Strategy for Delivery of Clinical Quality and Patient Safety North Norfolk Clinical Commissioning Group.

Strategy for Delivery of Clinical Quality and Patient Safety North Norfolk Clinical Commissioning Group. 1. Introduction 1.1 The aim of this document is to set out the strategy for North Norfolk CCG (NNCCG) to deliver high quality, safe healthcare to the people of North Norfolk. Over the coming months we will develop a clear framework that, in line with CCG development and key national guidance and directives (Francis Report, Report from Winterbourne view), will be shaped and owned by the Council of Members. It will demonstrate that for the organisation quality and safety is implicit both within that which it commissions and provides and the evolving vision for quality improvements across both. It will also identify the infrastructure that will support the required governance, assurances and clear lines of accountability as we move towards the future of Clinical commissioning. 1.2 The CCG fully acknowledges that the final Francis report into Mid Staffordshire expected in Autumn 2012 is likely to bring about profound change in how the NHS assures itself of the safety and quality of care and though the CCG has tried to anticipate the merging findings, it cognisant that it is likely that this strategy could need significant review in the light of the report. 1.3 The National Quality Board highlights the increased risks to quality and safety during this period of NHS restructuring ( Preparing for Handover ). As a commissioning organisation NNCCG therefore recognises the need to ensure that robust systems and communications are retained, in order to safely manage the disruption of established reporting lines and accountable relationships with a view to minimising the risks caused by a potential loss of organisational memory throughout this period of transition. 1.4 At this time however, there are also opportunities to identify what works well and to capture this within our new processes and practices, whilst being able to learn from the experiences of what is not successful and, where systems were ineffective and outmoded to develop and redesign improved governance structures to ensure a better fit for the new commissioning landscape. 1

1.5 Through this transition process we aim to develop a collaborative professional network with CCG colleagues across Norfolk and Waveney and a clear service interface with the Commissioning Support Unit (CSU), in order to maximise the opportunities to share information, innovation and transformation of safe and quality healthcare across Norfolk and Waveney. 2. Local Demographics 2.1 The health of people in the NNCCG area is generally better than average across England. Deprivation is lower than average, however about 2,500 children live in poverty. Life expectancy for both men and women is higher than the English average. 2.2 Approximately one third of the population of North Norfolk District Council is aged over 65 and the current predictions are that this will rise to about 42% by 2028. Broadland District Council has a similar age demographic with about 25% of the population being over retirement age. Over the last 10 years, all cause mortality rates have fallen. Early death rates from cancer and from heart disease and stroke have fallen and are better than the English average. 2.3 However, the overall level of health status masks variations between localities where health status is poor largely linked to deprivation, unemployment and the low level of educational attainment. Broadland District Council and North Norfolk District Council are ranked the 279 th and 146 th most deprived districts in England respectively. NNCCG has no Practices in the most deprived quintile in England and no Practices in the most deprived 10 in Norfolk and Waveney. 2.4 Challenges for health commissioning within the locality are: An older population living longer often with at least one long term condition A large rural area with poor transport infrastructure making access to services difficult requiring the need to deliver more care at or closer to home Unwarranted variation in health status and outcomes in particular parts of the locality particularly for young people A time of economic constraint and the need to prioritise resources accordingly. 2.5 The recent events at the Mid Staffordshire Hospital and more locally at the James Paget Hospital have amply demonstrated that older people in particular are vulnerable to neglect and harm in hospital and therefore given our demographics the safety and welfare of our population whilst in hospital will be of the highest priority for the CCG. 2

3. North Norfolk CCG - Our Ethos 3.1 Mission The mission of NHS North Norfolk Clinical Commissioning Group is to improve health and wellbeing: to support people to be mentally and physically well; to get better when they are ill; and when they cannot fully recover, to stay as well as they can to the end of their lives. The group will promote good governance and proper stewardship of public resources in pursuance of its goals and in meeting its statutory duties. 3.2 Values Good corporate governance arrangements, with honest and transparent decision-making, are critical to achieving the group s objectives. The values that lie at the heart of the group s work are: a) Putting patients first and working in partnership; b) Treating people with respect, dignity and compassion, ensuring no-one is excluded. 3.3 Aims The group s aims are to: a) Promote improvements in health, wellbeing and patient experience, ensuring the local community s voice informs the commissioning of high-quality, safe care; b) Maintain a focus on local clinical leadership; c) Maximise the potential of primary and community-based care, focussing activity on generating benefits for patients and enabling patients to make choices best suited to their needs; d) Support Health Education England to deliver an appropriately trained and qualified workforce; and e) Promote the integration of health-related and social care services. 3.4 We will achieve the delivery of high quality safe care by: Commissioning care that can be appropriately measured in order to demonstrate its quality and efficacy and that if breaches in quality and safety are identified they are acted upon promptly in order to safeguard those using the service. 3

