with Luxembourg and a number of NGOs (including ESQH) marked the occasion by publishing the so-called ‘Luxembourg declaration’ which was later adopted by the EU Council in 2008. Around that time also a group of ESQH executive members were invited for an informal day meeting with Bernard Merkel to brief him on the scope of quality in healthcare. A year later, the working group on patient safety which was one outcome of the HLRP, was expanded to include quality and became the patient safety and quality of healthcare working group (PSQCWG). This was a forum where Member State representatives met twice-yearly with key NGOs (including EPF, CPME, HOPE EFN, PGEU and ESQH). This continued, and did important work promoting and reviewing implementation of the patient safety recommendation (and other quality matters) until it was disbanded in 2016.
This second attachment (here) is a reflection paper on quality which was ‘curated’ if not written by a senior policy officer who was servicing the quality working group, Agnieszka Daval-Cichon. Having completed her contract she now works elsewhere in Brussels but is also now one of the four Directors of EHFF. Retrospectively the paper seems a very balanced and thoughtful overview of where ‘Quality’ had got to in Europe in 2009, given that quality improvement, tools and local actions had been a preoccupation for many of us for the previous 20 years.
The perennial problem, which has never been adequately resolved, despite strenuous efforts, is that of transferability and embedding of improved practice. 2009 and the few years either side of it could be seen as the zenith of the quality improvement movement as it was then conceptualised. Agnieszka’s overview is one perspective on the barriers to change on the larger level. For example, the suggestion of a multi-national platform was indeed explored, via the EUnetPAS project that followed Simpatie in 2007-10 as already described, and then the Joint Action, PaSQ, from 2012-2015.
At the end of 2018 where is the evidence that these actions, costing several millions of euros, have created a lasting legacy? Apart from the continued work of WHO Europe and OECD, with the demise of smaller organisations, the reasons for which will be touched on briefly, there remains ISQuA and, across the pond, IHI, the Institute for Healthcare Improvement which is a monument to the work of Don Berwick. ISQuA has always prided itself as being primarily an academic society, publishing a respected journal and as such can be ranked with the esteemed Institutes in Europe specialising in work on quality, such as NIVEL in the Netherlands, FAD in Spain and perhaps the Health Foundation in the UK. IHI and the IHI/BMJ conferences habe had a huge influence on both sides of the Atlantic in promoting quality improvement. The embarrassing reality is that there is scant evidence, once one looks beyond local examples of genuine excellence, that such influence has actually changed patient outcomes on a larger scale to any significant extent.
Some things change, some things stay the same.
The context in which ESQH was conceived has changed significantly in the last 20 years. There has been a substantial contraction of national quality societies for all kinds of reasons, two powerful ones being the centralisation of power within most European health systems, which has led to a reduction of opportunities for innovation and sustaining diverse voices and secondly the rise of the internet and other digital mechanisms for communication, ironic as the latter seems (although austerity, leading to reduced travel funding played its part). There are honourable exceptions, for example the Polish Society for Quality, which, led by Basia Kutryba, a former President of ESQH, staged what was probably the best recent European health quality conference, in 2011, as part of the Polish EU Presidency programme. With the demise of national societies, which made up one core component of ESQH as it was conceived, there remained a group of a dozen of special interest groups spread across Europe, the ESQH offices, one of which, the Lisbon Office for health futures, provided the basis for the evolution of EHFF as a separate entity. Without a robust community of activists driving the ESQH Council, and with the significant erosion of quality-related EU policy actions, ESQH over the last five years had lost the means to sustain itself. Its time is over.
There remains a substantial community of experts in the field who have strong and friendly ties, based on their positive experiences with ESQH over the years. On that basis EHFF convened, with the help of the Good Governance Institute in London, two successive meetings, of some of these experts in December 2016 and September 2017. Despite attempts to pursue a limited number of quality topics in the interim, the group decided unanimously to wind up the Charity. It is fair to say that ESQH lives on within the EHFF mission. There was much discussion within the two meetings about the nature of Quality 3.0. The problem seems to be that quality improvement is now seen as part of clinical or management routines (and inevitably therefore lacking incentives for imaginative approaches). The concept generally no longer has the capacity to excite people. Yet in contrast, three of the five areas that we had identified in 2007 as key directions for quality in the next 15 years when I was serving my term as President, patient empowerment, eHealth and better professional education are central to the current strategy of EHFF.
What hasn’t changed is the key insight which was already available at the time that ESQH was created. For quality processes to be embedded in organisations, whether or not the structures themselves need to be transformed, there are two inter-connected essential factors, culture and leadership. This is old news, but making it happen remains a fundamental challenge which has consequences for the whole of the health system (and in every country).
As a follow-on from this thought-piece and marking the end of a 20 year life-span for ESQH, we will be approaching a number of the players that have travelled the same road during that period. We want to get their perspectives on what has and hasn’t been achieved in the quality field and, based on their wisdom and experience, what implications their conclusions might have for the future of healthcare in Europe.