Quality Assurance in Primary Care

Transcription

1 Clinical Standards Board for Scotland Quality Assurance in Primary Care RCGP Practice Accreditation Progress Report September

2 CSBS 2002 First published September 2002 The Clinical Standards Board for Scotland (CSBS) consents to the photocopying, electronic reproduction by uploading or downloading from the website, retransmission, or other copying of this report for the purpose of implementation in NHSScotland. Clinical Standards Board for Scotland Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA

3 Clinical Standards Board for Scotland Quality Assurance in Primary Care RCGP Practice Accreditation Progress Report September 2002

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5 Contents Executive Summary 4 1. Background and Objectives 6 2. Methodology 7 3. Results 8 4. Discussion and Conclusions 15 Appendices Appendix A Questionnaire 18 Appendix B Detailed Feedback: Barriers to Achieving RCGP Practice Accreditation Time-scales 21 Appendix C Detailed Feedback: Support for RCGP Practice Accreditation 23 Appendix D Appendix E Appendix F Detailed Feedback: Assessor Recruitment and Selection Detailed Feedback: Assessor Reimbursement 26 Detailed Feedback: Comments and Suggestions to Improve RCGP Practice Accreditation 30 Key Contacts for RCGP Practice Accreditation and Primary Care Quality Initiatives 32 3

6 Executive Summary Context In March 2002, the Clinical Standards Board for Scotland (CSBS) distributed a questionnaire survey to determine Trust 1 progress in implementing the Royal College of General Practitioners Scotland (RCGP) Practice Accreditation scheme. The key objectives of the study were to determine current time-scales for the completion of RCGP Practice Accreditation by all non-training general practices in Scotland, barriers to achieving these targets, resource implications of supporting Practice Accreditation, and suggested improvements to the scheme. This report summarises the Trust responses to the survey, and incorporates recent data from the RCGP and Trusts on the number of practices that have completed the scheme in each region. Key Findings Significant enthusiasm was displayed for the RCGP Practice Accreditation scheme. Most Trusts projected time-scales for the achievement of Practice Accreditation by non-training practices had altered from initial estimates in March 2001, and Trust respondents noted that the time required to implement the scheme had been greater than expected. Possible barriers affecting uptake of the scheme included staffing and resource limitations, varying incentives for practices to complete the award, and lack of clarity over the voluntary nature of the scheme. A number of different initiatives are in place across Scotland to support RCGP Practice Accreditation, and the dissemination of current experience and good practice was requested by numerous respondents. Inconsistencies were highlighted between Trusts as to the amount and type of funding allocated to support Practice Accreditation, and methods for the recruitment and support of assessors. Correspondingly, suggested improvements to the Practice Accreditation model included a greater consistency of approach to administrative and financial issues, such as a centrally managed support system for assessors. Several Trusts also requested clarification and guidance over future aspects of the scheme. 1 For simplicity, the term Trust is used throughout this document to refer to all the NHS organisations included in the progress report. Most of them are Trusts, with the exception of the three Island NHS Boards Orkney, Shetland and Western Isles. 4

7 Executive Summary Proposals for Further Evaluation The RCGP and CSBS will consider the results of this study in planning the development and introduction of Version 2 of Practice Accreditation. To further evaluate aspects of the Practice Accreditation scheme from an independent perspective, an external evaluation exercise will be commissioned by CSBS and NHS Education for Scotland (NES). The results of the evaluation will influence the development of Version 2. In addition, this progress survey will be repeated in one year s time to assess changes in planned time-scales and support for RCGP Practice Accreditation. 5

8 1 Background and Objectives In June 2000, CSBS endorsed the RCGP Practice Accreditation scheme as the most appropriate methodology currently available to ensure the quality of primary care services in Scotland. CSBS asked Primary Care NHS Trusts and Island NHS Boards to support and resource the process of accrediting general practices in their area. A scoping study was conducted in March 2001 to determine each area s plans for implementing Practice Accreditation (Version 1), and CSBS was encouraged by the response to the roll out of the scheme. This follow-up study, one year later, has been conducted in order to determine the current position and resource implications of implementing Practice Accreditation in each area. The key objectives of this study were to ascertain: current time-scales for the completion of RCGP Practice Accreditation by nontraining practices in each Trust; barriers to achieving these targets; financial and administrative resources required to support Practice Accreditation; and changes that might be made to improve the process of Practice Accreditation. It was intended that this information would be presented to the CSBS Primary Care Reference Group, to allow it to make recommendations to both CSBS and the RCGP regarding future time-scales and resource requirements for Practice Accreditation. 6

