Item 12 Appendix 1 Hambleton, Richmondshire & Whitby Clinical Commissioning Group Quality Strategy 2017 Version: 1.0 Author: Angela Edmunds, Head of Quality & Safety/Deputy Chief Nurse Approved by: Governing Body Date of approval: Review date:
Executive Summary The quality of health care is difficult to both define and measure. In his NHS Review in 2008 Professor Lord Darzi identified three dimensions to a high quality service - Clinical Effectiveness, Patient Safety and Patient Experience. Two further dimensions have been added by the Care Quality Commission (CQC). These are - Organisational Culture and Leadership and Responsiveness. This strategy describes the mechanisms whereby Hambleton Richmondshire and Whitby CCG will commission for all dimensions of high quality services and ensure that such services are maintained, improved and are sensitive to changing needs. Clear expectations of quality will be embedded in contracts and service specifications throughout the commissioning cycle. The CCG Vision and Transformation programme along with Quality, Innovation, Productivity and Prevention (QIPP) schemes will be used to evolve services. Audit, patient experience information, public consultation, soft intelligence, and feedback from patients via Healthwatch, our own Health Engagement Network, complaints and compliments will inform change and enhancement of services. We will work with our providers, other CCG s, local authorities and regulatory bodies such as the CQC to ensure that all the dimensions of quality permeate all the services we commission and this strategy will be reviewed annually by the Quality and Safety Committee and updated as required. John James Secondary Care Doctor
Contents Page no: 1. Introduction 1 2. Background 1 2.1 Roles and responsibilities 1 2.2 The Commissioning Cycle 2 2.3 Key drivers for Quality 4 3. Context 6 3.1 local context 6 4. Vision and Plan 7 4.1 Consultation and key stakeholders 7 5. Quality Perspective 8 5.1 Our approach 9 6. Commissioning for Quality 9 6.1 QIPP 11 6.2 Contracting Process 11 6.3 Patient safety 13 6.4 Quality Accounts 13 6.5 Cost Improvement plans 14 6.6 Quality in Care Homes 14 6.7 Safeguarding 15 7. HRWCCG ensures quality and prevention of harm 16 8. Governance 17 7.1 Roles & responsibilities 17 8. Escalation 19 Appendix 22 References 23
Illustrations Page no: The Core Operating Principles for Quality 2 The Commissioning Cycle 3 Key Drivers 4 Functions and Responsibilities 10 HRWCCG ensures quality and prevention of harm 16 Escalation Matrix 20 NHSE Quality Concerns Trigger Tool (Nov 2016) 21
1. Introduction Building on the recommendations from reports such as Francis (2013), Keogh 2013), Berwick (2013) and Cummings (2012 & 2016), this strategy outlines HRW CCG s responsibilities as commissioners of health care services in describing what we mean by the term quality and how we will be assured that people within the population we serve receive high quality care. Ensuring that patients receive high quality care relies on a complex set of interconnected roles, responsibilities and relationships between the CCG, professionals, provider organisations, other commissioners, system and professional regulators, local authorities and other national bodies. This strategy defines our approach to monitoring and improving quality through these relationships and the ways in which quality information is escalated and used to inform the commissioning cycle. It also sets out the governance arrangements that ensure our Governing Body is sighted on the quality of our commissioned services. 2. Background 2.1 Roles and Responsibilities In addition to describing what patients have a right to expect from any health care service, The NHS Constitution (2011) also outlines the responsibilities of NHS organisations around commissioning for quality; To ensure that services commissioned are safe, effective, provide good patient experience and ensure continuous improvement To secure health services that are provided in an integrated way, working in partnership with the Local Authority To actively seek patient feedback on health services and engage with all sections of the population with the intention of improving services As a membership organisation, working with NHS England, support primary medical and pharmacy services to deliver high quality primary care. Further, the Health and Social Care Act (2012) makes it clear that all Clinical Commissioning Groups (CCG s) have the responsibility to ensure continuous improvement in the quality of local NHS services for everyone, now and for the future. It goes on to state that; 1
each clinical commissioning group must exercise its functions with a view to securing continuous improvement in the quality of services provided to individuals for or in connection with the prevention, diagnosis or treatment of illness 1 (The Health and Social Care Act 2012) The Core Operating Principles for Quality set out in the NHS constitution identifies the following behaviours which CCG s should seek to apply in response; The patient and the public come first not the needs of any organisation; Quality is everybody s business from the ward to the board; from the supervisory bodies to the regulators, from the commissioners to primary care clinicians and managers; if we (health and care professionals, staff as well as patients and the wider public) have concerns we speak out and raise questions without hesitation we listen in a systematic way to what our patients and staff tell us about the quality of care; and ; if concerns are raised, we listen and go and look. 2.2 The Commissioning Cycle Commissioning involves a series of stages usually conducted in a systematic, cyclical process over the course of a year which assist the CCG in deciding what services are needed and whether existing services require review. Continuous improvement is integral to this process. The diagram over the page helps to illustrate the responsibilities for CCG s to procure high quality services and ensure that robust monitoring processes are in place to enable early detection and escalation of quality concerns throughout the stages of the commissioning cycle. 1 Continuous improvement refers to the long-term approach organisations apply to work, that systematically seeks to achieve small, incremental changes in processes in order to improve efficiency and quality (http://searchmanufacturingerp.techtarget.com/definition/kaizen) 2