Developing mutually beneficial partnerships between stakeholders, patients, their families and those delivering healthcare services to ensure the care that we commission is safe, personal, effective and continuously improving. Working to prevent avoidable harm to individuals from the healthcare that they receive. Assuring that those using health services receive the most appropriate interventions and support to meet their needs at the right time, optimising resources to remove inefficiencies and ensure consistency of care delivered. 4. Our Quality and Safety Structure 4.1 While specific roles, reporting lines and accountable bodies are identified within the CCG, there is a clear understanding that quality must underpin all roles and responsibilities within the CCG and we will develop supportive systems which will allow our membership to readily identify and manage risks, quality and safety issues promptly and effectively. 4.2 Quality and safety will be represented at every structure of the organisation by: A nominated GP within the governing body to provide strategic leadership and accountability, supported by GP leads within the Governing Body with named responsibility for the main areas of commissioning, acute, mental health and learning difficulty, out of hospital, and out of hours. A lead for Quality and Safety who will provide both strategic and operational support to the governing body. This will provide the opportunity to not only develop process and systems that will internally influence risk identification and it s management, work cohesively with our professional network and CSU, but will also be patient facing in order to work proactively with service users and providers. Additional leadership from a nominated Lay member who will champion the agenda to challenge and assure transparency and contestability in order to maintain the thrust of continuous improvement. 4.3 Given that the CCG shares a common set of providers with Norwich and South Norfolk CCG, the CCGs have collectively committed to maintain a strong Patient Safety and Quality Function within the Norfolk and Waveney CSU, staffed by a team of experienced clinicians. This function will be responsible for much of the operational performance of the patient safety and quality agenda, such as collectively data and compiling regular reports, and thereby avoid duplication of effort and cost across the CCGs. The CSU will be responsible for supplying a regular suite of reports and 5Governing Body. A detailed service specification has been 4

agreed with the CSU for this. Though much of the operational activity will be delivered by the CSU function the CCG is accountable at all times for the safety and quality of the services it commissions and will exercise all significant decision making. 4.4 Again recognising the shared agenda with neighbouring CCGs, it has been agreed to establish a Joint CCG Quality and safety Committee with representation from North, South, Norwich CCGs as well as colleagues in Gt Yarmouth & Waveney, and West Norfolk CCGs. This arrangement will not only avoid the CSU team duplicating reporting and other activities but will also allow for the sharing of information, concerns and best practice between the CCG teams. This Committee builds on the success of the current Norfolk and Waveney Cluster Quality Committee and is formally constituted within the North Norfolk CCG Constitution. It will report regularly to the CCG Governing Body. 4.5 The Joint Committee will be complimented by a local Quality and Safety arrangements with clinical representation drawn from the 20 CCG practices, as well as the local authority. This will allow the opportunity to triangulate information and intelligence from practices about patient safety and quality with the reports and data drawn from providers, which will be reported through the Joint Committee above. This group will also seek to develop a relationship with the Local Area Team of the National Commissioning Board in supporting quality improvement in General Practice. 4.6 One of our key drivers for improving Quality and Safety will be to embed our shared vision aims and ambitions, engaging the practices and individuals within our membership in order to develop a co-ordinated structure of quality assurance throughout the CCG 5. National Policy Context The NNCCG will work within the framework of national policy to assure quality and patient safety 5.1 The NHS Constitution 5.1.1 The NHS Constitution establishes the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. All NHS bodies and private and third sector providers supplying NHS services will be required by law to take account of this Constitution in their decisions and actions. 5