9 Methodology 2 A questionnaire addressing the study s objectives was drafted by CSBS in collaboration with the RCGP (Appendix A). The questionnaire was sent to the Chief Executives of all Primary Care NHS Trusts, Island NHS Boards and the West Lothian Healthcare NHS Trust (17 in total), with a covering letter from the Chief Executive of CSBS. The questionnaire (with a freepost return envelope) was distributed on 6 March A three-week reply date was specified, following which the results were collated for presentation in this report. The interpretation of results was assisted by RCGP and Trust data on the number of practices completing Practice Accreditation in each region. Comparisons were also made with information from the CSBS scoping study conducted in March Data were analysed using Microsoft Excel 97. 7

10 3 Results 3.1 Response Rate Of the 17 questionnaires distributed, replies were not requested from two regions NHS Lanarkshire and Orkney. The questionnaire was not pertinent to Lanarkshire Primary Care NHS Trust as it is running its own clinical governance quality assurance scheme for primary care services in lieu of RCGP Practice Accreditation. Orkney NHS Board is currently considering introduction of the Practice Accreditation scheme, and did not yet have any data or comments to supply. Completed questionnaires were returned from all of the 15 remaining Trusts. Respondents were generally able to complete all sections of the questionnaire. 3.2 Projected Time-scales for Completion of RCGP Practice Accreditation by Non-Training Practices Trusts were asked to indicate progress towards and plans for achievement of RCGP Practice Accreditation by non-training general practices in their area. Training practices were examined separately (see section 3.8), as the main focus to date for quality assurance in training practices has been on completing the NES Training Practice Accreditation award. Compared with plans from March 2001, 14 of the 15 Trusts surveyed had altered their projected time-scales. Five areas extended the date by which all their nontraining practices were expected to achieve Practice Accreditation. The remainder redistributed the number of practices projected to achieve Practice Accreditation for each year up to and including Data from the RCGP and Trusts showed that at 22 July 2002, 128 of the 763 nontraining practices in Scotland (17%) had achieved Practice Accreditation. An average of 8 non-training practices from each Trust (19%) had completed the scheme, with levels of accreditation in Trusts ranging from 0 to 24 practices (0 to 73%), as shown in Figure 1. Currently, 12 out of the 15 Trusts surveyed anticipate that all their non-training practices will be accredited by December Of the remaining three Trusts, one predicts that all non-training practices will be accredited by 2005, while at present the other two cannot nominate a date. 8

11 Results 3 Figure 1 Number and percentage of non-training practices awarded RCGP Practice Accreditation at 22 July (48%) 24 (15%) (27%) (24%) Aryshire & Arran PCT Borders PCT Dumfries & Galloway PCT 8 9 (43%) 8 9 (19%) (73%) (17%) Fife PCT Forth Valley PCT Grampian PCT Greater Glasgow PCT Highland PCT 6 (16%) 0 (0%) 3 (8%) Lanarkshire PCT Lomond & Argyll PCT Lothian PCT Orkney NHS Board Renfrewshire & Inverclyde PCT (4%) 0 (2%)(13%) (0%) 0 (0%) 3 (21%) Shetland NHS Board Tayside PCT Western Isles NHS Board West Lothian Healthcare NHS Trust Trust Data source: RCGP & Trusts, Barriers to Achieving Time-scales Major barriers to achieving target time-scales for completion of RCGP Practice Accreditation by non-training practices were identified across the 15 Trusts surveyed, and have been compiled in Appendix B. While many Trusts provided responses specific to their own situation, several issues were consistently highlighted, and are summarised below: Time lack of protected time to undertake Practice Accreditation; single-handed practices not having time to prepare; and time and workload for assessors in small areas who have other competing priorities. Workload perceived workload attached to undertaking Practice Accreditation; and 9

12 lack of staff resources and team support within practices to support the process of Practice Accreditation. Financial assistance inadequate resources at practice level; and impact of central decisions and priorities on practices. Incentives clarification required from RCGP and CSBS as to whether Practice Accreditation will remain voluntary; less pressure on practices and less incentive to apply if Practice Accreditation remains voluntary; and some practices are unhappy with the feeling of being pushed into the process while the scheme remains voluntary. 3.4 Administrative Support for RCGP Practice Accreditation The ways in which the process of RCGP Practice Accreditation is supported varied considerably across the Trusts. Of the 15 Trusts surveyed, 13 currently have a designated officer to support Practice Accreditation, while the other two divide administrative and managerial tasks between a range of individuals within the Trust. Of the Trusts who have a designated officer to support Practice Accreditation, the time allocated to this task is often an integral part of the officer s duties, and difficult to quantify. However, several Trusts have an officer working full-time to support Practice Accreditation. The grades of staff responsible for supporting Practice Accreditation range from Administrative and Clerical Grade 5 to Senior Management Grade 4. Also, in two Trusts the designated person responsible for Practice Accreditation is the Medical Director. The ways in which Trusts facilitate the Practice Accreditation scheme have been compiled in Appendix C. From these responses, some recurring forms of support for Practice Accreditation have been identified as: administration and support from clinical governance departments; financial and administrative support from Local Health Care Co-operatives (LHCCs); assessor meetings and networks; practice support through visits, workshops, mentorship and mock assessments; and 10