This strategy sets out a number of measurable actions and related outcomes that will help ensure the CCG is commissioning safe, effective services which meet patient needs and describes the various mechanisms that are in place to assure itself of quality. 2.3 Key Drivers for Quality Health care is influenced by a number of political, economic, socio-technological, legal and environmental factors which come in to play at both a national and local level. A sample of the key documents and initiatives which have helped to shape the quality agenda in the commissioning and provision of local health care services is outlined over the page; 3
Care Quality Commission (QCQ) Standards: All providers of health care are required by law to register their services with the CQC, who are the regulator of health and adult social care in England. Registration is subject to compliance with a regulatory framework based on a series of fundamental standards of quality and safety The Next Stage review: High Quality Care for All (2008) The review placed emphasis on being more patient centred, clinically driven, valuing people and promoting lifelong learning and improving quality of commissioned services Quality Accounts (2010) NHS organisations are required by law to report its performance on the quality of care, and to have these reviewed by stakeholders NHS Constitution (2014) Standards of care and the rights that all patients have and should expect NHS Outcomes Framework (2015) A national framework to drive local improvements in quality and outcomes for patients NHS Operating Framework (2016/17) Places quality as the organising principle through contracting and payment systems; sets out national priorities and performance targets to drive continuous improvement. Quality Schedules in contracts Contracts with providers contain both national and locally set quality indicators which allow CCG s to monitor and measure performance. Contractual levers can be applied if quality is not achieved CCG Outcome Indicator Set Aims to support and enable CCG s to plan for health improvement by providing information for measuring and benchmarking outcome of commissioned services 4
NICE Quality Standards A set of prioritised statements designed to drive measurable quality improvements in a particular area of healthcare. Guidance is derived from high quality independent input from a wide variety of health and social care professionals who consider patient experience, safety, equality and cost effectiveness in the development Equality, Diversity and human rights: Promoting equality, valuing diversity and upholding human rights is integral to the pursuit of quality and addressing gaps in health inequalities. The NHS Equality Delivery System (EDS) (2011) enables the CCG to assess itself on performance of the nine protected characteristics against 18 outcomes to inform and drive improvement NHS England Accountability and Assurance Safeguarding Framework: The purpose of the framework is to set out clearly the safeguarding roles, duties and responsibilities of all organisations commissioning NHS health and social care, to protect people s health, wellbeing and human rights and enabling them to live free from harm, abuse and neglect. CCG s need to assure themselves that the organisations from which they commission have effective safeguarding arrangements in place and hold them to account through contracting processes. CCG s are also responsible for securing the expertise of Designated Professionals on behalf of the local system Learning from failure & patient feedback: National enquiries and reports often follow failures in care and come with recommendations to prevent recurrence such as that which followed the investigation into Winterbourne View and Jimmy Saville. The CCG scrutinises all such reports and incorporates into its accountable functions including holding providers to account for delivery of changes where required A review of the NHS Hospitals Complaints System: Putting Patients back in the Picture was published post Francis Report highlighting changes required to ensure providers listened to patients and carers, looked for trends, disseminated lessons learnt and made changes to ensure care improved. Patient and Public Involvement (PPI) Commitment to working with patients carers, community and voluntary groups and other partners to involve, engage and listen in order to identify commissioning priorities 5
3. Context Following a number of high profile reports and enquiries, particularly the public enquiry into the care at Mid-Staffordshire NHS Foundation Trust (2013) carried out by Sir Robert Francis, it was reiterated by the Department of Health (2014) that CCGs had key roles and responsibilities for continuous improvement of quality in healthcare. During the last few years there have been a number of investigations of hospitals and care homes that have highlighted the tragic consequences of poor care and treatment, neglect and abuse. This has resulted in decisive action from the Department of Health (DH) including further in-depth inspections of poorly performing Hospitals/Care homes, a national review of patient safety, complaints and support worker training. The two notable reviews are Winterbourne View (2012), a Hospital for people with Learning Disabilities, and the Francis public inquiry into Mid Staffordshire Hospital (2013). As a result of lessons learned, policy changes and guidance have been introduced. The recommendations accepted in the Francis report provide the framework for this document alongside recommendations in reports which followed, namely: The Munro Review into Child Protection: Final Report, (2011) Winterbourne and follow up Winterbourne View Concordat (2012) A promise to learn- a commitment to act. Improving the Safety of Patients in England, Berwick Report (2013) Safeguarding children and young people: roles and competencies for health care staff Intercollegiate Document (2014) Compassion in Practice. Nursing, Midwifery and Care Staff Our Vision and Strategy. (2012) Leading Change, Adding Value, a Framework for Nursing, Midwifery and Care Staff. (2016) Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015, (2015). The main key quality recommendations from the Francis Enquiry and Winterbourne View can be found in Appendix 1 (p.23) 3.1 Local Context Hambleton, Richmondshire & Whitby CCG (HRWCCG) has 23 GP member Practices covering a population of approximately 142,000 people. It is responsible for planning NHS care across the 3 localities, working with local health care providers to ensure that services meet the needs of all patients. 6
