Delivering Quality and Value: Focus on High Volume Care

The Delivering Quality and Value team at the NHS Institute for Innovation and Improvement have published a range of documents reflecting their work identifying, testing and promoting a comprehensive and detailed range of specific or system improvements along the entire patient pathway, from primary care through referral and treatment to discharge and rehabilitation for the following Healthcare Resource Groups (HRGs) or similar groupings:

This follows the team's earlier initial work signposting high impact improvements that could be made in the areas:

The work on these is summarised in the initial focus document which can be downloaded, together with the individual documents on the patient pathways and an executive summary from the links below. Please note that these are large, illustrated documents and, as such, may take some time to download properly.
The Delivering Quality and Value team's final deliverable will be to produce pathway guidance in a form that allows it to be applied to further pathways or other care groupings by others in the wider NHS.

If you would like to be involved in the work, or have any comments, please contact the Delivering Quality and Value team at

Delivering Quality and Value - Focus Document (PDF, 252KB)
This initial discussion document aims to help local health communities and organisations improve the quality and value of care for NHS patients. It is designed to build on the Productive Time Delivery Board’s Efficiency Map by focusing on HRGs with the highest potential for improving the quality and value of clinical care.

Focus On High Volume Care - Executive Summary (PDF, 1.91MB)
The aim of this document is to summarise the initial outcomes of the Delivering Quality and Value programme, focusing on eight high volume areas of care.

Focus on Acute Admissions in Adult Mental Health (PDF, 2.72MB)
Developments in adult mental health as a result of community care policies and encouraged through the National Service Framework (NSF) have seen investment and the redirection of resources into services in the community. This aims to improve quality of care and reduce the need for inpatient admission – as well as the length of stay – for the majority of acutely ill people.

Focus On Acute Stroke (PDF, 2.83MB)
Stroke is the leading cause of death in England and Wales after coronary heart disease and all cancers combined. Each year 110,000 new strokes and 30,000 recurrent strokes occur. Two-thirds of these patients will survive, but half will be left with a disability. Historically, stroke has been seen as a disease of old age, even though a quarter of all strokes occur in patients under 65 years of age.

Focus On Caesarean Section (PDF, 3.41MB)
In the past 15 years, the proportion of CS births has been increasing steadily in England. In 1989/90, CS accounted for 12% of all births, while in 2005/06 the rate had risen to 24%. (The proportion of vaginal instrumental deliveries remained unchanged over the same period.) This increase in operative births has not been accompanied by a measurable improvement in the outcome for the baby, and has been shown to carry an increased risk to the mother of morbidity and mortality over normal delivery.

Focus On Cholecystectomy (PDF, 3.96MB)
A total of 49,077 cholecystectomy procedures took place in England between 1 April 2005 and 31 March 2006, of which 86% were performed electively (42,402) and 14% (6,675) during an emergency admission. Overall, 84% of cholecystectomies were undertaken laparoscopically. There is large variation between trusts, with high performers achieving over 90% laparoscopic rates (includes day case and inpatients' cholecystectomies) compared with some low performers where the rate of laparoscopic cholecystectomy is under 50%.

Focus On Fractured Neck of Femur (PDF, 3.48MB)
Fractured neck of femur is the most serious consequence of falls among older people, with a mortality rate of 10% at one month after a fall, 20% at four months and 30% at one year. Many of those who recover suffer a loss in mobility and independence. Hip fractures account for 87% of the total cost of all fragility fractures, and, as such, they are the most expensive fractures associated with osteoporosis. In 2005/06, 68,416 patients with a fractured neck of femur were operated on in England at a cost to the NHS of at least £384 million.

Focus On Frail Older People (PDF, 3.13MB)
‘Frail older people’ are defined as patients who are usually over 75 years of age – and often over 85 years – with multiple diseases (which may include dementia). They tend to present at hospital with symptoms such as falls, immobility and confusion. The main characteristic of ‘frailty’ is reduced functional reserve, and hence frail older people are more susceptible to developing complications in hospital.

Focus on Primary Hip and Knee Replacement (PDF, 3.53MB)
The demand for orthopaedic services – and particularly for primary hip and knee replacements – has grown steadily over the past 20 years and continues to do so. The complexity of both the conditions treated and the treatments available has also increased. The waiting times for joint replacements have been up to two years in the past, but current waiting targets are six months, and services are working towards achieving the 18-week target in 2008.

Focus on Short Stay Emergency Care  (PDF, 2.84MB)
This document focuses on the emergency care interface between primary and secondary care. Effective processes for urgent care management in primary care can result in fewer patients requiring referral for possible admission. Such processes include improved access to primary care and evidence-based management of long-term conditions. Sub-optimal care in primary care can result in higher admission rates. Optimisation of the clinical pathway for patients requiring short stay emergency care will result in marked improvements in the quality of care for this group of patients and other patients accessing acute and elective care.

NHS Institute for Innovation and Improvement