13 Results 3 development of written and electronic resources on Practice Accreditation and practice policies or procedures. 3.5 Financial Support for RCGP Practice Accreditation The range of financial support for Practice Accreditation also varied widely across the Trusts surveyed, both in value and the purposes for which funding was provided. A common method of funding saw the allocation of a lump sum (ranging from 1,400 to 250,000) for central support of Practice Accreditation, plus small sums ranging from 500 to 1,560 for each practice - either upon achieving Practice Accreditation or to support the process of applying. In some cases (eg where 250,000 was made available), the central support sum was allocated to the LHCCs who made local decisions on how this would be used. In other cases, funding was sliced from the clinical governance budget, or allocated to practices on the basis of their number of whole-time equivalent GP principals. The financial resources identifed above to support Practice Accreditation were allocated on a recurring basis in 12 out of the 15 Trusts surveyed. As mentioned, there was considerable variability in the amount and form of this funding. While it would be expected that the geographical size and catchment population of each area would impact on resources allocated, there appeared to be little consistency in the funding provided across the 15 areas. 3.6 Assessor Recruitment and Reimbursement The number of RCGP trained assessors in each Trust ranged from 3 to 17, with a mean of 10 assessors per area across the 15 regions surveyed. The number of assessors in each area appeared to be only partially related to geographical size and number of practices, with the ratio of assessors to practices varying from around 1:1 to 1:15. There also appeared to be a crude correlation (r = 0.5) between a higher ratio of assessors to practices and the number of practices that had achieved Practice Accreditation to date in each Trust. The major processes identified for recruitment and selection of assessors across the 15 Trusts have been compiled in Appendix D. There was a degree of variation in these methods, but the main processes employed are summarised below: letter from Trust Medical Director or LHCC to all practices seeking nominations; advertisements via LHCCs; names of potential assessors submitted by LHCC to Trust, or individuals submit expressions of interest; 11

14 further recruitment through head-hunting and canvassing of practices which have achieved Practice Accreditation; consideration of candidate s qualifications and experience; and panel interview and appointment. The different forms of payment provided to assessors have also been compiled in Appendix D, and included: sessional rates to cover absence; reimbursement of locum fees for GPs; reimbursement of travel expenses; and reimbursement of time for community staff, rather than direct payment. In several areas, reimbursement of sessional rates covered pre-assessment preparatory work and follow-up, as well as time spent at the visit. Other Trusts allocated a specific fee per visit, or a specific number of sessions for reimbursement per visit. While methods of payment generally follwed one of the above forms, there was noticeable variation in the amount of reimbursement between the 15 Trusts surveyed. 3.7 Comments and Suggestions to Improve RCGP Practice Accreditation A number of comments and suggestions about Practice Accreditation were received, and these have been compiled in Appendix E. Issues arising from these comments focused on the voluntary nature of the scheme, incentives for practices to complete the award, and staffing and resource limitations. Many of these comments correlated with points raised in Section 3.3. The major suggestions given to improve the process of RCGP Practice Accreditation can be summarised as: provide guidance on future aspects of the scheme, including its voluntary nature; provide incentives to make Practice Accreditation attractive to less enthusiastic practices; improve consistency of approach to implementation across Scotland, eg central management; increase support and resources provided to practices to undertake Practice Accreditation; and facilitate networking between Trusts to share knowledge and good practice. 12

15 Results Training Practices A section was also included in the questionnaire to assess Trust time-scales for the completion of NES Training Practice Accreditation and RCGP Practice Accreditation by training practices. Trusts were asked to indicate how many training practices had achieved, or would undergo, either: Training Practice Accreditation only; a joint Training Practice Accreditation/Practice Accreditation visit; or separate Training Practice Accreditation and Practice Accreditation visits. Some confusion stemmed from the wording of this question, and the responses did not clearly indicate whether practices would be applying for initial Training Practice Accreditation or re-accreditation, thus compromising the data. However, for those practices planning to undertake Training Practice Accreditation nearer to 2004, there was a strong trend towards completing a joint Training Practice Accreditation/Practice Accreditation visit. Several of the survey respondents queried the future of the joint visits, and requested clarification on this issue. Separate data from the RCGP and Trusts showed that at 22 July 2002, 42 of the 295 training practices in Scotland (14%) had achieved Practice Accreditation (see Figure 2). The award was achieved through both joint Training Practice Accreditation/Practice Accreditation visits and independent Practice Accreditation visits. 3.9 Quality Practice Award In addition to RCGP Practice Accreditation and the NES Training Practice Accreditation scheme, the RCGP also offers the Quality Practice Award, a more challenging scheme that takes training or non-training practices one to two years to complete. Currently, 36 practices have achieved the award, representing 3% of Scotland s general practices (see Figure 2). Undertaking the more rigorous Quality Practice Award is considered by the CSBS Primary Care Reference Group as at least equivalent to completing the Practice Accreditation scheme. These figures should therefore be taken into account when considering the number of general practices which are meeting the standards of Practice Accreditation. The Quality Practice Award was introduced in 1995, four years before Practice Accreditation, and all of the practices completing the Quality Practice Award to date have done so without first completing Practice Accreditation. Practices achieving Practice Accreditation are now being encouraged to progress to the Quality Practice Award. 13