It has a predominantly elderly population spread across a wide geographical area. The largest provider of health care services in the area is provided by South Tees NHS Hospital Trust (STHFT); a large NHS hospital foundation Trust who are responsible for providing both acute and community services in the Hambleton and Richmondshire area. As the CCG sits geographically across the border of North Yorkshire and the North East, patient flows are also seen into Darlington, York and Harrogate Trusts. In Whitby community services are provided by Humber FT (HFT). Mental health services for the whole population are provided by Tees and Esk Wear Valley (TEWV). There are also approximately 37 care homes in the area that are responsible for providing nursing and residential care for people on behalf of health and social care, according to their level of need. CCGs commission activity from providers that are registered with the Care Quality Commission (CQC), and, as part of the contracting arrangements the CCG works closely with them, other stakeholders and partner agencies to deliver continuous improvement. Need to mention individual packages of care via CHC 4. Our Vision and plan Our vision is better health for the people, accessible closer to home facilitated by being responsive to the health needs of the local population, and commissioning high quality services in a timely and cost effective way. Broadly, our plan is to ensure quality of services through the continuous improvement in effectiveness, experience and safety of health and social care services provided for the local population, within available resources. It is our aim to improve the clinical outcomes for patients through a combination of; 1. Partnership working, 2. A greater emphasis on prevention 3. Redesigning the way services are provided and 4. Assessing and monitoring the impact from a quality perspective of all commissioning decisions. By supporting member practices and social care teams to work together, share best clinical practice and to develop a strong communication network we aim to deliver care closer to home so that hospitals are used only when appropriate, for urgent and specialist treatments for those that will benefit most. Thus ensuring services are changed for the better. 7
We also aim to constantly improve the quality of care through active engagement with all stakeholders throughout the commissioning processes and we feel it is imperative to our planning process that quality is measured not just through clinical outcomes but also through patient experience. 4.1 Consultation and key stakeholders Through the Quality and Safety Committee (QSC), in the development of this strategy we have consulted with the following colleagues and stakeholders: Quality Leads of our commissioned services Local Health and Wellbeing Board NHS HRW CCG PCU Healthwatch Safeguarding Boards and members there of GPs, Practice Managers and Practice Nurses North Yorkshire County Council 5. Quality Perspective Quality is difficult to define and measuring quality and gaining assurance can be complex. For the NHS, Lord Darzi introduced a single definition of quality in his 2008 review. His definition set out three dimensions to quality that must be present to provide a high quality service; clinical effectiveness (which encompasses cost effectiveness, equality and diversity) patient safety and patient experience (which encompasses accessibility, acceptability and appropriateness) The Care Quality Commission s (CQC) new inspection approach for providers of care includes 2 additional dimensions; Organisational culture and Leadership and responsiveness. These now create a common framework through which providers, commissioners and regulators of health care communicate about the quality of services delivered. For the purpose of this strategy, quality is therefore considered to be the continuous improvement in effectiveness, experience and safety of health and social care services for the local population which incorporates the CQC s dimensions and takes in to account the key drivers as mentioned in section 2. 8
5.1 Our Approach Overarching aim;- HRWCCG is committed to ensuring the people within Hambleton, Richmondshire & Whitby experience services which are safe, high quality, deliver patient centred outcomes within available resources. The diagram on p.10 illustrates HRWCCG s approach to ensuring continuous improvement in the commissioning cycle and the range of service areas which it seeks to assure itself of, under the umbrella of 4 broad dimensions of quality. The approach respects the local importance of including professional leadership in an assessment framework for the commissioning of quality services across the area and also makes the distinction between quality improvement and quality assurance functions (which are interdependent and utilised at different stages of the commissioning cycle) 2. In order to achieve the CCG s aim of moving care closer to home it is essential to nurture and support leadership capability of the primary care nursing workforce across all the professions and including e.g. clinical pharmacist project, physio etc. Against a backdrop of national workforce issues and unrelenting financial challenge, the CCG need to develop community teams in new and innovative ways to establish a workforce that is both fit for the future and capable of delivering high quality care. The CCG is committed to working proactively to share information and intelligence about the quality of care so that it can identify potential problems early, prevent harmful impacts and manage risk across the system. The CCG is also committed to working reactively as required, to react and respond in the event of a potential or actual serious quality failure coming to light, enabling informed judgments about quality and ensuring that appropriate and timely responsive actions are implemented. 