NINA MURPHY ASSOCIATES

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1 NINA MURPHY ASSOCIATES Review of Out of Hours Services Commissioned by NHS SW London Cluster Patient Care 24 Harmoni HS Ltd and East Berkshire Primary Care February 2013 Reviewers Sheeylar Macey Siobhain O Donnell Dr Sadru Kheraj

2 Table of Contents Executive Summary 3 Introduction 4 Terms of Reference 5 Methodology 5 Confidentiality 6 Background 7 Individual Organisational Findings 7 Patient Care 24 7 Harmoni HS Ltd 19 East Berkshire Primary Care out-of-hours (EBPCOOH) 26 Overall Findings 31 Conclusions 33 Recommendations 38 Appendix A Terms of Reference 40 Appendix B Questionnaire Sent to OOH Providers 43 Appendix C The Reviewers 48 2

3 Executive Summary This review was commissioned by NHS South West London. Its purpose is to describe the present governance arrangements within the three organisations that provider Out of Hours service within the area. The review was required to provide assurance following the issue that arose out of the significant incident investigation at Croydoc, the previous Out of Hours provider in Croydon. This investigation had identified significant weakness in the governance arrangements within the organisation. In particular, the fact that one individual held all the senior roles. Interviews were undertaken with senior staff within each of the three organisations. In addition, each organisation was asked to complete a questionnaire and provide documentary evidence to demonstrate their approach to corporate and clinical governance. The review obtained a broad overview of the quality and safety of the three organisations by examining the systems and processes in place to support their corporate and clinical management arrangements. All three organisations demonstrated that their governance arrangements offered reasonable assurance that care is delivered safely and effectively. Their financial, clinical and activity performance monitoring arrangements and the processes in place to support clinicians in their work demonstrated this. The commissioner effectively monitors each contract and there is evidence to show that the transition to CCGs has been supported. The cluster team have regular meetings with the OOH providers, these meetings are fully minuted and there is considerable evidence of challenge to providers to ensure that services are delivered appropriately. 3

4 Introduction Nina Murphy Associates LLP 1 (NMA) were commissioned by NHS South West London to review the provision of out-of hours services by the three organisations operating in the area: Patient Care 24, Harmoni HS Ltd and East Berkshire Primary Care Out of Hours. The issues that arose out of the significant incident investigation at Croydoc were the main stimulus for this consideration of all the Out of Hours providers in South West London. Croydoc was a GP owned company. It had the same man in the following roles: Chairman, Medical Director, Operations Director and Financial Director. 2 In addition this same person was Chairman of the Professional Executive Committee of Croydon Primary Care Trust. Such a plurality of positions is not in keeping with acceptable corporate governance. 3 In view of the changes in the NHS and with changing landscape of Out of Hours commissioning, NHS South West Cluster perceived the need to describe the present governance arrangements within the three providers. This review was commissioned to undertake an outline assessment of the approaches within each organisation to providing assurance. The review, its purpose and terms of reference were communicated to the providers of the service by a letter from Neil Roberts, Director of Primary Care Contracting on 4 th September This is attached as Appendix A. The review looks at each of the three providers in detail. It considers how their systems to provide effective governance results in assurance for commissioners. In addition we have considered how the commissioner interpret the performance monitoring data that it receives bhttp:// HOURSSYSTEM.aspx 3 4

5 In addition, we have considered if the providers systems are commensurate with principles of good governance and assurance. 3 This report provides a snapshot of the providers and commissioners at a point in time. Terms of Reference The full terms of reference are attached at Appendix A. In essence the terms of reference for the review were to: evaluate the performance of the providers against the service standards (NQRs 4 etc) applied and the associated provider performance management arrangements of these. evaluate and test the clinical and corporate governance arrangements within the service report on the findings and make recommendations as appropriate. Methodology Each organisation was visited between November 2012 and January During the visits, interviews were held with the Chief Executive, Finance and Medical Directors with Harmoni and Patient Care 24 (PC24). In the case of East Berkshire Primary Care (EBPC) it was not possible to arrange a meeting with the three officers due to competing time pressures in a small organisation and advice about this was therefore sought from the commissioner. In order to deliver the report in an acceptable timescale the commissioner of the review agreed with the provider that an interview Clinical Executive of EBPC would be an acceptable variation of the terms of reference as the service offered by EBPC related to call handling only. The three services were also asked to complete a questionnaire prior to the visits and to provide copies of their systems and process, which support their corporate and clinical management arrangements. 4 National quality requirements in the provision of out of hours service. DH

6 The data and evidence shared with us was reviewed and our findings and recommendations are based on this evidence. A copy of the blank questionnaire is attached as Appendix B. The original timescale for the return of questionnaires was shifted as one provider was unable to supply data due to the absence of the Chief Executive. During the interviews we sought to ask open questions about the out-of hours services provided, its governance and the assurance gained from this. We found those interviewed to be co-operative and appropriately reflective about the systems upon which they relied. The systems for considering the quality of the individual GP consultations were considered and evidence of good practice was identified. The officers of NHS South West London who hold responsibility for monitoring the out of hours contract were interviewed and information on contract monitoring was supplied. Croydon CCG has monitored the Patient Care 24 contract since January The Interim Urgent Care Project Manager provided monitoring Information. Neither the CCG Accountable Officer nor the Project Manager was available for interview during the review period. Information was provided by the First Point of Contact Committee, which monitors the EBPC service. A telephone interview was carried out with a manager. Confidentiality Nina Murphy Associates shall not disclose to any person or organization any confidential information relating to One Patient Care 24, Harmoni HS Ltd or East Berkshire Primary Care Out of Hours without the prior and written consent of those organisations. The information provided to NMA has been redacted where required. Summaries of all the information provided to the reviewers are available on request. 6

7 Background All General Practice services outside the hours of Monday to Friday in South West London are provided by specialist providers. Urgent care networks exist and commissioners and some providers link into these to support a panoramic view of the provision of service. The commissioning of these services is complex and provision is now more fragmented with different providers involved in different parts of the process, for example call handling may be separate from clinical advice. There is widespread negative press coverage of Out of Hours care, a short internet literature search will reveal reporting of concerns and poor care but little evidence of appreciation of the service offered. It can be argued that this is simply typical of present day reporting. However, no other aspect of the NHS is reported with such consistent negativity. This review attempts to consider these issues as well as providing a detailed consideration of the organizations involved. Individual Organisational Findings The findings for each of the three out-of-hours services reviewed are set out separately below. Patient Care 24 Patient Care 24 is a stand-alone organisation and operates as a Social Enterprise. It is registered under the Industrial and Provident Act Publically available accounts can be seen online at the FSA mutual public register. The company is not part of wider health care organisation. In April 2012 it entered into a contract with Virgin Care to provide GP out-of hours face-to-face services and home visits to patients in Croydon. The organisation had recently gone through a reorganisation and not all senior posts had been filled at the time of the review. The organisation has separation of responsibility between the Chair, the Chief Executive and the Director of Finance. 7

8 Corporate Governance The Board Governance and Management Structure and the Organisational Structure were updated in The Scheme of Delegation (Draft July 2012) sets out the arrangements for the delegation of functions to other committees or subcommittees by the board. It was reported that board members (both Executive and Non-Executive Directors) come with a broad range of skills and experience and have held senior positions in large organisations both within and outside the health sector. Job descriptions and competencies are supported by training e.g. The Effective Board: Essential Competencies, roles and responsibilities: what it is to be a corporate body, Corporate Risk Management, Board Assurance /Board Competencies (in June 2011) and Safeguarding Vulnerable People (in September 2011). The Board Action Plan sets out the Governance Issues and progress in addressing these as at September The Board Constitution a review of the constitution to ensure that it is fit for purpose. This included the establishment of Member Stakeholder Groups (staff and partners). A member of these groups attend board meetings and have a voice in the appointment of Non Executive Directors. Two practicing GPs will soon be appointed to the vacant Non Executive Directors posts. This, as well as the broad corporate experience that the Executive Directors bring to the board, was seen as a way of providing the opportunity for clinical challenge of and two way communication with the board as well as fostering an open culture across the organisation. The Board ensures that the organisation conducts its business in accordance with the requirements of good corporate governance enshrined in the Nolan Principles 8

9 of Public Life. 5 It does this by delegating responsibilities to the various sub committees of the board and those holding senior posts. The organisation appears to have systems to exercise control over its finances and reported that an independent report commissioned to test the effectiveness of its systems of internal control. The organisation was judged as having a substantial assurance rating, the highest rating possible at the time of the audit (March 2012). The report was not shared with the reviewers. The Finance Director is a qualified accountant. Board Assurance Framework The Board Assurance Framework (BAF) provides the organisation with reasonable assurance that systems are in place to identify and control risks that may prevent the organisation from achieving its strategic objectives. The BAF seen set out the risks for the organisation s strategic objectives and the controls in place to address those risks. The BAF is reviewed monthly by the board. Further assurance is provided via the corporate risk register which covers financial, clinical, HR and operational risk. This is monitored by the senior management team on a monthly basis at the Integrated Governance and Clinical Governance Committee. Any strategic risks identified are escalated to the board and included on the BAF. Scrutiny of the executive Non Executive Directors (NEDs) It was reported that NEDs provide robust challenge to the decision making of the Executive Directors. The Board Chair and vice chair are NEDs and two other NEDs, who are doctors, will soon be taking up posts. The reviewers were unable to test how the NEDs perform this function in detail but the board minutes seen (September 2011 to April 2012) have as a minimum on the agenda NEDs report, Medical Director s report, Board Assurance Framework and Finance report

10 Governance Systems The Audit Committee receives reports from both the internal and external audit and that it monitors the corporate governance arrangements, financial statements internal controls and risk management systems. The terms of Reference of the committee sets out the how this will be carried out and includes review the integrity of the internal financial controls and risk management systems, receive reports from the auditors and consider issues associated with the corporate governance of PC24. The evidence provided confirms that controls are in place but the Internal Audit 2011/2012 Action Plan has not been updated and the only minutes of meeting for this committee for 2012, which were provided, were dated May PC24 s accounts are audited externally and the auditors attend the Audit Committee to give advice and report on their findings. Integrated Governance and Clinical Governance Committee (IGCGC) The IGCGC is chaired by Non Executive Director and its overall purpose, as set out in the Terms of Reference, is to oversee the development, implementation and monitoring of the service s integrated governance arrangements. It provides assurances on the systems and processes by which it leads, directs and controls its functions in order to achieve organisational objectives - safety and quality of services. In order to discharge its duties effectively, the Integrated Governance Committee receives the following information: Combined Corporate Risk Register and Board Assurance Framework and Action Plans Quarterly Risk Indicator reports Updates on the annual work-plan for the development and review of Clinical Policies and Procedural Guidelines Relevant extracts from quarterly Performance reports Relevant internal and external audit reports External assurance reports, e.g. CQC 10

11 Minutes of other Committees/Sub Committees. Appointment and Remuneration Committee This committee oversees all recruitment and remuneration of all staff on behalf of the board. Systems to Ensure Good Governance Below is a summary of the systems and processes that the organisation relies on to ensure good governance: Policies and procedures which are stored on the Intranet Executive reports to the Board by the Chief Executive, Finance and Medical Director Progress against NQR indicators reports monthly Compliance audits e.g. call handler and GP Performance audits Performance monitoring by the Integrated Governance and Clinical Governance Committee NQR Reports to the commissioners Quarterly contractual performance meetings (to discuss performance against NQR indicators, complaints, previous remedial actions, service experience issues, payments) with Primary Care Contract Managers and Borough Commissioning Leads A programme is currently in place to review and update key documentation (e.g. Organisational Policies, Terms of Reference) The Risk Register which is reviewed monthly by the Integrated Governance and Clinical Governance Committee Changes in response to a previous Nina Murphy Associates review include: A refreshed code of conduct, reflecting the Nolan Principles, was developed in October 2011 for staff and the Board. This requires disclosure of and a register of interests. Performance appraisals of both staff and are being strengthened Reports to the Integrated Governance and Clinical Governance Committee - monthly review of complaints, serious incident investigations, reports from the Medical Director which clinical performance, audits and significant event 11

12 analysis. It was reported that no serious incidents were reported in the year up to June Other matters which are reviewed medicines management, infection control inspections, health and safety audits, human resources management information, safeguarding, training, patient liaison and satisfaction monitoring Whistleblowing and anti-fraud policies in place including arrangements for confidential reporting arrangements. The budget is agreed by the board and monitored by the Finance Committee It was reported that lessons learned is cascaded through the organisation Other Performance Data Other performance data submitted to commissioners include: Balanced scorecard - the most recent seen, February 2011 to November 2011, confirms that the service was compliant to within 5% for all the standards (except for Standard 9c in February 2011). Information on NHS111 performance. A questionnaire was developed to capture concerns/complaints from patients and service users. A questionnaire was also developed to establish whether the criteria for allocating visits were appropriate. The outcome of these is considered at the weekly 111 Clinical Governance Meeting. Clinical Quality The Integrated Governance and Clinical Governance Committee receives monthly reports on complaints and progress on any investigation on serious incidents. The committee also receives reports from the Medical Director, which includes updates on the work of the clinical teams, the clinical governance framework, clinical performance, audits and analysis of significant issues. Other matters considered are - medicines management, infection control inspections, safeguarding children and adults, patient engagement and patient satisfaction survey results. The Medical Director reports monthly to the board on the work of the committee. Clinical performance is also reported to the Clinical Out-of Hours lead of Virgin Care. 12

13 The Head of Integrated Governance and Company Secretary had only recently joined the organisation and was in the process of updating the risk and governance strategies as well as the governance structures. It was reported that the emphasis would be on developing an open culture and a learning organisation by empowering staff to learn from experience. Staff appraisals and objectives would be linked to the organisations objectives and goals. The timescale for implementing this this is not clear as the plan was still in the development stage. Reviewing the Work of the Clinical Staff The RCGP Audit tool (Urgent and Emergency Care Clinical Audit Toolkit) 6 is used to audit a minimum of 1% of clinical consultations. If the auditor feels that the outcome of the consultation is below standard a Call to Reflection is generated. The clinician involved is invited to a meeting with a member of the clinical team to discuss the outcome of the audit. Gaps in knowledge with advice on how to improve practice is discussed. Complaints, incidents and compliments relating to the clinician are also discussed at those meetings. The Calls for Reflection are anonymised and published as a learning tool for clinicians. The reviewers had sight of how this process works in practice. Information on average telephone, base and home visit consultation times, triage activity, assignment priority base visits, activity visiting activity and KPI performance data is collected and considered. It was reported that the organisation is piloting a patient feedback questionnaire aimed at capturing patient satisfaction post consultation. Initial feedback is positive. A colleague (a mixture of medical and non- medical staff) questionnaire which aims to capture feedback from colleagues is currently being piloted. 6 ahttp:// 13

14 This approach offers valuable information for GPs to retain in their revalidation portfolios and could be seen as a method of encouraging GPs to work with the organisation. Doctors on shifts have access to real time support from colleagues. All prescriptions for controlled drugs are audited and clinicians who prescribe outside the controlled drug policy are identified and asked to reflect on their prescribing. The incident is also reported to the Controlled Drug Local Intelligence Network. Opportunities for continuing professional development are provided via e-learning, quarterly educational sessions based on topics identified from complaints and Calls for Reflection as well as relevant disease areas. Educational alerts are circulated weekly with relevant information regarding, for example, Health Protection Agency and CAS alerts. Management of Rotas Rotas for both clinical and non-clinical staff are managed online using the IQUS RotaMaster 7 software. Planning involves the use historical mapping data to cater for fluctuating levels of demand. The system is managed on a day-to-day basis by a dedicated rota team and monitored by the Operations Managers, the Medical Director and the Chief Executive. Rotas are completed months in advance and shifts are covered by the clinicians using their log in details to enter the system and request shifts to be allocated to them. Later a list of vacant shifts is circulated and when all shifts are covered clinicians are encouraged not to hand back shifts unless in an emergency

15 Recruitment Processes All clinicians whether employed, self-employed, locums or agency applying to work for PC24 must be a practicing GPs and on a Primary Medical Performer s List. An application form is sent to the clinician who is asked to attend for interview. The following checks are carried out: Contact with The Local Primary Care Support Services Passport Visa Original CRB check GMC certification Medical defence organisation certification Copy of CV Application form Copy of appraisal Two references one from current employer One reference from previous OOH provider Following successful completion of the application process clinicians are supplied with an Induction Pack and must attend an induction session with the Medical Director before starting work. An Agreement between Clinician and Patient Care24 is signed. All clinicians working in the service must have evidence of a current appraisal. Plans were underway at the time of the review to introduce 360-degree appraisal. In the past year one GP has been referred to the Fitness to Practice directorate of the General Medical Council (GMC). Contract Monitoring For Sutton and Merton and Croydon Contracts the data showing performance against NQR targets is submitted monthly. Where performance is not in line with expectations explanations are sought by the commissioner and options discussed. For Croydon reports are first sent to Virgin Care before submitting them to the Croydon Commissioners. 15

16 It was reported that achievement against targets monitored on a daily basis by PC24 with explanations sought if expectations are not met. Contract monitoring meetings with the Sector take place quarterly. Virgin GP OOH and Urgent Care Centre Contract Monitoring Evidence of contract monitoring, for example a meeting by Virgin Care dated the 21 st November 2012 was seen. The following items were on the agenda but the minutes of the meeting were not available. Finance and SLAM reporting (OOH and UCC) KPI reporting Quality reporting Equalities Impact Assessment Serious Incidents Complaints GP feedback Clinical audit Patient and staff feedback Safeguarding OOH specific issues Home visits report System wide performance (interrelationships between 111, LAS, etc) Review Issues and Action Log Most of the records relating to contract monitoring meetings made available to the reviewers related to 2011 (except July 2012). However the NQR returns May to July 2012 as well as other performance reports were seen e.g. Summary of Patient Care 24 Performance October 2012, Urgent care Weekly Dashboard December 2012 and Urgent Care KPIs Performance Reports for October to December We have made an assumption that these are discussed at monitoring meetings with commissioners as well as internal governance meetings. There is also a monthly 111 meeting with Harmoni. 16

17 There is an Urgent Care Network, which meets monthly and to which the OOH providers are invited. The Urgent Care Centre manager is a participant in the recovery board for Croydon University Hospital. There is a process to discuss issues arising between the CCG, the urgent care manager and the hospital trust via regular conference calls. Patient/Service User Feedback Feedback from patients and service users is collected via complements, complaints and questionnaires. Participants are selected at random and results are discussed at the Integrated Governance and Clinical Governance Committee. Suggestion boxes are also used to capture patient feedback and the service is working with Virgin Care to introduce the net promoter score, which will provide a gauge of patient experience in real time. It was reported that the organisation plans to strengthen relationships with patients and service users by setting up patient/citizen groups and to strengthen relationships with CCGs, practices and other providers. No firm plans or a timescale had been put in place for this at the time of the review. Feedback and use of surveys is discussed regularly at monitoring meetings and it appears that this remains an area for further development. Complaints are handled using the NHS Complaints procedures. 8 Communication with staff and other stakeholders Communication with staff and other stakeholders takes place in a number of ways. These include: Weekly updates Intranet Staff meetings 8 The Local Authority Social Services and National Health Service Complaints (England) Regulations

18 Staff Liaison Group Staff Member on the Board GP events attended by the board It was not possible to verify this directly as the review team was not commissioned to undertake discussions with staff. 18

19 Harmoni HS Ltd Harmoni HS Ltd is a limited company, which during the course of this review was taken over by Care UK a company with wide healthcare involvement. Harmoni is registered with Companies house and with the CQC. All of the description of processes here relate to Harmoni prior to the takeover. We understand that the takeover has not led to operational changes. Corporate Governance The Board membership includes the Chief Executive (Chair) the Managing Director, Medical Director, Finance Director, Sales and Marketing Director and the Chief Information Director. Reports are received from each member at the meeting and the minutes are forwarded to Harmoni HS Ltd Shareholder Board. This board is co-chaired by Dr N Merali and Mr Wood and attended by a Non Executive Director, the Chief Executive and the Finance Director. In addition there are quarterly Quality and Risk meetings which are chaired by the Medical Director and attended by the board co-chair and, a Non Executive Director, the Chief Executive, Harmoni HS Managing Director, the Nursing Director and the Director of Governance. The organisation has separation of responsibility between the Chair, the Chief Executive and the Director of Finance. Local contracts are monitored monthly at Performance Review Meetings, which are co-chaired, by the Managing Director and the Medical Director. The following areas are covered on the Performance dashboard: People People Performance Performance Performance Performance Staff Satisfaction Workforce Planning Contractual Compliance Efficiency Technical Outcomes 19

20 Finance Finance Patients Patients Service Quality Service Quality Service Quality Complaints and Incidents Complaints and Incidents Complaints and Incidents Budget Management Cost Effectiveness Patient Feedback Patient Safety Clinician Performance Call Handler Performance Staffing levels Complaints Management Significant Incident Management Other Incident Management This demonstrates a co-ordinated approach to Governance ensuring that the different Governance functions are linked and not seen in isolation. Scrutiny of the Executive Scrutiny of the executive is carried out by the Non Executive Directors (Dr Merali, Mr Wood, Mr Relph) who may challenge decisions made by Directors to ensure that the organisation follows good governance. It was reported that the focus of the organisation is on quality and Clinical Governance is a standing agenda item in all Board Meetings. The Regional Governance Manager is supported by Clinical Leads each who provide assurance to the Executive and Non-Executive Directors. The two co-chairs of the Board have different backgrounds (Business and Clinical) and understand the NHS environment. It is believed that this shared responsibility provides a level of protection whereby issues can be raised in a positive way. Governance Systems The Board determines and leads the strategic objectives by ensuring alignment of the governance systems across the organisation. To do this it has established arrangements that have clear terms of reference with delegated powers and reporting requirements. The Quality and Risk Committee enables transparent reporting to the non executive officers of the company. 20

21 The Harmoni Quality Management Procedures (February 2012) clearly sets the procedures to be followed and responsibilities for all staff, from call handlers to clinicians, with reference to the relevant documents and procedures. Key board assurance groups include: Risk Forum Health and Safety Forum Clinical Governance Groups Oversight and Scrutiny Fora How these groups report to the board is clearly set out in their Terms of Reference. The main risk reported was ensuring that there are sufficient GPs are available to cover shifts. Other Performance Data As well as the NQR data the organisation reports on the demand profile noting whether over or under predicted volumes to assist in the interpretation of the NQR results. Other additional presented include the number of breaches, patients satisfaction survey results, incidents and complaints. Separate reports are produced for Kingston, Richmond and Twickenham and Wandsworth as well as an overarching report. Reports submitted to commissioners and seen by the reviewer include: operational and clinical staff rotas on a weekly basis to demonstrate transparency of staff usage analysis for all breaches including clinical risk assessment by the Clinical Leads Ad hoc reports as required by the commissioner or where deemed appropriate by local managers. For example current analysis of walk in patients versus pre-booked appointment percentages at one of the South West London Primary Care Centres will inform contract meetings of demand profile 21

22 How Clinical Quality is Assessed and Promoted The organisation s Clinical Governance Strategy sets out how the organisation aims to achieve continuous improvements in patient centred, safe and effective care across the regions it is responsible for providing out-of-hours services for. The Clinical Governance Strategy seen by the reviewers sets out clear aims and objectives aimed at ensuring that frameworks and standards are set across the organisation to ensure safe and effective care delivery. To embed the strategy s aims and objectives management of clinical governance is delivered through regional accountability that is required to delivery satisfactory performance against the Clinical Quality Indicators. These are governance requirements setting out the key tasks and associated guidance and policy documents which the local and regional areas are required to adhere to. Regional Clinical Governance facilitation supports teams at local level and a Central Clinical Governance and Quality Assurance Team is responsible for overseeing the clinical governance arrangements and scrutiny of procedures across the regions. At the London region corporate and local policies support the delivery of Clinician Performance, Risk Management, Education and Training, Audit, Medicine Management and Patient experience. Through the reporting and audit process, trends, variations and exceptions across the business are analysed and learning is disseminated and shared across the service to improve patient care. Reviewing the Work of the Clinical Staff The Clinical Performance Management Policy outlines the key steps in the performance management of clinical staff - identifying the need to recruit and selection, interviewing clinicians, induction and 4, 8, and 12 week reviews and on going Clinical Performance Management. 22

23 The interview involves a clinical scenario as well as a practical section. Once appointed the clinician is expected to attend a face-to-face induction with the London Regional Induction Clinical Lead. A records review is carried out on all new doctors after their first shift. At the 4, 8, and 12 week review meeting any issues are discussed with their clinical lead. As well as the audit of clinical records further monitoring of clinical staff performance includes: 1% audits of clinical records Call listening audits Prescribing audits Monitoring of time keeping and reliability Complaints and concerns Incidents Compliments Weekly report from RotaMaster All GPs who work for Harmoni on a contractual basis or for more than twenty hours a week have yearly appraisals. No GPs working for Harmoni have been referred to the GMC or NCAS in the year ending June Nurses (Advanced Nurse Practitioners) are also employed to provide triage and advice. A challenge to this part of the service was raised by the GPs in Richmond during this review. We were able to observe the challenge and the response from Harmoni. The strength of the concerns expressed and the speed of response from the provider were evident. Regional quality assurance meetings are held monthly basis where cases are all discussed as well as the listed performance data. In addition there are monthly Clinical Leads meetings alternately held regionally and nationally to provide a forum for shared learning and discussion around clinical performance. 23

24 Reflect is a learning tool, which captures and circulates examples from incidents as well as complaints, audits, compliments and good practice throughout Harmoni. Management of Rotas and Induction The IQUS RotaMaster rostering system is used to manage staffing levels. The system allow rotas to be adjusted in line with historical demands and trends and to send group texts in case of sudden increase in demand or cancellation of shifts. The system also generates a weekly report detailing clinicians first shifts and attendance variation to scheduled rotas. This information is circulated to Clinical Leads and the Senior Management Team for audit and review purposes. A weekly conference call takes place to discuss the previous weeks NQR performance and rota fill for the following week. All clinicians including locums and agency staff are required to undertake a faceto-face induction before starting work. An Induction Pack is provided for locum and agency staff as well. Recruitment Processes Employment requirements include: Registration with the GMC Membership of a medical defence organisation Presence on a Local Performers List The above information is checked annually. Employed GPs have a contract of employment with Harmoni. Self-employed GPs have a contract of services where no employment rights are involved. Contract Monitoring Monthly formal performance meetings take place with the South West London commissioners. Issues discussed include - NQRs, recruitment, rota fill, CQC, quality issues, patient feedback, complaints, complements and risks. In addition pertinent issues are discussed as they arise e.g. concerns about GPs. Other issues discussed include pressure on the service, forward plans. There is considerable evidence of challenge and response between the cluster and Harmoni. 24

25 Harmoni appear to respond promptly to information requests. In addition we were provided with evidence to demonstrate changes which result from the monitoring process. As previously mentioned we saw evidence of communication with Richmond GPs and Harmoni which focussed on patient safety and the quality of services. We saw no evidence suggesting that the commissioner met with resistance in the provision of information to enable them to monitor the contract. Patient/Service User Feedback 10% of patients are randomly chosen to complete a satisfaction questionnaire. Notices are also put up in in all Primary Care Centres inviting patients to provide feedback either by letter, phone or . The Harmoni website is also well publicised. In addition, as well as working with LiNKs, Harmoni listens to staff who have regular contact with patients and they plan in the future to work with practice based patient groups. Complaints, complements and incidents are also used to gauge patient satisfaction. Communication with Staff and Other Stakeholders Communication with staff and other stakeholders take place in a number of ways including via , the intranet where all policies, procedures, agendas and minutes of meetings are posted, newsletters relevant to each area. There is an organisational newsletter called INSIGHT and another called REFLECT which the Education, Training and Governance Team produce. This newsletter is used to share learning from incidents and complaints across the organisation. Quarterly staff meetings for staff, including clinicians, where issues can be raised and feedback given, an annual staff surgery hosted by the Managing Directors in each areas, and staff conferences. Annual staff surveys are also carried out. Webinars are also used to communicate information across the organisation. 25

26 East Berkshire Primary Care out-of-hours (EBPCOOH) All the GPs in the NHS Richmond area are opted in to provide OOH cover and are therefore contractually responsible for their out of hours services. Harmoni is subcontracted by NHS Richmond GPs to provide the face-to-face contact for patients requiring OOH services. In April 2011 East Berkshire Primary Care Out of Hours Service were commissioned to provide the call-handling element of the OOH service. EBPCOOH is a not for profit organisation registered under the Industrial and Provident Act Publically available accounts can be seen online at the FSA mutual public register. EBPC is registered with CQC. The company is not part of wider health care organisation. Corporate Governance The Clinical Governance Framework in conjunction with the Quality, Governance, Patient Safety and Risk Committee (QGPSR) oversees the Corporate Governance arrangements. The Terms of Reference of the QGPS&R sets out how the Council is assured that quality assurance, clinical governance and patient safety mechanisms and processes are integral to providing services across the organisation and to ensure that patients have effective and safe care with a positive experience. The Clinical Governance Framework demonstrates the organisation s holistic approach to governance whereby there is no segregation between clinical nonclinical, financial or corporate governance. This approach emphasis the inter-relation between all governance functions with reports from each function presented at board meetings by the relevant leads. Organisational Structures and Accountability The Council has overall responsibility for the scrutiny of the clinical governance agenda and outcomes, and for meeting all statutory requirements and adhering to guidelines issued by the Department of Health and or other regulatory bodies in respect of governance. 26

27 The Chief Executive has overall accountability for corporate governance. The Clinical Executive is the delegated persons who on behalf of the Chief Executive, is accountable for the clinical and quality governance within the organisation) and will discharge their responsibilities through the Quality, Governance Patient Safety and Risk Committee as its Chair. The Chief Executive holds the responsibility for managing the strategic development and implementation of organisational risk management. The Medical Director and Clinical Governance Manager jointly share the delivery of clinical effectiveness and clinical and quality governance. Scrutiny of the Executive Scrutiny of the executive is carried out by the Council Board. How the board holds the Executive Directors to account is set out in the Company Rules. In relation to reporting mechanisms the Council receives reports on the organisations business at each meeting and evidence of this was seen in the Council Agenda template and minutes of meetings (July 2012). Governance Systems As part of their preparation for the CQC registration EBPCOOH carried out an audit of all the corporate and clinical systems and processes that it relies on to ensure good governance across the organisation. As a result of this exercise all policies were reviewed and updated. A range of policies relating to governance were seen by the reviewers. These, as well and the interview with the Medical Director offer reasonable assurance that the infrastructure is in place to ensure that the organisation is fit for purpose and has appropriate controls in place to ensure care is delivered safely. However the scope of the review was such that we were unable to test the extent to which the policies and procedures are embedded across the organisation. Other Performance Data The organisation sends the following performance to the commissioners: Patient experience outcomes Incidents, complaints, compliments and concerns 27

28 HR and appraisals Education and training uptake Information governance toolkit outcomes Financial indicators Clinical Audit Sickness absence monitoring Monthly service reports are also produced. How Clinical Quality is Assessed and Promoted It was reported that clinical services delivery is underpinned by the Quality, Governance, Patient Safety and Risk Strategy (QGPSR). This is a comprehensive strategy and to ensure that it is embedded across the organisation all key functions are represented - clinical governance, information governance IT, HR, patients/carers and clinicians. Its committee meets monthly and reviews adverse and serious incidents, the risk log, complaints and patient experience, lessons learned and reports regarding data quality, performance and clinical audit, corporate risk register and the Information Governance toolkit. The QGPSR committee is chaired by the Medical Director and reports to the Management Executive who in turn reports to the Council Board. The specific arrangements and reporting structure for both clinical and corporate governance are clearly set out in this strategy. All the quality areas have designated executive leads. A range of policies were seen by the reviewers, which support clinicians in their roles. These include the process for reporting risk, adverse incidents, Personal Development Review also a Stress Policy, Dignity at Work Policy, Equal Opportunity and Diversity Policy, Alcohol Substance Misuse Policy and Disciplinary Policy. The following committees report to the QGPSR committee Management Executive Committee, Management Operations Committee, Information Governance Group, Medicines Management Committee and the Education and Training Group. 28

29 Reviewing the Work of the Clinical Staff Audit of clinical staff work is carried out through an on going programme of clinical audit. The Clinician Guardian software 9, an online audit database which monitors clinician performance is used. It is designed to pick up clinical practise, which might give cause for concern. Colour coding allows the auditors to identify new clinicians and those who may need additional support. The results are discussed and performance managed at the Quality, Governance, Patient Safety and Risk Committee. Annual appraisals for employed are also carried out but not for GPs in their out-of hours role. Management of Rotas and Induction The RotaMaster web based system is used for regular GPs. Locums are allocated regular sessions and are required to work twelve shifts before they can qualify as an out-of-hours GP. Following this they are required to work two sessions shadowing a GP trainer. Medical rotas are produced and monitored by the Resource Manager. All new staff, including locums and agency staff, are required to attend an induction programme, which includes shadowing a GP trainer. The staff handbook and all policies and procedures are available on the intranet. Recruitment Processes The Recruitment and Selection Policy sets out the process for recruiting and selecting staff including the specific identification documents for clinicians as well as GMC registration and CRB checks. References are also taken up. GPs employed by the organisation are required to sign a Service Level agreement on appointment

30 Three GPs have been referred to the GMC in the year up to June 2012 but these were not referred by EBPCOOH. Contract Monitoring The First Contact Committee is the main vehicle for monitoring the contract and this meets regularly with the providers. The committee is a mix of clinicians and managers and is governed by terms of reference. The terms of reference suggest that meetings were initially monthly and then reduced. Formal contract monitoring meetings take place with commissioners. Minutes of the formal minutes were not seen. It was reported that out of hours staff have access to commissioners between those meetings on an informal basis to discuss issues as they arise. The committee has signed agreement from the practices to carry out this work on their behalf. Patient/Service User Feedback The Compliments, Comments, Concerns and Complaints Policy and Procedure sets out the organisation s commitment to listen to patients and to take their complaints seriously and learn from them. A leaflet is available for patients setting out clearly how to make a complaint and how the organisation will deal with it. Patient experience is monitored monthly and it was reported that a patient representative attends the QGPS&R committee who offers useful feedback and challenge. The organisation plans to review how it can improve compliance with patient satisfaction questionnaires. Communication with Staff Communication with staff is via a news bulletin, annual staff surveys, website and the intranet. This is a small organisation where many of the GPs know one another through other networks, which augment those of EBPC. 30

31 Overall Findings Contract monitoring Commissioner Contract Monitoring The arrangements for delivering out-hours-services across NHS South West London (NHS SWL) is set out in the following table: PCT Provider Opted in GPs Opted out GPs Richmond and Harmoni and East Berkshire 32 0 Twickenham Primary Care OOH Kingston Harmoni 3 24 Sutton and Merton Patient Care Wandsworth Harmoni 2 41 Croydon Patient Care TOTAL The Monitoring Process Each contract is effectively monitored and there is evidence to show that the transition to CCGs has been supported. The cluster team have regular meetings with the OOH providers, these meetings are fully minuted and there is considerable evidence of challenge to providers to ensure that services are delivered appropriately. The team have endeavoured to be inclusive of CCGs in their approach. The monitoring of the Croydon area contracts has been undertaken by the CCG since January Wandsworth CCG took over contract management for that area in November Due to the mix of contracts the monitoring procedure differs between the opted in and opted out practices and the monitoring process for all providers is set out in the document Contract Management Assurances for Out-of-Hours Services OOH providers are required to submit monthly reports that measure their performance against the National Quality Requirements (NQR). In addition to the above NHS SWL holds quarterly contractual performance meetings with the OOH providers. These meetings are held between senior provider representatives and the Primary Care Managers as well as Borough Commissioning Leads. 31

32 Evidence of those meetings confirms that the emphasis is on performance against NQR standards, complaints, serious incidents and finance. Breaches and issues of non-performance are discussed and action plans agreed to address the breaches. (Examples are: Harmoni 16 October 2012, 22 January 2013, Action Plan for South West London, PC24 24 July 2012, letter to Harmoni 16 February 2012, Performance Summary October 2012, Contract Management Assurances for Out-of-Hours Services 2012, NHS Richmond OOH Committee Year End Assurance Report). The Year End Assurance Report , summaries the monitoring and reporting arrangements and sets out the breaches with actions to address them. Internally each organisation reported that the above were discussed at board meetings. Evidence of this was seen in agendas. Minutes of board meetings from PC24 made available were mainly from 2011 to March 2012 and while performance against NQR standards was discussed there is little detail in the minutes to track progress on previous actions agreed or action on issues raised. We note that on occasion information has not been provided to commissioners when requested because PC24 were not sure what the trust planned to do with the information. Contract Monitoring minutes from East Berkshire Primary Care were not made available due to the confidential nature of the content EBPCOOH Questionnaire question 10). 32

33 Conclusions The three organisations reviewed are very different in scope, style and construction. We found evidence of good practice in all three organisations. Each organisation has systems in place which should help it to avoid the issues seen at Croydoc where one individual held many positions and where reports into the issues there suggest that challenge to and within the executive was not effective. We have been able to consider how the boards gain their assurance of the services which are provided. We have not been able to test within each organisation how embedded the approaches to governance are, but we have been able to form a view of what the systems appear to achieve. The review obtained a broad overview of the quality and safety of the three organisations by examining the systems and processes in place to support their corporate and clinical management arrangements. All three organisations demonstrated that their governance arrangements offered reasonable assurance that care is delivered safely and effectively. Their financial, clinical and activity performance monitoring arrangements and the processes in place to support clinicians in their work demonstrated this. NQRs were monitored monthly or quarterly and all three organisations this was supplemented by a range of other performance data to accompany the NQRs. Support from commissioners was reported as generally positive. We would note that NQRs are to be replaced by quality indicators, as they have not been substantially revised since We would observe that Harmoni as might be expected of a large organisation with a single service model are particularly responsive to information requests and dealing with service concerns. This makes managing the contract more straightforward. For example we saw no evidence of a refusal to share information with the commissioner by Harmoni whereas we did see this on the part of Patient Care

34 The evidence gathered by this review suggests that the relationship between the commissioners and Harmoni is totally business orientated. The monitoring of these contracts by commissioners appears to be particularly rigorous. Whereas in the cases of EBPC and Patient Care 24 there are residual aspects of a system of trust and assumption which harks back to GP co-op days when organisations were small and everyone appeared to know everyone else. It is not clear at this stage how this approach will play out in new NHS organisations, it might be advantageous. EBPC are particularly dependent on a small staff team and in particular their Chief Executive. His absence through illness created a number of problems for the organisation including a serious delay in providing information for this review. We would also note that EBPC have a clear view of the type and scale of organisation, which they wish to be and have geared their systems to this. All three organisations demonstrated that they were responding to the changing NHS landscape by trying to ensure that their infrastructures were fit for purpose when CCGs come into their full role in April 2013 while ensuring that quality and patient safety was not compromised in the transition. However, while the reviewers were reasonably confident that all three organisations had adequate patient safety systems in place the scope of the review was unable to test the extent to which these were embedded in the day to day work of clinicians, call handlers and all staff as well as experience of practices whose patients are cared for by the out-hours-services and the local LiNKs. This would have allowed them to test out the evidence gathered from the questionnaires and in interviews and to get a feel for the culture of the organisations reviewed. The focus of CQC visits will be on the experience of patients and staff and whether the culture of the organisation enhances the quality and safety of services delivered. For this reason they will spend more time talking to staff and patients and will only examine documentation to confirm evidence collected during those discussions. 34

35 This is a different type of assessment to those previously undertaken and whilst it may not always be methodologically clear and the sample size of those spoken to may be small, it is apparent that CQC feel that it is appropriate. There were some good examples of data analysis to try to get a feel at a granular level what the quality of the service being delivered by individual clinicians looks like. The way in which user complaints are treated appear to meet the requirements of the present complaints process and all three organisations were able to cite processes for sharing learning. All three organisations had policies for those who needed to raise clinical concerns. All three reported that they had mechanisms to deal with individual clinical performance issues which linked to PCTs. PC24 in particular had a well thought through approach to revalidation and use of OOH data. As the future arrangements for commissioning of out-of-hours services emerge pressure will be on current out-of-hour services to compete against other providers entering the market on volume, quality and cost. All three organisations were confident that their management arrangements were flexible enough to respond to those challenges. The challenge for commissioners, therefore, will be to demonstrate rigorous evaluation of bids and on going contract monitoring to ensure that issues, which may compromise patient safety, are identified and addressed at an early stage. Where private companies provide services under a contract and that company is taken over by another company, the commissioner finds themselves in contract with a different organisation to the one with whom it agreed the contract. This scenario was played out when Harmoni was taken over by Care UK during this review. OOH services are awarded by a competitive tendering process. Contracts should contain clauses which will protect commissioners interests and ensure that providers of service are appropriate and acceptable. The way in which such changes are conveyed to both GPs who work for the service and patients who use it can require very careful handling. 35

36 We note that the failure of some organisations and the replacement of the service by another provider has not changed the way in which OOH is delivered but has been perceived negatively in the local health community. There are also challenges where GPs are not all opted in or all opted out to the provision of service. Present guidance shows two different commissioners for these two approaches. In addition where companies exist or are set up by GPs to bid for services within a CCG area it will be important to understand clearly how perceived conflicts of interest may be handled. The NCB is to be the arbitrator in contract disputes via their Area Teams, the detail of how this will work is not yet clear and whilst few cases go to arbitration, all parties need to be confident in the independence of the NCB to carry out this task. GPs may work in OOH services as well as their practices; this may be a valuable source of soft information and a potential source of checking data. As yet this information source sits outside contract monitoring and if it is to be used, it needs to become systematised. CCGs may be in a good position to understand the variation in patient use of OOH services and of other urgent and emergency care services. The analysis of such variation is complex and requires careful assessment and handling. However, it could be a tool to provide a really effective understanding of the quality of services and as one to change these. The development of the sector offered an opportunity to commission OOH services across a wide area. This approach was mooted but was not enacted. Such an approach might be revisited especially as changes occur to the provision of nonbooked access to urgent and emergency care services with the downgrading of A&E departments. GP Out of Hours care is provided to patients for hours (69%) of a week. We would observe that both commissioning and contract monitoring teams for OOH are small and covering wide areas, their ability to analyse data and follow up on information is likely to be limited. 36

37 At the same time services associated with OOH care may be provided by different organisations, call handling separated from provision of advice and face-to-face service. Out of hours is usually a part of a commissioner s work load in the same way that out of hours is part of a doctor s. Given the risks associated with this service and the greatly expanded role and time for which the service operates, new NHS organisations need to consider how they can effectively monitor out of hours services contracts for quality and obtain sufficient assurance. 37

38 Recommendations During the transition period commissioners need to plan for a smooth handover of responsibility to the new commissioners. At the same they need to involve out-of-hours services in discussions about emerging developments both locally and from the NCB. This includes working in partnership with other organisations to develop local solutions to local problems. In the light of the Francis Report commissioners also need to be assured that outof-hour services, just like other services, continue to develop services based on quality, effectiveness and patient safety. This can only be done by rigorous and challenging monitoring arrangements which hold out-of-hour services to account. Therefore commissioners should consider how they intent to continue discharge their responsibilities in this area. The present NQRs are to be replaced and do not provide sufficient detail for full assurance. In some cases (e.g. NQR 9 when services are front ended by 111) they are redundant. Commissioners should work together to identify what good quality reporting standards should be with a view to implementation. In addition commissioners should work with out-hour-services to develop and monitor the implementation of the NHS 111 service to ensure that patient safety is not compromised during implementation. This should include ensuring that issues are identified and addressed as they arise and lessons learned are shared. Rigorous monitoring of contracts needs to continue using all information available including information gathered from a range of sources e.g. patients and local groups, social services, staff, clinicians and practices. CCGs should consider how they will be accessing such information in relation to OOH and urgent care. The detailed and sensitive analysis of the outputs of contract monitoring need sufficient resourcing and linkage to wider urgent care networks. This approach should enable commissioners to have a clearer understanding why services are used as they are and which levers to use to implement pathway change. CCGs should consider if they have systems and individuals in place to deliver this. In addition they should clarify with professional representative bodies 38

39 such as the LMC their approach to the use of information obtained via contract monitoring. Commissioners should ensure that changes to OOH services are well communicated and be proactive in managing public relations in this area. Given that OOH is an area where GPs may well be commissioners and providers of services, clear processes to identify conflicts of interest and perceptions of plurality of position is vital if confidence is to be maintained in both the healthcare and wider community. 39

40 Appendix A Terms of Reference 40

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