16 3.10 Overall Uptake of Quality Initiatives At 22 July 2002, 170 of the 1,058 general practices in Scotland (16%) had completed the Practice Accreditation scheme and 36 practices had completed the Quality Practice Award, as shown in Figure 2. A further 291 non-training and training practices have applied to undertake Practice Accreditation, representing a combined national uptake of over 45% for Practice Accreditation and the Quality Practice Award. In addition, a number of practices are undertaking independent clinical governance and quality assurance initiatives, which are currently being conducted in several Trusts. Figure 2 Number and percentage of general practices awarded RCGP Practice Accreditation or Quality Practice Award at 22 July (49%) 32 (37%) 31 (14%) 34 (32%) Aryshire & Arran PCT Borders PCT (21%) 8 (28%) 9 (15%) (36%) Dumfries & Galloway PCT QPA awarded practices PA awarded training practices PA awarded non-training practices Fife PCT Forth Valley PCT Grampian PCT Greater Glasgow PCT Highland PCT 16 (22%) Lanarkshire PCT Lomond & Argyll PCT Lothian PCT Trust 1 (1%) 9 (19%) 0 (0%) Orkney NHS Board Renfrewshire & Inverclyde PCT 4 (7%) 2 (20%) 5 (7%) 0 (0%) 3 (13%) Shetland NHS Board Tayside PCT Western Isles NHS Board West Lothian Healthcare NHS Trust Data source: RCGP & Trusts,

17 Discussion and Conclusions 4 This study provided an indication of the considerable enthusiasm for the RCGP Practice Accreditation quality assurance scheme from those working in primary care services in Scotland. From the responses generated, it was apparent that there are a number of different initiatives in place to support and resource RCGP Practice Accreditation across Scotland. Most Trusts projected time-scales for the achievement of Practice Accreditation by non-training practices have changed from initial estimates last year, although not by a long way, and respondents noted that the time required to implement the scheme has been greater than expected. Themes identified included a range of barriers that may affect uptake of the scheme, problems with the current administration of Practice Accreditation, and suggestions for improving this process. The results of the survey must be considered in the context of over 1,000 general practices in Scotland, and the relatively recent introduction of the Practice Accreditation scheme. The existence of alternative quality assurance mechanisms, such as clinical governance schemes operated by some Trusts and LHCCs, may be one factor contributing to the observed discrepancies in uptake and funding for the scheme. Practice Accreditation has been set up with very limited earmarked funding; progress locally and nationally therefore needs to be considered against this background. Several Trust respondents suggested that the RCGP needs to allow time for all practices to undergo Version 1 of Practice Accreditation before a second version is introduced. The RCGP and CSBS will consider the results of this study, in particular the proposed time-scales for progress, in planning the development and introduction of Version 2 of Practice Accreditation. An external evaluation of Practice Accreditation, currently being commissioned by CSBS and NES, will also influence the development of Version 2, and some of the barriers and facilitating factors to the implementation of Practice Accreditation identified in this study may provide initial direction to such research. In addition, the quality framework being developed nationally for the new GP contract may influence the future direction of Practice Accreditation. Problems with uptake and administration of the Practice Accreditation scheme identified by the 15 Trusts surveyed included several recurring issues, as outlined in Sections 3.3 and 3.7. Two main themes from the feedback were the desire for dissemination of knowledge and experience of Practice Accreditation across 15