6. Commissioning for Quality Commissioning is not one action but many, ranging from assessing the health-needs for a population, through the clinically based design of patient pathways, to service specification and contract negotiation or procurement, with continuous quality assessment. The role of commissioning, as a key driver of quality, efficiency and outcomes for patients, has become increasingly important to the health system in England. 2 Quality improvement is focused on increasing the ability to fulfil quality requirements. It involves frequent measurement and testing and adapting of approaches in order to arrive at the best possible process for achieving desired outcomes effectively and reliably. This is required at the strategic planning stage. Quality assurance is the systematic monitoring and evaluation of the various aspects of a service or facility. It is in place to maximise the probability that minimum standards of quality are being attained and/or being developed to meet specific requirements. This is required to evaluate efficacy of services already being delivered. 9
Key Functions and Responsibilities around Ensuring Quality and Safety of Services Quality Improvement Aspiring Developing Quality Assurance Monitoring CORE FUNCTIONS PATIENT SAFETY CLINICAL EFFECTIVENESS PATIENT EXPERIENCE PROFESSIONAL LEADERSHIP Risk Management including Serious Incidents (SI s) Never Events NPSA Safety Alerts Sharing Good practice across primary and secondary Care Health Care Associated Infections (HCAI s) Medicines Management Safeguarding Adults & Children Performance Reports; monitoring clinical outcomes Benchmarking against national standards and clinical guidelines Contract Development; approval and monitoring Workforce Statistics Equity of Access to Services Impact on quality of cost improvement plans National Friends & Family Test (FFT) Primary Care Soft Intelligence Complaints monitoring Patient Stories Patient/ service User Surveys Patient Reported Outcome Measures (PROMs) Litigation/Claims Primary Care workforce development Practice Nurse Engagement Revalidation Partnership working and engagement with NHS England Equality and Diversity Clinical Quality Reviews Monitoring Patient Harms Triangulation with Care Quality Commission (CQC) & Monitor reports Engagement through voluntary sector small grants schemes 10
The mechanisms include: monitoring of provider performance visits to providers to see how care is delivered first hand assessment and monitoring of provider quality reports and Quality Accounts which are published each year and Quality and Safety Committee (QSC) which has oversight of quality in each of the main providers. The following sections outline the various mechanisms available to commissioners and which HRWCCG use to execute its duties around quality and continuous improvement. 6.1 Quality, Innovation, Productivity and Prevention (QIPP) schemes At the front end of the commissioning cycle, quality improvement initiatives are designed in accordance with strategic objectives, and identified funding streams. As part of planning for the commissioning of quality services across the CCG s population which represents the best use of public money, CCG s increasingly have to make difficult decisions about what services to commission and/or decommission in the future. QIPP schemes represent how CCG s plan to deliver high quality services within the allocated financial envelope each year. In the development of the CCG s QIPP schemes, Quality Impact Assessments and Equality Impact Assessments (EIA s) are completed by the programme leads, to determine the level of risk to quality by any scheme and/ or initiative. All QIA s are reviewed at least once by the QSC and at agreed periodic intervals where large scale services are being developed over a specific time interval. Finance, performance and quality committees play a role in reviewing the QIPP programmes to make sure that the impact from a quality perspective has been considered alongside ensuring the delivery of schemes. Throughout the commissioning cycle, quality assurance mechanisms are used to help inform and lever action. These take many forms; 6.2 Contracting Process Ensuring that patients have access to a range of high-quality services is the core function of NHS commissioning. The Contract supports this by giving a robust framework through which a commissioner can set clear standards for a provider and hold it to account for the quality of care it (and any sub-contractors) delivers. The contract requires providers to run services in line with recognised good clinical or 11
healthcare practice, and providers must comply with national standards on quality of care and any agree local quality requirements (NHS Standard Contract 2015). The contract is managed by Contract Management Boards and relevant sub contract groups (e.g. quality & performance or finance and activity). These forums address under performance against quality requirements and agree action plans for improvement and provide a process for escalation. Each commissioned provider is required, contractually, to submit information on recognised indicators of the safety, quality and effectiveness of services. This includes: Patient experience information from internal and external surveys, Family and Friends, complaints and PALS information Incident and Serious Incident reporting data, compliance with national and local reporting timeframes. Quality of reporting, analysis, including medication errors, never events and completed investigation reports Infection prevention and control measures, including clinical practice, environmental audit data and numbers of healthcare associated infections and outbreaks of infections identified. This information is reviewed and considered along with the context of other available data and intelligence, external agency reports and benchmarking against comparable organisations where appropriate. 6.2.1 Quality Schedules The NHS contract includes clauses which serve to focus the provider and commissioner on the achievement of quality improvement and places emphasis on avoiding harm. In addition to the terms within the main body of the contract there are also specific schedules which both parties work on collaboratively prior to sign off which are directly related to quality. 6.2.2 Key Performance Indicators (KPIs) Key performance indicators assist the CCG to define and measure progress on a range of issues. In year targets and trajectories are set to demonstrate ambition towards continuous improvement, in conjunction with existing and emerging national and local priorities. These will also consider areas where the CCG considers priority of need to improve where quality and performance issues have been identified during the year. 6.2.3 Commissioning for Quality and Innovation (CQUIN) The National NHS Contract includes the CQUIN payment framework which allows commissioners to reward innovative solutions and/or quality improvements beyond the standard. There are two sets of CQUINS. One is nationally prescribed, the other is locally determined and can include as few or as many as are agreed. The financial 12
reward equates to 2.5% of the contract value, with 0.5% attributed to the national schemes and Commissioners can determine the split of financial reward across the schemes weighting payments across the year as the objectives are met. The provider reports against CQUINS on a monthly or quarterly basis through the contract management route. 6.3 Patient Safety A key priority for commissioners is to commission high quality care which is safe, prevents avoidable harm and risk to patient safety including robust systems to protect patients and manage and learn from incidents. Indicators the CCG will routinely monitor include: Serious Incident Management Safeguarding Adverse outcomes such as pressure ulcers and falls Care of the Deteriorating Patient Medicines Management Summary Hospital Level Mortality Indicators (SHMI) 6.3.1 Serious Incident Reporting All Serious Incidents (SIs) are reported through the Department of Health s central Strategic Executive Information System (STEIS). Incidents are reported and investigated in line with providers and CCGs policy, which both reflect the National Framework (NHS England 2015). The expectation is that learning from incidents is shared across the whole of the provider and if appropriate shared more widely. Providers Serious Incident Investigation reports are reviewed at the SI Panel to ensure comprehensive investigations with appropriate action plans demonstrating organisational learning. The Quality and Safety Committee and Governing Body will receive regular reports summarising the Serious Incidents, highlighting any relevant themes, trends and learning. 6.3.2 Duty of Candour A duty of candour is included in the standard NHS contract (NHS England, 2015). Its function is to ensure patients and their families are told about patient safety incidents which affect them, receive an apology, informed of the investigation plus its outcomes and provided with support. Compliance with Duty of Candour is reported on all investigation reports plus submission of evidence via quality schedule contracting processes. 13
6.4 Quality Accounts All NHS foundation trusts are required to produce reports on the quality of care (as part of their annual reports). Quality reports help trusts to improve public accountability for the quality of care they provide (Monitor 2015). The CCG is responsible for providing scrutiny and a supporting statement which will be included in the account which is publicly available. 6.5 Cost Improvement Plans (CIPs) CIPs are integral to all trusts financial planning and require good, sustained performance in order to be achieved. CIP success varies among trusts and no single approach works for all organisations. However, several factors are common in organisations performing well in CIP planning, delivery and sustainability. A successful CIP is not simply a scheme that saves money. The most successful organisations have developed long-term plans to transform clinical and non-clinical services that not only result in permanent cost savings, but also improve patient care, satisfaction and safety. The CCG has a duty to examine the Cost Improvement Plans of its main service providers and the process by which these are agreed and ratified. This is done as part of the contractual arrangements by the Contract and Quality & Performance Teams. 6.6 Quality in Care Homes and the domiciliary care sector Ensuring quality in care homes and the domiciliary care home sector is challenging and complex. The CCG recognises it has an important role in supporting providers to deliver high quality services and improvement plans, in order to contribute to the sustainability of out of hospital care. These services provide care to frail, vulnerable people and often care is joint or wholly funded by the CCG under NHS responsibilities for continuing healthcare, a joint package of care, or through a contribution to the registered nursing care that a person who is a resident in a care home with nursing will receive. The Planning Guidance for 2016/17 Delivering the Five Year Forward View, makes it clear that systems needs to develop and implement an affordable plan to make improvements in quality particularly for organisations in special measures and the CCG contributes to this support to care homes. The CCG will work on a multi-agency basis to collaboratively deliver improvements in the quality of care in care homes and provided by domiciliary care, including medicines management, intermediate care and rehabilitation. 14