5.1.2 The NHS Constitution was created to protect the NHS and make sure it will always do the things it was set up to do in 1948, to provide high-quality healthcare that s free at the point of delivery and available for everyone. The Constitution sets out the rights of an NHS patient. These rights cover how patients access health services, the quality of care patients receive, the treatments and programmes available to patients, confidentiality, information and the right to complain if things go wrong. 5.1.3 The Care Quality Commission are required to regulate and register providers of health and social care. They produce a method of reporting which outlines compliance of providers against the range of care quality standards and therefore a route by which providers can be monitored for quality and safety. NNCCG will utilise CQC reporting in order to scrutinize commissioned services and triangulate against additional data and information. 5.2 The National Quality Board (NQB) 5.2.1 The aim of the NQB is to champion quality and ensure alignment for improving quality throughout the health service. 5.2.2 The focus of the NQB report published in August 2012 Quality in the new health system maintaining and improving quality from April 2013 is how the new health system will work together to identify, respond to and prevent serious failures in quality. The report describes how improving quality is the responsibility of everyone working in the health service, both individually and collectively. Doctors, nurses and other health professionals, their ethos, values and behaviours are the first line of defence in maintaining quality. Whilst the leadership within organisations providing care is ultimately responsible for the quality of care provided to patients. 5.2.3 The different organisations in the new health system also have distinct roles and responsibilities to ensure quality and promote a culture that places the patients at the heart of the health system. Collectively these organisations must collaborate where appropriate and work closely together in order to effectively maintain and improve the quality of care that the health service delivers for its patients. A network of local and regional Quality Surveillance Groups (QSG), which will be in action from 1 April 2013, they will bring together commissioners, regulators and other bodies, in a virtual team, to share information and intelligence about quality across the system. 5.2.4 The NQB is publishing Quality in the New Health System in draft form so that it can be updated in the light of findings or recommendations from the Mid Staffordshire NHS Foundation Trust Public Inquiry, which is due to be published this Autumn. 6

5.3 Quality Handover 5.3.1 Recent failings in the health and social care system in England have highlighted the need for greater clarity about who is responsible for identifying and responding to failures in quality. The National Quality Board (NQB) has addressed this through the publication of two reports: Review of early warning systems in the NHS (24 February 2010) Maintaining and improving quality during the transition (March 2011) 5.3.2 In May 2012 the NQB issued a guide on HOW TO: Maintain Quality during the Transition: Preparing for handover. It was developed in response to feedback from the service. This report contains clear guidance, timetables and templates and sets out the requirements for a good handover on quality. A quality plan has been developed for the PCT cluster and work is on-going to ensure a comprehensive document is developed to support a quality handover to the CCG s. (Annexe B) 5.4 The Commissioning Outcomes Framework (COF) 5.4.1 The NHS Outcomes Framework is structured around five domains, which set out the high-level national outcomes that the NHS should be aiming to improve. The NHS Commissioning Outcomes Framework at a glance (Annex A). 5.4.2 The five domains were derived from the three part definition of quality first set out by Lord Darzi as part of the NHS Next Stage Review. Domains one to three include outcomes that relate to the effectiveness of care, domain four includes outcomes that relate to the quality of the patient experience and domain five includes outcomes that relate to patient safety. The five domains focus on: Domain 1 Domain 2 Domain 3 Domain 4 Preventing people from dying prematurely; Enhancing quality of life for people with long-term conditions; Helping people to recover from episodes of ill health or following injury; Ensuring that people have a positive experience of care; and 7

Domain 5 Treating and caring for people in a safe environment; and protecting them from avoidable harm. 5.4.3 The COF will allow the NHS Commissioning Board to identify the contribution of clinical commissioning groups to achieving the priorities for health improvement in the NHS Outcomes Framework, while also being accountable to patients and local communities. It will also enable the commissioning groups to benchmark their performance and identify priorities for improvement. 5.5 NHS Midlands and East Strategic Health Authority (SHA) Cluster Ambitions The SHA have identified 5 ambitions to radically transform local care: Eliminating avoidable grade 2, 3 and 4 pressure ulcers; Significantly improving Quality and Safety in Primary Care; Create a revolution in patient and customer experience; in particular championing the use of the Net Promoter Score surveys of acute hospitals Making Every Contact Count through systematic healthy lifestyle advice delivered through front line staff; Ensure radically strengthened partnerships between the NHS and local government; Though we do not know if the NCB Local Area Team will continue to support these initiatives the CCG will continue to work with the providers to ensure these ambitions are delivered. 5.6 NHS Safety Thermometer 5.6.1 The NHS Safety Thermometer is an improvement tool for measuring, monitoring and analysing patient harms and harm free care. The Thermometer is currently being used by the PCT cluster and emerging Clinical Commission Groups to drive forward and monitor the ambition to eliminate avoidable grade 2, 3 and 4 pressure ulcers. 5.6.2 The analysis charting functions are built in to the NHS Safety Thermometer, so results can be seen immediately. As well as recording pressure ulcers, falls, catheters, UTIs and VTEs, it will also record and analyse additional local information. 5.6.3 The NHS Safety Thermometer includes a function for merging patient safety data across teams and wards within organisations, and has a built in mechanism to submit data to the NHS Information Centre for inclusion and publication in the national database. 8

5.7 Commissioning for Quality and Innovation Framework (CQUIN) 5.7.1 The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare providers' income to the achievement of local quality improvement goals. CQUIN schemes form part of the contract between the Clinical Commissioning Group and its main providers of health care and acts as a vehicle for improving patient safety, experience and outcomes. 5.7.2 The CCG will continue the use of CQUIN as a means to incentivise providers to improve quality standards. 5.8 Quality Accounts 5.8.1 It is a statutory responsibility for providers of acute, mental health, learning disability and ambulance services to produce and publish a Quality account. The accounts aim to: Increase NHS accountability by making a greater level of information about the quality of healthcare services available to the public Support Provider Boards and senior managers to focus on quality improvements by requiring that they assess and report nationally on quality across the entire range of their services and state where and what improvements they intend to make. 5.8.2 Through their Quality Account key providers will have demonstrated a commitment to improving outcomes for the patients of North Norfolk, in relation to improving patient experience, reducing admissions and further reducing deaths. There is a need to work closely with providers of health care to ensure that they achieve this commitment to the population. 5.9 Quality, Innovation, Productivity and Prevention (QIPP) 5.9.1 There is a good deal of evidence to affirm that poor quality is both commonplace and costly. There is evidence world wide of the high financial and human cost of poor quality in the harm caused by healthcare and by sub-optimal care in the overuse, misuse and underuse of treatments. It has been estimated that the costs to the UK NHS of hospital acquired infections are 1 billion a year (Mayor 2000), and adverse drug events are estimated to be between 0.5 9

billion (Pirmohamed et al 2004) and 1.9 billion (Compass 2008). Patients with chronic diseases do not always receive optimal care and the cost of avoidable emergency admissions is high. 5.9.2 Nationally it is estimated that one in ten hospital patients suffer an adverse event and a significant number are harmed, requiring additional treatment. Common adverse events include infections, adverse drug events, surgical complications, pressure ulcers and falls. Poor quality which may not result in an adverse event occurs at higher rates with underuse, misuse and overuse of treatments and often have a high cost to the patient in terms of experience as well as the financial cost to providers and commissioners. 5.9.3 Quality and safety improvements are essential elements of the QIPP plan and are fully considered along with productivity. It is known from evidence and experience that the economic pressures facing the NHS will put increasing strain on services, and measurement will be vital for monitoring safety and improving quality in the context of the requirement to improve productivity and efficiency. North Norfolk CCG will consider quality monitoring in relation to patient safety, clinical effectiveness and patient experience. 5.10 Reporting systems : 5.10.1 Quality Quality Dashboards: The National Quality Board is developing a dashboard of quality indicators. Whilst not a performance management tool, the dashboard will contain useful indicators and metrics to support benchmarking and monitoring. The aim is to make the dashboard user friendly, with a facility to drill down into data. Analysing these indicators could prompt further questions and conversations to help uncover any problems. The dashboard is fully aligned with CQC s quality and risk profiles. The National Quality Team is also working on a dashboard for quality in primary care. Evidence collated for the quality handover has been utilised to inform future quality reporting and monitoring. 5.10.2. Safety We will monitor and triangulate these key areas for safety Quality dashboards Provider Assurance Framework (risk register) Never Events Serious Incidents Rule 43 / Coroners Inquests 10

Safety Thermometer HCAI s Serious Case Reviews Clinical Investigations (e.g., Local Supervisory Midwifery Reports; Homicide reports) Safeguarding concerns Safety Alerts Monitoring visits to providers Litigation and provider risk profiles 5.10.3 Effectiveness Will be Monitored and supported through: Data from Quality Observatory NICE guidance Indicators for Quality Improvement Evidence base, for example, prior approval Better care better value indicators Knowledge Management / Map of Medicine Integrated work with the Local Authority Partners 5.10.4 Patient Experience Key areas to monitor and achieve patient experience improvements are: CQC reports Complaints Patient Advice and Liaison Services (PAL s) Family & Friends net promoter Feedback from General Practices Patient surveys Staff Surveys Local Involvement Networks (LINks) Norfolk Health and Overview Scrutiny Committee The CCG will also explore using its Referral Management Centre to follow up sample patients who have used services commissioned by the CCG so as to collect detailed and systematic data on their experience of using local services. Formatted: Indent: Left: -0.25 cm, No bullets or numbering 6. Safeguarding 11

6.1 We recognise that Safeguarding those who are most vulnerable within our communities is a major aspect in managing quality and safety in our commissioned services and safeguarding is therefore a key area. 6.2 In order to discharge our statutory duties and responsibilities for safeguarding Children (Working together to safeguard Children, Promoting the health and wellbeing of Looked after Children and young people DH 2009) and Adults ( No Secrets DH 2000, and the suite of guidance documents issued by the DH in 2010 referencing the roles of Health professionals, Managers and Boards, and Commissioners towards safeguarding adults) we will follow national and local guidance and legislative requirement (Mental Capacity Act 2005, Mental Health Act) 6.3 We will also ensure that we maintain focus on the management of Domestic violence and sexual abuse (CAADA guidance, DH 2011 guide for Commissioners re: services for Women and Children who are victims of domestic violence and abuse), hate crime (recommendations from Hidden in Plain Sight 2011, and the DH PREVENT agenda in order to encompass all of those who are or might become vulnerable within our community. 6.4 We have in place strong countywide multiagency pathways, policy and procedures, with relevant boards and working groups to support development within all of these areas. Health safeguarding commissioning representation has been integral to how these systems have evolved and has to date been provided by the designated professionals for children and adult safeguarding for Norfolk and Waveney. They provide a key strategic leadership role and support providers and CCG s across all aspects of the commissioning cycle 6.5 Priorities for Safeguarding within commissioning are to: Ensure that the necessary contract schedules agreements and expectations are in place for all commissioned healthcare services for Safeguarding Adults, Children and Looked after Children(LAC) Provide specialist information and guidance to inform commissioning and contracting decisions Pro-actively work with healthcare professionals who have concerns about potential abuse Monitor provider performance against contractual expectations in relation to the safeguarding frameworks and linking this to the wider clinical quality and patient safety agenda Routinely monitoring of care providers and, where concerns are identified, instigate an urgent and appropriate response 12

Provide a health and clinical perspective to quality of services and multi-agency visits to care organisations in relation to safeguarding concerns. Supporting investigations/clinical reviews on behalf of the safeguarding adult an children s pathways. 6.6 To ensure that we retain the focus, specialist skills, knowledge and relationship of this group of professionals we have formally agreed CCG hosting arrangements for both Children s and Adult safeguarding across our professional networks which will be supported by a memorandum of understanding within the CCG s across Norfolk and Waveney. It will clearly set out parameters for function - expectations, communication links, reporting lines and responsibilities for the safeguarding service, but will also identify CCG commitment to their developing responsibility for engagement across the multiagency pathways and representation to LSCB/LSAB boards, ensuring that Safeguarding becomes fundamental within the commissioning organisations in Norfolk and Waveney. 6.7 NNCCG will host the adult safeguarding service, whilst Gt Yarmouth and Waveney CCG will host the children s safeguarding service. It is proposed that for the foreseeable future that the teams will remain co-located and centrally based which will enable continued close working arrangements for areas where their responsibilities cross and also effective interface with the CSU. These arrangements will ensure that NNCCG will have: Established appropriate systems for safeguarding and empowerment of vulnerable individuals. A clear line of accountability which is reflected in CCG governance arrangements and reports to the CCG Governing Body. Evidence of clinical leadership at CCG chair level and an accountable officer for safeguarding Arrangements in place to co-operate with the Local Authority in operation of LSCB/LSAB with agreements from local safeguarding board chairs and directors of social services Agreed hosting arrangements providing dedicated access to designated Nurse and doctor for safeguarding children and LAC, and a safeguarding adult lead/lead for Mental Capacity which will be embedded within the organisation in terms of process and policy Plans in place to train staff in recognising and reporting safeguarding concerns NNCCG will ensure that safeguarding is a strategic objective and commission services accordingly. 13

7. Conclusion 7.1 NNCCG s Safety and Quality Strategy is above everything about delivering real improvements that impact upon the people who access our services, and that by working with our CCG colleagues across Norfolk and Waveney we will maximise opportunities to guide and learn from each other as to how we improve the health of our county by commissioning high quality safe care, and maintaining it through robust monitoring and triangulation of data and information, but additionally by expanding the way in which we capture patient experience and outcomes. 7.2 The strategy builds on much good practice already established by NHS Norfolk and Waveney but offers real potential to achieve even more effective arrangements by virtue of the strong engagement of GPs and the local population. 7.3 This strategy represents the basis of the framework for delivering quality and safety, which will evolve as we begin to fully take on the responsibility of clinical commissioning, as work progresses we will identify ways in which to strengthen our internal processes, work more cohesively within our professional network and establish clear functions with our CSU. It provides surety as a starting point. 7.4 The membership of NNCCG will together establish a shared understanding of safety and quality and it s commitment to place it at the heart of everything that it does. We will develop key relationships across stakeholders and service users to ensure we benefit from wide ranging views and collaboration to commission services which are holistic, seamless and meaningful. Author: Jackie Schneider, Head of Patient Safety and Quality. Approved by: NNCCG Executive Team 18/9/12 14

15