18 Trusts, and for clarification and guidance from the RCGP and CSBS about future aspects of the scheme. It should be noted here that neither the RCGP, nor CSBS, has a mandate as to whether the scheme remains voluntary or otherwise; however, a range of issues around support and administration clearly need to be addressed. Recent work by the RCGP and NES has resolved many of the details pertaining to joint Training Practice Accreditation/Practice Accreditation visits. There is much overlap in the content of the two schemes, and NES is committed to ensuring that practices undertaking Training Practice Accreditation visits can also achieve Practice Accreditation without the need for a further visit. For a practice to achieve Practice Accreditation in conjunction with a Training Practice Accreditation visit, the RCGP requires that an RCGP trained assessor take part in the visit and complete the relevant pro forma to indicate which criteria have been met. NES convened a working group earlier this year to review the Training Practice Accreditation paperwork, and as a result joint paperwork has been developed and was launched at the start of August. The RCGP and NES now need to ensure that this information is disseminated widely across Trust networks and all relevant stakeholders. The survey identified many initiatives in place across Scotland to support Practice Accreditation, and it is hoped that this report will act as a catalyst for the dissemination of examples of good practice between Trusts. Inconsistencies were highlighted between regions as to the amount and type of funding allocated to support Practice Accreditation, and the RCGP needs to address this issue in consultation with Trusts. Where some practices do not receive any funding for completing Practice Accreditation (compared with others who are allocated up to 1,560), this may be a disincentive to completing the award. A good number of Practice Accreditation assessors have been recruited to date, although different methods are being utilised for recruitment of these volunteers, with varying degrees of success. A crude correlation was evident between a higher ratio of assessors to practices and the number of practices that had achieved Practice Accreditation to date in each Trust. If Trusts are to meet their target time-scales for the accreditation of all practices, there would appear to be a requirement for the training of more assessors, and therefore further resource requirements. Additionally, as one respondent noted, variable financial and administrative support for assessors may compromise the validity and integrity of the scheme. It was suggested that it might therefore be more 16

19 Discussion and Conclusion 4 appropriate for the assessment process to be managed centrally, and Scotland could look to international models to provide guidance for future development. In summary, the information gathered via the questionnaire was extremely informative and will be used to guide future time-scales and development of the Practice Accreditation scheme. Practice Accreditation takes on particular relevance in light of the new draft GP contract, which includes quality criteria covered by the scheme, and the proposed annual appraisal system. Work will commence in 2003 on finalising Version 2 of the scheme, and it is expected that Trusts will continue to provide support and facilitation to practices and primary care teams to promote and implement this initiative. 17

20 Appendix A Questionnaire PRACTICE ACCREDITATION SUPPORT & RESOURCES TIME-SCALES 1. We would like to ascertain your progress towards achieving Practice Accreditation in your area. By what date do you intend that all nontraining practices will be accredited? 2. Of the non-training practices in your area please indicate, using the table below, how many practices have applied to participate in Practice Accreditation, how many have achieved initial accreditation, and numbers projected to achieve initial accreditation by (For your information, a spreadsheet is attached detailing your response to this question one year ago.) Year Year Year Year Applied Achieved Projected 3. Please identify any barriers that will make it difficult to achieve these targets. 4. For the training practices in your area please indicate, using the table below, how many practices have achieved Training Practice Accreditation/Practice Accreditation, and your projected plans to Year Year Year Year Deanery visit (TPA) only Joint visit (TPA & PA on same day) Separate TPA & PA visits 18

21 Appendix A RESOURCES 5. In what ways do you support Practice Accreditation? Is there an officer(s) in the Trust responsible for supporting Practice Accreditation? If so, please specify this individual and indicate how much time is allocated to this (eg staff grade and WTE)? 6. Please indicate, using the table below, what financial resources have been allocated to support Practice Accreditation in your area Central support Resources available to the practices themselves Have you set aside financial resources for Practice Accreditation on a recurring annual basis? 7. How many assessors do you have in your area? How much and in what way do you pay them? What is your process for recruitment and selection of assessors? 19

22 DEVELOPMENT 8. Please provide any other comments or suggestions about Practice Accreditation. Thank you for taking the time to complete this questionnaire. An analysis of the data will be available shortly, and we will forward you a copy of the resulting report upon completion. Trust/NHS Board: Form completed by: Contact details: Date: 20

23 Appendix B Detailed Feedback: Barriers to Achieving RCGP Practice Accreditation Time-scales Trust Responses It will be very difficult to achieve 100% Practice Accreditation for a number of reasons. These include: five practices have achieved the Quality Practice Award and others are working towards it and therefore will not be applying for Practice Accreditation; some training practices do not see the benefits of applying for Practice Accreditation; and there is an increasing number of practices requiring greater support in areas of audit, advice, system development and encouragement to apply for and achieve Practice Accreditation. Single-handed practices having time to prepare. Practices perceive the process of working towards accreditation as timeconsuming. There are no financial resources to fund protected time for practices. As long as accreditation remains voluntary, there is no pressure on practices to apply. The projected figures are as a result of a quick survey of practices in the area. Targets will be dependent on the uptake by practices. Uptake will be dependent on the practices having the appropriate resources, willingness of all staff and dedicated time to prepare for Practice Accreditation. Unforeseen difficulties at practice level resulting from GP recruitment problems, staff changes, local LHCC priorities. Initial start-up period to allow marketing and planning. However, it is now fully expected that the project will roll and that Practice Accreditation for all practices will be achieved by Due to the small and rural nature of many of our practices, we have problems regarding time, space, skills, etc, to allow practices to achieve accreditation. 21