6.6.1 Care Home Closure NHSE together with partners have published good practice guidance for Local Authorities, CCGs, NHSE, CQC, Providers and Partners. It helps partner s coordinate action, avoid duplication and prevent confusion from providers of health and care staff in the home closing or that receive residents from homes that close. Managing Care Home Closure aims to ensure that when closure arises, there is a joined-up and effective responsive from all partners to minimise as much is possible the impact on people using services, their families, carers and advocates. The guidance can be found here: http://www.nhs.uk/nhsengland/keogh-review/documents/quickguides/1577_quickguide-carehomes_9.pdf 6.7 Safeguarding Robust safeguarding processes are integral to all aspects of patient safety and are informed by the Working together (ref). The CCG Executive Lead for Safeguarding Children and Adults is the Chief Nurse. The Chief Nurse is supported in this role by the Designated Professionals. The CCG acknowledges its statutory function and responsibility as both a commissioner of services and as an employer and has clear governance processes in place for safeguarding children and vulnerable adults. Related policies are: Safeguarding Adults Policy Safeguarding Children Policy Mental Capacity Act and Deprivation of Liberty Safeguards Policy Allegations Against Staff Policy The CCG provides training for its staff and supports member practices by investing in capacity. The CCG works in partnership with local authorities to discharge its statutory functions and sits on relevant Safeguarding Boards. The CCG recognises the importance of parity of esteem for those with mental health and learning disability needs. This applies to the monitoring and assurance of all commissioned services. The CCG ensures that safeguarding requirements are integral to any contracts with providers and holds them to account for the delivery of those standards. 15
7. How HRWCCG ensures quality and prevention of harm Strategic objectives for quality identified in the Operational Plan and which infiltrate through all programmes of care The regular, routine measuring and monitoring of quality indicators and data within the contract, escalating and taking action where required Commissioner assurance visit programme (clinical visits/walk rounds): schedule of announced and unannounced visits to a range of provider organisations, designed to look and see services in action Collaboration working with Providers to identify challenges and design pathways of care Hearing the voice of the person, their carers' and families through complaints / compliments / surveys and development of key relationships with Healthwatch and other appropriate forums Collection and scrutiny of soft intelligence through the CCG portal and by partnership working Scrutiny of Risk Registers Dialogue with Quality Leads across Yorkshire and Humber (and Cumbria and North East region) and participation in key pieces of work such as the National Maternity Review Assurance Contribution to inspections and monitoring of action plans from CQC and others; proving a supportive function to GP practices with regards to quality and safety concerns Sharing of information and intelligence across the system and appropriate escalation via Quality Surveillance Groups (NHSE) Safeguarding processes 16
8. Governance Items are routinely monitored by the Quality lead, managed at source and raised at QSC for discussion before highlighting to GB if indicated. Internal governance regarding quality is via the QSC. This is a sub group of the Governing Body. It meets monthly to receive reports and discuss quality concerns regarding the local health and social care system. It has representation from NYCC, primary care and local Healthwatch. 8.1 Roles and responsibilities of partners in the system 8.1.1 Providers Providers have a responsibility to understand what high quality care looks like and must strive to deliver this. They are required to have robust governance arrangements in place to monitor, manage and drive improvements and must publish an annual Quality Account (excluding primary care). All providers are governed by legislation and regulation by various agencies. The CCG is on level 2 primary care co-commissioning and has partially delegated commissioning responsibilities for GP practices from NHSE. As such primary care is subject to the same monitoring of agreed quality indicators and potential action taken if quality is at risk, although this currently remains a shared function between the CCG and NHSE. 8.1.2 Regulators The Care Quality Commission (CQC) is the agency responsible for monitoring, inspecting and regulating services. The CQC seeks to ensure services meet fundamental standards of quality and safety and publish their findings, including performance ratings to help people choose care. The CCG scrutinises these reports and monitors action plans for improvement. National Health Service Improvement (NHSI) acts as the main regulator of Foundation Trusts and NHS Trusts ensuring they are well-led, and have regard to whether their services are effective, efficient and of good quality. NHSI has been set up to support providers to deliver, helping the NHS meet its short-term challenges and secure its future. Ofsted is the Office for Standards in Education, Children s Services and Skills. They inspect and regulate services that care for children and young people, and services providing education and skills for learners of all ages and publish their results. The 17
CCG will participate in inspections and be part of developing and implementing any actions for children. Professional regulators such as the Nursing and Midwifery Council (NMC), General Medical Council (GMC) and Health and Care Professional Council (HCPC) set standards, hold a register, quality assure education and investigate complaints. The CCG has the responsibility to ensure compliance with regulatory standards of the professionals they employ and report concerns of practitioners. 8.1.3 Planning and Advisory Bodies Healthwatch is the national body that champions people who use health and social care and has a key focus on the design of integrated care. Each local authority has a local Healthwatch Group which feed into the national network. A Healthwatch representative sits on the CCG Governing Body to hold it to account and meets with key members of the CCG to share patient feedback. Health and Wellbeing Boards (H&WB) were established as part of the Health and Social Care Act 2012 where leaders from the health and social care system come together to improve the health and wellbeing of their local population. Its main concern is to reduce health inequalities. They have a statutory duty to involve local people in the development of the Joint Strategic Needs Assessment (JSNA) and the development of joint health and wellbeing strategies. The CCG attend and contribute to the H&WB ongoing agenda. Overview and Scrutiny Committees (OSC) were established under the Local Government Act 2000. They are made up of locally elected councillors who are independent of executive or cabinet parts of the council. They can investigate any area of concern in the local area and they have powers to require officers, including the CCG to attend meetings and answer questions and must comply with requests for information. They hold decision makers to account. Local Safeguarding Boards - Section 13 of the Children Act 2004 requires each Local Authority to establish a Local Safeguarding Children s Board (LSCB). The Care Act 2014 requires Local Authorities to establish Safeguarding Adults Boards (SABs). The SAB must lead adult safeguarding arrangements across its locality and oversee and coordinate the effectiveness of the safeguarding work of its member and partner agencies. The CCG is a statutory partner on the Boards. The Public Health function sits in Local authorities who tailor local solutions to local problems, and using all the levers at their disposal to improve health and reduce inequalities. The Director of Public Health supports local political leadership in improving health. They champion health across the whole of the authority s business, promoting healthier lifestyles and scrutinising and challenging the NHS and other partners to promote better health and ensure threats to health are 18
addressed. The CCG works closely with Public Health and the Director of Public Health is a key member of the CCG Governing Body. 8.1.4 NHS England NHS England commissions specialised services, primary care (when CCGs do not have delegated authority), offender healthcare and some services for the armed forces. It has four regional teams but is one single organisation operating to a common model with one management board. The CCG works with NHSE to share quality surveillance information and to work together across the system to monitor and improve quality. Quality Surveillance Groups (QSGs) were established in advance of the new health and care system going live on 1 April 2013. They were introduced following the publication of the National Quality Board s (NQB s) report Quality in the New Health System: Maintaining and Improving Quality from April 2013. The NQB brings together the leaders of national statutory organisations across the health system, alongside expert and lay members. Members of QSGs, including the CCG should work together, as part of a culture of open and honest cooperation, to identify potential or actual serious quality failures and take corrective action in the interests of protecting patients. The CCG also collaborates with education bodies such as the Health Education England, Academic Health Science Networks and local Universities. 9. Escalation Quality concerns are initially managed and investigated internally. All programme leads seek assurances from provider organisations on the quality and safety of services they are responsible for overseeing. Sustained or significant quality concerns are brought to QSC for discussion. Issues (and concerns) are escalated to GB where there is lack of assurance around any particular element of service and/or where the quality risk represents significant reputational risk to the CCG. The graphic on p.20 illustrates the stages of escalation of quality concerns according to the impact and reputational risk to the organisation, highlighting where the different organisations may be required to intervene. Where NHSE have requested or where there are unresolved issues (which cannot be addressed independently), the CCG will escalate to area wide quality surveillance groups (QSG s) in Cumbria and North East and Yorkshire and Humber (see NHSE Quality Concerns Trigger Tool p. 22). 19
NATIONAL OUTLIER REGIONAL OUTLIER REPUTATION BREACH OF LOCAL PLANS VARIANCE AGAINST PLAN FINE ESCALATION MATRIX IMPACT NONE WARNING SIGNS TAKING LOCAL ACTIONS SIGNIFICANT ISSUES AND IMPACT ON NHS CONSTITUTION Business as usual; key performance indicators (KPI s) monitored through routine processes CRITICAL QUALITY, PERFORMACNE AND FINANCIAL ISSUES CCG and associates managing the business via the contract management board and regular quality and performance meetings: key lines of enquiry (KLOE s) pursued in areas where further investigation is warranted CCG and associates at Contract Management Board and QSC with FT Directors, Executive Team and QFP engagement: performance management oversight of plans to provide assurance CCG and associates with Governing Body and Trust Director level engagement, including NHSE and Regulators NHS ENGLAND, NHS IMPROVEMENT, CQC- SIGNIFICANT INTERVENTION 20
Quality Concerns Trigger Tool November 2016 Routine Quality Monitoring CQC minimum standards Serious incidents/never events NHS Constitution/Mandate Leadership/workforce numbers Complaints/Friends and Family test Governance arrangements NHS Improvement monitoring Delivery against contract specification Safeguarding Emergency admissions data and referral rates GP Outcomes Framework Contract Review Meetings Partnership working arrangements Quality Assurance Framework Nov 16.do Persistent and/or Increasing Quality Concerns Identified Step up to Enhanced Quality Assurance Process Formal communication to Provider via Quality Meetings Targeted Quality /Monitoring Assurance Visits Was assurance gained? Develop Provider Quality Risk Profile and arrange Enhanced Quality Review meeting with commissioners and regulators to determine next steps. Access QRP Template from NHS England Was evidence gained that concerns would be resolved within a reasonable timeframe? Yes No No Single Item QSG Triggers Lack of confidence in the providers ability to improve Serious patient safety concerns Serious contract breaches/contractual notices Issues outside of providers control Persistent failure to meet CQC standards Risk Summit Triggers serious failings within a provider a need to act rapidly to protect patients and / or staff a single, material event Share Risk Profile with provider and arrange Single Item QSG Increasing assurance / Reducing Risk Yes Maintain Enhanced surveillance for a minimum 3 months communication to provider Yes RRR/Risk Summit nqb-organise-risk-su mmit.pdf No 21 The escalation to a rapid response review or risk summit could be instigated at any point in the process if patient safety concerns require urgent action.
Appendix 1 Francis Enquiry key quality recommendations: GPs need to undertake a monitoring role on behalf of their patients who receive acute Hospital or other specialist services The Commissioner is entitled to and should, apply a fundamental safety and quality standard in respect to each item of service it is commissioning, and agree method of measurement and redress for non-compliance Local commissioners must be provided with the infrastructure and the support necessary to enable a proper scrutiny of its providers services In selecting indicators, the principle focus of commissioners should be on what is reasonably necessary to safeguard patients and to ensure that at least fundamental safety and quality standards are maintained Commissioners not providers should decide what they want provided Commissioners need to identify and make available alternative sources of provision Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis during the contract period. They must also have the capacity to undertake their own audits, inspections and investigations Commissioners should be entitled to intervene in the management of an individual complaint on behalf of a patient where it appears to them, it is not being dealt with satisfactorily Consideration should be given to whether commissioners should be given responsibility for commissioning patients advocates and support services for complaints against providers Commissioners should have contingency plans to ensure that patients are protected from harm, if they are risk from substandard or unsafe services Winterbourne Key Quality Recommendations: One shared vision, driven forward by active senior leadership, based on the presumption that hospitals are not homes, and that people should be supported to live in the community. One pooled budget, allowing maximum flexibility for commissioners to fund what individuals truly need, and aligning the financial incentives on all commissioners to invest in community-based provision. One robust plan for commissioning on a whole life-course basis, supporting early intervention and support (from early childhood onwards), expanding the provision of community-based support and care, and reducing the number of inpatients and inpatient provision. 22
References Berwick Review (2013): A promise to learn a commitment to act. Improving the Safety of Patients Care Quality Commission (2015): Guidance for providers on meeting the regulations. Department for Education (2011): Professor Eileen Munro. The Munro Review of Child Protection Department of Health (2004): The Children Act Department of Health (2008): High Quality Care for All NHS Next Stage Review Final Report. Lord Darzi Department of Health (2012): Health and Social Care Act Department of Health (2012): Transforming Care - A National Response to Winterbourne View Hospital Winterbourne Department of Health (2012): Compassion in Practice. Nursing, Midwifery and Care Staff; Our Vision and Strategy. Professor Jane Cummings. NQB Department of Health (2014): The Care Act Department of Health (2014): Introducing the Statutory Duty of Candour. A consultation on proposals to introduce a new CQC registration regulation Department of Health (updated 2015): The NHS Constitution for England 2013 Department of Health (2016): Adass, Local Government Association, Care Provider Alliance and NHSE. Managing Care Home Closures, a good practice guide for local authorities, clinical commissioning groups, NHS England, CQC, providers and partners. Department of health (2016-17): The NHS Outcomes Framework Francis Report (2013): Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 23
Keogh (2013): Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report HM Government (2015): Working together to safeguard children; A guide to inter-agency working to safeguard and promote the welfare of children Mazars (April 2011-March 2015): Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust National Quality Board (2013): Quality in the new health system -maintaining and improving quality National Quality Board (2014): How to Organise and Run a Risk Summit NHS England (2014): Five Year Forward View NHS England (2015): Safeguarding Vulnerable People in the NHS Accountability and Assurance Framework NHS England (2015/16): CCG Outcomes Indicator Set 2015/16: At-A-Glance Guide NHS England (2016): Leading Change Adding Value: A framework for nursing, midwifery and care staff. Professor Jane Cumming NHS England (2016/17): CCG Improvement and Assessment Framework 2016/17 Right Honourable Ann Clwyd MP and Professor Tricia Hart (2013): A Review of the NHS Hospitals Complaints System Putting Patients Back in the Picture Royal College of Paediatrics and Child Health (2014): Safeguarding Children and Young People roles and competences of health care staff. Intercollegiate document 24