24 There is optimism that all practices could achieve accreditation by March However, it is likely that those initially presenting for accreditation will have a background in GP training and, therefore, of assessment. Other practices may be reticent to come forward for a number of reasons including: lack of protected time to undertake accreditation; lack of understanding and clarity of the process; perceived workload attached to accreditation; and the feeling of being pushed into the process. Towards the end of the three-year programme, it is likely that there will be a number of less well-prepared practices to support through accreditation. Clarity is required from RCGP and CSBS as to the voluntary nature of accreditation. Lack of time, staff hours, team support, and financial assistance. Lack of time available within practices, not lack of commitment to become accredited. Inadequate resourcing of Practice Assessors network against the background of a difficult financial position. The development of an extensive Practice Assessors network has not been seen as a priority, which limits our ability to support the assessment process. Lack of protected time for practices. Many practices have expressed an interest to become involved, but in the absence of there being resources available at the practice level did not feel in a position to progress accreditation. No incentive for practices to become accredited. Two practices have stated no interest. The time that it takes for staff to work on the award alongside existing commitments. Time and workload for assessors in a small area who also have other competing priorities. 22

25 Appendix C Detailed Feedback: Support for RCGP Practice Accreditation 2 Trust Responses Team of advisors/assessors. Regular workshops at LHCC level. One-to-one advice and support for practices. Monthly assessors meeting to review progress. LHCC gives some funding towards achieving clinical governance. Local workshops are held on hot topics, eg Significant Event Analysis/Audit offered at educational session. Administration from within clinical governance office. Visit practices as required. Compilation of practice policy guide to aid practices. Presentations (eg Practice Managers Conference, LHCC conferences). Practice visits to discuss process with practice staff. Mock assessments. Ad hoc support from clinical and non-clinical assessors. PGEA points for GPs working towards Practice Accreditation. We employ a Project Manager, in post from end February Additional funding. Resources collaboration with NHS Education for Scotland staff with audit support. We are encouraging practices to work towards this through the LHCCs and also through Practice Managers groups. We are also working on a website that will give practices examples of policies and procedures that will be useful to them. 2 If you wish to obtain more information about any of the initiatives listed, please contact Ms Claire Higgins at CSBS on Tel: , or claireh@clinicalstandards.org, for redirection to the appropriate Trust. 23

26 Appointment of a lead assessment team (1 GP, 1 community nurse, 1 practice manager). The role of this team will be to promote and co-ordinate the Practice Accreditation programme. The lead assessors will also offer advice and mentorship to practices wishing to achieve accreditation. Managerial and administrative support for the delivery of the scheme. Regular quarterly meetings with assessors and RCGP representative. Financial support to participating practices in the form of lump sum funding. Financial support to assessors in the form of reimbursements. Annual/bi-annual workshop for practices wishing to participate. Advice and support to assessors through Trust officers. Development of assessor into advisor role at LHCC level. Prior to the commencement of Practice Accreditation, a number of evening sessions were organised for GPs and their practice staff. The purpose was to promote Practice Accreditation and to identify the support needs of the practices. Subsequently, we have: provided practices with an application pack that outlines the Practice Accreditation process, step by step, and includes application form, selfassessment checklist, sample timetable for the visit, paper on written evidence; provided guidance on how to interpret Confusing Criteria. The guidance has been developed in conjunction with our assessors and the Associate Medical Directors; initiated and developed a web based resource pack, held on the Trust server, which can be accessed by all practices. This pack contains links to both internal and external sites providing information and guidance on policies/procedures/good practice etc and contact names for further assistance; developed a package on Significant Event Analysis; and held assessors meetings on an ad hoc basis. It is intended that practices who have achieved Practice Accreditation will be visited by Trust staff with a view to gathering quality examples of good practice to be incorporated in the resource pack for the purpose of sharing with other practices. 24

27 Appendix C Steering Group. Internal support within LHCCs. Appointed accreditation adviser. LHCC support and regular meetings with assessors. Primary Care Development arrange training sessions and pass on information from RCGP. Practice Assessors Network supports 15 assessors to meet monthly. A coordinator within the network is at one session per fortnight to support the assessors group. We are in the process of negotiating funding for these sessions. All resources for practice assessment are devolved down to LHCCs through clinical governance monies. Clinical Governance Co-ordinators have the lead role for supporting LHCCs within each area. Primary Care Clinical Governance Steering Group, which meets sixweekly. Occasional assessors meetings. Offer to help with preparation, patient satisfaction surveys, etc. Fund Time to Learn, which allows practices to close one half day a month. We provide financial resources to practices to provide the additional staff time necessary to work towards achieving the award. LHCC gives financial support for assessor fees and expenses. 25

28 Appendix D Detailed Feedback: Assessor Recruitment and Selection Trust Responses Advertisements Panel interview Appoint Train Assessors volunteered. Assessors volunteered following Medical Director s letter in June 2000 seeking interest from within practices. Request nominations from LHCCs. Expressions of interest, to the Associate Medical Directors, from appropriate personnel interested in being trained to participate in assessment visits. At present our assessors consist of GPs, non principal GPs, practice managers, practice nurses. Annual workshop helped to gauge interest for initial group of assessors. Recent recruitment drive was aimed at LHCCs through general managers. GP recruitment through LMC. Advertisement for practice managers. Further recruitment by canvassing GPs and practice managers whose practices have achieved accreditation. We try to be as multidisciplinary as possible. Accredited assessors are volunteers with relevant experience. Recruitment: letter to all partners and appropriate staff seeking volunteers, or names submitted by LHCC. Selection: perusal of appropriate qualifications & experience. No formal recruitment process. Applications invited via LHCCs. Contacted all practices in writing and discussed with LHCCs. There are a number of potential assessors but, unfortunately, the resources for our assessors group does not allow us to recruit further. Have advertised and head hunted. 26

29 Appendix D Open invitation letter sent to all practices seeking nominations from individuals interested in being assessors. Through LHCC. 27

30 Detailed Feedback: Assessor Reimbursement Trust Responses One session per week in payroll. Community staff not paid directly, but time reimbursed. Practice managers and GPs paid sessional rate to cover absence. 100 per visit completed, plus locum and travelling expenses paid for all meetings/visits as required. Locum fees for pre-visit preparation, Practice Accreditation visit and report writing. Fund assessors to attend national symposium. Estimated that an assessment will take a full day (8 hours) including preparation, actual visit and follow-up. GPs paid professional fee of 320 per assessment ( 40/hour) plus travelling expenses - individual s own responsibility to pay locum costs. Practice managers paid professional fee of 124 per assessment (8 max. A&C level 7) plus travelling expenses. Practice nurses paid professional fee of 121 (8 max. Whitley Scale G + 2 disc points) plus travelling expenses. Trust-employed nurses paid professional fee calculated from normal pay rate. All assessors are reimbursed for: pre-assessment visit preparatory work (reviewing submitted documents from practices), time spent at visit and travelling costs. GPs are reimbursed for locum costs where required. All other assessors are reimbursed at current professional rate, eg practice manager, practice nurse. Reimbursed for 2 sessions per practice visit (ie GPs = 166 x 2 = 332, Practice Managers = 70 x 2 = 140 ). Doctors are reimbursed a locum fee of 260 per day. Other non-trust staff are paid replacement costs. Sessional payments for community nurse and practice manager. GPs receive locum fee Practice managers - mid point grade %, employer costs. GPs - either or reimbursement of locum costs to maximum

31 Appendix D 200 for training. 150 per assessment. One session per month plus two sessions preparation and one session per visit. Paid 1.5 days replacement costs. Funding of any locum costs to cover time out of practice. Sessional fees and expenses. 29

32 Appendix E Detailed Feedback: Comments and Suggestions to Improve RCGP Practice Accreditation Trust Responses There is a difficulty in allowing local healthcare systems to prioritise the degree of support given to Practice Accreditation. Clearly there are different pressures in different parts of Scotland, and within areas that are net losers under Arbuthnott there is not the resource available to support and develop the scheme locally. Varying degrees of support for the practice assessors could potentially compromise the validity and the integrity of the assessment process. It is probably more appropriate for the assessment process to be managed centrally with costs top sliced from each region to standardise the support given to the practice assessors. The issue of financial support for practices to undertake the Practice Accreditation process is a real one. Undergoing assessment is not without cost to practices and, with a lack of clear incentives, it is not clear how they will become more engaged. Clear guidance is needed for Trusts regarding approach to joint Training Practice Accreditation/Practice Accreditation. Until the accreditation becomes mandatory, there is no pressure on practices to apply. Although we are aware that a number of practices are working towards accreditation, they are slow in coming forward. Making the accreditation mandatory would give them the push they need. It might also be encouraging if there was a set time-scale from the expression of interest stage to applying for the assessment visit. Consistency of approach to implementation is imperative if we are to maintain the standards of Practice Accreditation across Scotland and ensure appropriate evaluation. It is not yet apparent that this has been addressed at a national/rcgp level. We recommend that Version 2 should not be introduced until all practices have been through the accreditation process using Version 1. During , applications and encouragement were driven at various levels within each LHCC supported by the Working (Steering) Group. Projects should now be driven centrally by designated personnel who would be supported by the Working (Steering) Group. There should be extensive networking between NHS Boards throughout Scotland to share knowledge and experiences. 30

33 Appendix E We welcome the decision to extend Version 1 of Practice Accreditation to December There is a need to market the scheme more vigorously. Particular issues identified by assessors include clarity around audit. Guidance would be welcome as to the need for audits to have completed a full cycle, together with the provision of marking schedules for assessors in relation to audit, clinical and significant events. Practice Accreditation has taken our practices longer than anticipated. Maybe some thought could be given to providing central support to smaller areas where both staff and resources are limited. As well as Training Practice Accreditation, two practices are working towards the Quality Practice Award. Practice Accreditation needs a large carrot to make it attractive to less enthusiastic practices. 31

34 Appendix F Key Contacts for RCGP Practice Accreditation and Primary Care Quality Initiatives RCGP Scotland Mrs Cath MacDonald Quality Initiatives Manager Royal College of General Practitioners (Scotland) 25 Queen Street Edinburgh EH2 1JX Tel: NES Dr Colin Hunter National Co-ordinator for Primary Care NHS Education for Scotland 2nd Floor, Hanover Buildings 66 Rose Street EDINBURGH EH2 2NN Tel: CSBS Ms Hilary Davison Review Team Manager Clinical Standards Board for Scotland Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA Tel: Ayrshire & Arran Primary Care NHS Trust Ms Joanne Sharp Senior Manager Medical Directorate Ayrshire & Arran Primary Care NHS Trust 1a Hunters Avenue Ayr KA8 9DW Tel:

35 Appendix F Borders Primary Care NHS Trust Dr Sheena MacDonald LHCC Lead Clinical Governance Leader Medical Group Earlston Heath Centre Kidgate Earlston TD4 6DW Tel: Dumfries & Galloway Primary Care NHS Trust Mrs Marion Glover Clinical Governance Project Officer Dumfries & Galloway Primary Care NHS Trust 1st Floor Crichton Hall Crichton Royal Hospital Dumfries DG1 4TG Tel: Fife Primary Care NHS Trust Mrs Joyce Kelly Primary Care Manager Fife Primary Care NHS Trust Cameron House Cameron Bridge Leven KY8 5RG Tel: Forth Valley Primary Care NHS Trust Ms Evelyn Hadden Primary Care Contracts Manager Forth Valley Primary Care NHS Trust Royal Scottish National Hospital Old Denny Road Larbert FK5 4SD Tel:

36 Grampian Primary Care NHS Trust Mrs Shona Smith Development Manager Grampian Primary Care NHS Trust Summerfield House 2 Eday Road Aberdeen AB15 6RE Tel: Greater Glasgow Primary Care NHS Trust Ms Fiona Middler RCGP Accreditation Project Manager Greater Glasgow Primary Care NHS Trust Gartnavel Royal Hospital 1055 Great Western Road Glasgow G12 0XH Tel: Highland Primary Care NHS Trust Mrs Fiona Duff Project Manager Highland Primary Care NHS Trust Royal Northern Infirmary Ness Walk Inverness IV3 5SF Tel: Lanarkshire Primary Care NHS Trust Dr Shiona Mackie Director of Clinical Standards & Health Improvement Lanarkshire Primary Care NHS Trust Strathclyde Hospital Airbles Road Motherwell ML1 3BW Tel:

37 Appendix F Lomond & Argyll Primary Care NHS Trust Ms Kathleen Donnelly Development & Partnership Manager Lomond & Argyll Primary Care NHS Trust Trust Offices Latta Street Dumbarton G82 2DD Tel: Lothian Primary Care NHS Trust Ms Maureen McGregor Practice Accreditation Adviser Lothian Primary Care NHS Trust Stevenson House 555 Gorgie Road Edinburgh EH11 3LE Tel: Orkney NHS Board Dr Malcolm Alexander Medical Director Orkney Health Board Garden House New Scapa Road Kirkwall Orkney KW15 1BQ Tel:

38 Renfrewshire & Inverclyde Primary Care NHS Trust Ms Shona McIntosh Primary Care Development Officer Renfrewshire & Inverclyde Primary Care NHS Trust Dykebar Hospital Grahamston Road Paisley PA2 7DE Tel: Shetland NHS Board Mr Michael Johnson LHCC Manager Lerwick Health Centre South Road Lerwick Shetland ZE1 0RB Tel: Tayside Primary Care NHS Trust Dr Andrew Russell Associate Medical Director Tayside Primary Care NHS Trust Ashludie Hospital Monifieth Angus DD45 4HQ Tel: West Lothian Healthcare NHS Trust Dr Donald Macaulay General Practitioner Ashgrove Health Centre Blackburn EH47 7LL Tel:

39 Appendix F Western Isles NHS Board Ms Alison Clark Primary Care Manager Western Isles Health Board 37 South Beach Street Stornoway Isle of Lewis H51 2BB Tel:

40 Our Commitment The Board will: involve NHS staff, patients and the public in all parts of its work; work with and support NHS staff in improving standards; assist NHSScotland in delivering the highest quality of NHS care to each patient; base its conclusions and recommendations onthe best evidence available; be open and transparent in all its work through wide circulation of reports written in language that can be understood by all and is jargon free; seek to avoid duplication of effort through working closely with other national organisations involved in improving the quality of care within the NHS; ensure that its own work is subject to quality assurance and evaluation.

41 Clinical Standards Board for Scotland Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA T: F: