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Stafford & Surrounds Clinical Commissioning Group Governing Body Meeting
To be held on Monday 15th April 2013, 14:30 – 17:00 Stafford Gatehouse Theatre, Stafford
AGENDA A=Approval D=Decision I=Information
Enc Lead A/D/I 1 Welcome by the Chair MJ
2 Apologies for Absence MJ
3 Conflicts of Interests MJ I Presentation of Register of Members Enc 01 SY I Interests 4 Minutes of the last meeting : • Unconfirmed minutes of the Governing Body held 4th February Enc 02 MJ A 2013 • Matters arising Enc 03
5 Chair of the Governing Body Verbal MJ I
6 Chief Officer Report Enc 04 AD A/D
• Transition and Capacity
• Conflict of Interest • Individual Funding Request Policy • 111 Update • Government Initial Response to Mid Staffordshire Public Inquiry • CCG Response to the Monitor review • Conversation Staffordshire • Local Health Quality Premium Enc 00 Scheme
7 Quality Report Enc 05 VJ A 8 Follow up to Francis Report Verbal VJ I 9 Finance & Performance • Finance Report –Month 11 Enc 06 AC I • Finance Plan 2013/14 Enc 07 AC A (Presentation) • Performance Report-February 2013 Enc 08 AC I
10 Everyone Counts-Plans for 2013/14 Enc 09 AB A
11 Innovation Plan Verbal PM I 12 Items for Information VJ I • Joint Quality Committee Minutes Enc 10
13 Any Other Business • Governing Body meetings in public Enc 11 MJ
14 Questions from the public
15 Date of Next Meeting : Monday 20th May 2013 14:30 (venue tbc)
Item 3 Enc 01
STAFFORD & SURROUNDS CCG GOVERNING BODY - DECLARATION OF INTERESTS REGISTER
November 2012
Member Position Interest Margaret Jones Chair Partner in Penkridge Medical Practice, Pinfold Lane, Penkridge, ST19 5AP. Provide Primary Care Services to the NHS under a General Medical Service (GMS) contract. Gareth Morris Lay Member (PPI, who Head Teacher – Flash Ley Primary School, will also be the Vice Chair Stafford. of the CCG) Commissioner for Education, Staffordshire County Council Neil Chambers Lay Member (Governance Joint post between SAS CCG and CC who will also Chair the CCG. Audit Committee) Board Member – Wyre Forest Community Housing Group, Kidderminster Manjit Obhrai Secondary Care Joint post between SAS CCG and CC Consultant CCG. Associate with Hygeian Consulting. Associate with Obhrai Healthcare Consulting.
Val Jones Registered Nurse Joint post between SAS CCG and CC (Director of Quality and CCG. Safety) Spouse is a Staffordshire County Councillor Anne-Marie Houlder Clinical Leaders GP at Weeping Cross Provide Primary Care Services to the NHS under a Primary Medical Service (PMS) contract.
Husband is a GP in Brewood
Husband is partner Brewood Medical Services. Paddy Hannigan Clinical Leaders Partner at Holmcroft Surgery, Stafford. Provide Primary Care Services to the NHS under a Primary Medical Service (PMS) contract
Item 3 Enc 01 Paid post ½ day per week as Medical Officer to Weston House Nursing Home (Dementia Care Home) owned by Methodist Homes. Sue Knight Clinical Leaders GP at Browning Street Surgery, Stafford. Spouse is Assistant Director of Commissioning at the Cluster of Staffordshire PCT’s.
Marianne Holmes Clinical Leaders Partner at Great Haywood Surgery, Hazeldene House, Great Haywood, Staffs. Provide Primary Care Services to the NHS under a Primary Medical Service (PMS) contract. Director - Great Haywood Healthcare LTD Director - Trent Valley Community Health LTD
Paul Brown Member Practice Manager Practice Manager at Mansion House Surgery, Stone. Andrew Donald Chief Officer Spouse is Chief Operating Officer (COO) with SSOTP.
Joint post between SAS CCG and CC CCG Andy Chandler Chief Finance Officer Joint post between SAS CCG and CC CCG Jane Chapman CCG Director Nil to Declare Sally Young Head of Strategic Joint post between SAS CCG and CC CCG Compliance and Governance Katie Woods Board Secretary Joint post between SAS CCG and CC CCG Adele Edmondson Internal Relationship Joint post between SAS CCG and CC CCG Manager
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Minutes of Stafford & Surrounds Governing Body Meeting Clinical Commissioning Group Held on Monday 4th February 2013
Present Action Dr Margaret Jones (MJ) Chair Andrew Donald (AD) Chief Officer Andy Chandler (AC) Chief Finance Officer Steve Powell (SP) Chair, Membership Board Dr Manjit Obhrai (MO) Secondary Care Consultant Val Jones (VJ) Nurse Board Member /Director of Quality & Safety Dr Anne-Marie Houlder (AMH) Clinical Lead Dr Paddy Hannigan (PH) Clinical Lead Dr Sue Knight (SK) Clinical Lead Dr Marianne Holmes (MH) Clinical Lead Paul Brown (PB) Member Practice Manager
In Attendance Jane Chapman (JC) CCG Director Sally Young (SY) Head of Strategic Compliance & Governance Adele Edmondson (AED) Internal Relationship Manager Katie Woods (KW) Executive Assistant
1.0 Welcome & Introductions 1.1 MJ thanked members of the public for attending and stated that it was encouraging to see a large turnout. In future to accommodate the high numbers wishing to attend, the Governing Body will look for a larger venue.
1.2 MJ explained that Governing Body was a meeting held in public not a public meeting. The Governing Body will not be able to discuss the Francis Inquiry, Monitor review into MSFT or individual cases.
2.0 Apologies for Absence 2.1 Neil Chambers & Gareth Morris
3.0 Conflicts of Interests & Presentation of Register of Interests 3.1 SP, PB, PH, MH, AMH and MJ all declared an interest in Item 11 Local Enhanced Service Review and AMH declared an interest in Item 12 Vasectomy Service Specification.
4.0 Minutes of the previous meetings
1 Item 4 Enc 02
4.1 Governing Body Minutes 5th November 2012 The Governing Body agreed the minutes as a true and accurate record.
4.2 SaS and CCG Quality Committee
The minutes were assigned to SaS CCG only. The Quality Committee is 4.3 a joint committee between SaS CCG and Cannock Chase CCG and the error would be corrected.
Discussion was raised over the number of open Serious and Adverse 4.4 incidents reported in December. VJ confirmed the incidents relate mainly to pressure ulcers. Staffordshire & Stoke on Trent Partnership Trust (SSOTP) had the largest number but this had been raised at contracting and performance meetings with currently no overdue incidents outstanding although some were still being investigated .
4.5 The Governing Body discussed a possible never event at Rowley Hall, VJ clarified that the event did not meet national criteria and confirmed that the incident was recorded as a Serious Incident (SI).
4.6 The Governing Body received and noted the minutes.
4.7 Audit Committee AC informed members that the Audit Committee held in December reviewed the Terms of Reference, (ToR), Conflict of Interests and reviewed the business cycle in key areas. AD reported to the Governing Body that Grant Thornton have been named as SaS CCG External Auditors.
4.8 The Governing Body received and noted the verbal update.
QIPP Committee 4.9 The QIPP Committee had focused on governance arrangements. The Governing Body received and noted the verbal update.
5.0 Chair of the Governing Body Report 5.1 MJ advised that • The authorisation process is continuing to progress, SaS CCG have 10 remaining conditions however, this may reduce before Authorisation in April due to the work plans in place. • Work with Monitor around MSFT is on going. • SaS CCG aim to develop strong sustainable leadership, additional clinicians have been recruited to focus on particular development areas, research, innovation and Long Term Conditions • Joint meetings with Cannock Chase CCG had been held to address QIPP plans. A series of Practice visits will take place with a focus on QIPP. • Work to ensure governance processes are fit for purpose is on going.
The Governing Body was asked to note the report.
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6.0 Chief Officer Report 6.1 Authorisation In February, the CCG will receive a formal letter setting out its terms of authorisation. From this date, the CCG will be a statutory body. SaS CCG has submitted their ‘Plan on a Page’ to the NHS Commissioning Board (NHSCB). This plan outlines how the CCG will deliver ‘Everyone Counts’ the new planning framework for CCGs. An update will be provided at a future Governing Body meeting.
6.2 The Governing Body noted the update.
6.3 Legacy & Transition SaS CCG will be meeting with Staffordshire Cluster to formally handover legacy issues as the CCG move closer towards April 1st 2013. Further areas of work not initially identified are now being transferred to CCG’s, these include:
• the implementation of Choose & Book • the introduction of the Summary Care Record
6.4 The new areas of responsibility may be a challenge given the current capacity of staff.
6.5 The Governing Body noted the update.
6.6 Quality, Innovation, Productivity and Prevention (QIPP) 2013/14
6.7 The delivery of QIPP in 2013/14 will be challenging. The expectation is that the CCG will deliver 4-5% efficiency savings A detailed QIPP plan will be presented for sign off at the April Governing Body meeting.
6.8 The Governing Body noted the update.
6.9 Policies The following policies are available on the members’ area of SaS CCG website for information. The policies demonstrate how the CCG intends to fulfil its statutory requirements. • Private Sector Sub Policy • Information Governance Framework • Information Governance Policy • Information Governance Strategy • Guidance for Inclusion of Information Governance Requirements • Confidentiality Staff Code of Conduct • Information Security Procedures
• Information Sharing Code of Practice
• Privacy Impact Assessment Guidance
• Information Risk Assessment and Management Plan • South Staffordshire PCT Statement of Terms and Conditions • South Staffordshire PCT CRB Policy and Employment with a Criminal Conviction • Gifts and Hospitality Policy
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6.10 The Governing Body approved the above policies and agreed to adopt the two PCT policies until these could be redrafted to a CCG format
6.1.1 Petition 38° 38° is a UK campaigning community with more than 1 million members. They are writing to all CCGs to ask for specific requirements to be included in each CCG’s Constitution. A petition signed by 565 (not 240 people as noted erroneously in the CO’s report) has been handed into Stafford & Surrounds CCG by 38 degrees. The CCG had responded to the petition and AD reported that all the areas raised had already been included in the CCG constitution.
6.1.2 The Governing Body noted the petition delivered by 38° and the actions undertaken to address issues raised.
7.0 Quality Report 7.1 The report provides the Governing Body assurance of continuing progress by the CCG of its capacity and capability to support successful transfer of responsibility for commissioning quality, safe services from April 2013.
7.2 The report also;
• describes the establishment of the Joint Clinical Quality Committee for SaS and CC CCGs
• advises the members on the role of the newly formed Quality Surveillance Groups in sharing vital information and intelligence on provider quality and safety performance.
• provides an update on key quality and safety matters as reported
to the Clinical Quality Review Groups (CQRMs).
7.3 Discussion was raised regarding 13.1 thematic review, VJ advised that the team are awaiting an action plan which will include improved investigation process and communication with family and carers.
7.4 VJ gave assurance that any quality or safety issues from other providers are reported and actioned via Clinical Quality Review Meetings (CQRM) Members discussed the rise in trajectory for C Difficile. Remedial plans are in place and overseen by Infection Prevention and Control team.
7.5 VJ reported to the Governing Body that a review of District Nursing has
been released in the North and reported at SSOTP CQRM. The
outcomes from that review will be used to inform a action in the South . The Governing Body noted that action in the South should focus on issues identified by the review in the North and not merely a repeat review to get best benefit.
7.6 Action: Further information to be discussed at next Quality Meeting. VJ 7.7 Members discussed the increased number of complaints received by South Staffordshire and Shropshire Foundation Trust. The Trust Complaints manager is working with neighbouring Mental Health Trusts
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to develop a benchmarking programme. VJ would outline timescales at the March meeting.
7.8 The Governing Body received and noted • The continuing progress made by the CCG in preparation for transfer of commissioning responsibility form April 2013. • The role of the newly established Quality Surveillance Groups for promoting quality and safety issues. • The key quality and safety matters reported to the Clinical Quality Review Group and actions taken in response.
8.0 West Midland Quality Review Service Report into Long Term Conditions 8.1 The West Midland Quality Review was completed for those with Long Term Conditions in October and did not highlight any immediate concerns.
8.2 The report identified four key system wide areas for improvement, which
were integration of services, information sharing and communication,
documentation and care for people with multiple LTC. There were also a number of additional findings that relate to individual organisations.
8.3 Each organisation will ensure it addresses the actions required to improve services and as commissioners the CCG will hold them to account. However, where the improvements require a system wide approach the Commissioning Board that oversees the Clinical Services Implementation Programme (CSIP) will manage the response via the Clinical Working Groups.
8.4 JC presented a draft action plan to address the areas for improvement.
This will be reviewed by the Commissioning Board.
8.5 The Governing Body noted • work to develop the action plan in response to the West Midlands Quality Review • that the action plan when complete will be brought back to the Governing Body for sign off.
9.0 Finance Report 9.1 AC presented the report to members, which sets out the in-year financial position at month 9, based on 8 months of Secondary Care data. The CCG is currently showing an overspend of £1.6m against plan. The CCG planned position was break-even at the end of period 9. A number of significant pressures have been identified.
The main areas of risk remain around the Acute Contracts which show an overspend of £2.2m as at Month 9, which is forecast at c£4.2m at the 9.2 year-end. There is also an over performance on Continuing Health Care at Month 9 of £0.6m with a forecast overspend of £0.9m. QIPP achievement also remains a key area of risk.
9.3 The Governing Body noted that, although projections would suggest a
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year end deficit of 1.6 million, the CCG is still planning for a year end break even as 2.5 million is factored in with 0.8 million of further mitigating action.
9.4 SP asked how the mitigating action would be delivered and AC explained that current overperformance would need to be maintained at current level and 0.4 million QIPP savings to year end were planned.
9.5 The Governing Body noted the current financial position.
9.6 Audit Committee – Revised Terms of Reference
• The committee shall now be made up of Lay Members including Lay Member for Governance as Chair, Lay Member for Patient Public Involvement (PPI) and Secondary Care Consultant as a committee member. • Frequency of meeting shall be increased to five a year as per advice from internal auditors.
9.7 The Governing Body approved the new ToR for the Audit Committee
10.0 Performance Report 10.1 The Governing Body noted the significant improvements in December. Performance at MSFT has improved with achievement of Referral to Treatment Time (RTT) achieved with no current concerns in RAG rating; the hard work which had produced these improvements was acknowledged.
10.2 Discussion was had regarding Emotional Well Being in South Staffs (EWISS) . Time till initial assessment had markedly improved but clinical members felt there was still some delay in accessing treatment.
10.3 Action; JC to check EWISS waiting time for SK & AMH JC 10.4 The Governing Body asked AC for the reason of breaches within cancer wait and if it related to any specialty. AC advised the figure related to more complex cancers that may require specialist treatment.
10.5 The Board accepted the Performance Report
10.6 Performance Monitoring & Assurance Update The report details processes to monitor both internal and external performance across the CCG, through CCG dashboards. Exception reports will give members a triangulation of all areas, foster greater improvement in performance and introduce a performance management culture into the CCG.
10.7 The Performance Team will be working with all partners and providers in Health Economy.
10.8 Data will also be published in the public domain to drive better performance for clinical care. 10.9 Future reports will include QIPP performance reports and comparative
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data from practices including practice referral data.
10.1.1 Action; Chris Wood, Head of Performance, to present an update of this work to the next Board. AC 10.1.2 The Governing Body noted progress to date in the development of a structured Performance Framework.
11.0 Local Enhanced Service Review 11.1 GPs and other primary care contractors have been commissioned in the past to provide services that currently are outside the standard contract in the form of a Local Enhanced Service (LES). From April 2014 services will be commissioned by the CCG with 2013/14 being a transitional year.
11.2 The Local Area Teams will commission some enhanced services
nationally, equivalent to Directed Enhanced Services (DESs). Where it is agreed that current DESs should roll forward to 2013/14, the NHS Commissioning Board, will become responsible for them.
11.3 The Board was asked to approve a plan to roll over all existing LES schemes for a minimum of six months in order for review of on-going need. From April 2014 all continuing services will be commissioned using NHS standard contracting and procurement processes.
11.4 Discussion regarding clinician’s ability to have an input to decision
making whilst avoiding a conflict of interest followed; it was agreed that
independent clinical input could be provided.
11.5 The Governing Body asked that the LES review is to be brought back in six months, which would allow sufficient notice time for any changes to contracts.
11.6 The Governing Body approved the plan for LES review.
12.0 Vasectomy Service Specification 12.1 The report presents a service specification for a community vasectomy service; the specification has been reviewed by the Membership Board but requires a final approval from the Governing Body before going to Any Qualified Provider (AQP) Procurement.
12.2 JC advised that the bulk of activity would be carried out in the community however, patients would still have the option to go into secondary care.
12.3 The Governing Body agreed quality and equality impact assessments are outstanding for this specification.
12.4 The Governing Body approved the specification in principle subject to completion of quality and equality impact assessments.
13.0 Any Other Business 13.1 None identified
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14.0 The Chair thanked all for attending the meeting and the meeting was closed at 4.45pm..
• 15th April 2013, 14:30, Mountbatten Suite, Stafford Gatehouse Theatre( Meeting in to be held public)
Agreed as a true and accurate record:
Signed ……………………………………… Date ………………………………….
Print ………………………………………… (CHAIR)
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Item 4 Enc 03
STAFFORD & SURROUNDS CCG GOVERNING BODY
Action List
Meeting Date Agenda Item Reference Action Officer Update Responsible 04.02.13 7.0 Quality Report 7.6 Further information VJ Proposal received regarding District from SSOTP Nursing to be regarding District discussed on Nursing capacity, 15.04.13 under review with Chief Officer. 04.02.13 10.0 Performance 10.3 JC to check EWISS JC Completed Report waiting time for SK & AMH 04.02.13 10.0 Performance 10.1.1 Head of Performance AC Chris Wood to Report to present update discuss under performance item.
Item No: 6 Enc: 04
REPORT TO THE Clinical Commissioning Group Governing Body Meeting TO BE HELD ON: Monday 15th April 2013
Subject: Chief Officer’s Report Board Lead: Andrew Donald Officer Lead: Andrew Donald
Recommendation: For Approval √ For Discussion √ For Information
PURPOSE OF THE REPORT: • To update members on transition and capacity matters • To advise members on revised information related to conflict of interest matters • To agree the policy for Individual Funding Requests • To update on the implementation of 111 • To note the initial Government response to the report of the Mid Staffordshire NHS Foundation Trust Public Inquiry • To provide a response to Monitor Contingency Planning Teams Report • To update the Governing Body on Conversation Staffordshire • To seek approval for the introduction of a Local Health Quality Premium
KEY POINTS: • CCG is now authorised with three conditions • Transition / handover of key documents has been completed / awaiting outstanding transfer orders • Individual Funding Requests Policy – a key policy for dealing with patients with exceptional requests • Note the implementation issues related to 111 • The Government initial response highlights issues a call for excellence in five key areas (Preventing problems, Detecting problems quickly, Taking action promptly, Ensuring robust accountability and Ensuring staff are trained and motivated) • Contingency Planning Team Report recommends three options for future models alongside protected services and commissioning aspirations • Over 250 people engaged with Conversation Staffordshire awaiting feedback from the events • Local Health Quality Premium (LHQP) sets out a framework for delivering high quality evidence based care within resources available
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Relevance to Key Goals A 10% reduction the levels of obesity Local Health Quality Premium will support all against the expected prevalence goals
A reduction in the proportion of people Local Health Quality Premium will support all with undiagnosed disease from 30 – 10 goals %. A “levelling up” of health outcomes so Local Health Quality Premium will support all that all residents experience the same goals health care outcomes
A reduction in excess winter deaths of Local Health Quality Premium will support all 50% goals
A reduction in unplanned admissions to Local Health Quality Premium will support all hospital for people with Long Term goals Conditions of 50%
Implications Legal and/or Risk Transition and handover not completed, this would be a risk to the CCG in undertaking its statutory duties CQC Response to Francis report is critical to ensure high quality safe services and building public confidence Patient Safety Response to Francis report is critical to ensure high quality safe services and building public confidence Patient Response to Francis report is critical to ensure high quality safe Engagement services and building public confidence Financial Local Health Quality Premium developed to support the CCG in meeting its statutory obligations Sustainability Workforce /
Training
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RECOMMENDATIONS / ACTION REQUIRED: The CCG Governing Body is asked to: The Governing Body is asked to: • Note the report • Note the transition and capacity matters • Note the conflict of interest documents and ask the Chief Financial Officer and Lay Member for Governance to report back on the how this guidance could be incorporated into the CCGs systems and processes • Approve the policy subject to confirming their preferred position with regards to the makeup of appeals panels • Note the issues with 111 and the mitigating actions • Note the Governments initial response to the Mid Staffordshire Inquiry “Patients First and Foremost” • Note the receipt of the Contingency Planning Team report • Note the update on Conversation Staffordshire • Approve the development and implementation of the Local Health Quality Premium Scheme
KEY REQUIREMENTS Yes No Not Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Have partners / public been involved in design? Are partners / public involved in implementation? Are partners / public involved in evaluation?
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Report to Stafford and Surrounds CCG Governing Body
Chief Officer’s Report
1.0 Purpose
• To update members on transition and capacity matters • To advise members on revised information related to conflict of interest matters • To agree the policy for Individual Funding Requests • To update on the implementation of 111 • To note the initial Government response to the report of the Mid Staffordshire NHS Foundation Trust Public Inquiry • To provide a response to Monitor Contingency Planning Teams Report • To update the Governing Body on Conversation Staffordshire • To seek approval for the introduction of a Local Health Quality Premium
2.0 Transition and Capacity
On the 20th February Stafford and Surrounds CCG received their formal letter of authorisation. The CCG has been authorised with three conditions related to finance and risk management.
All these conditions can be reviewed quarterly. The conditions relate to the significant challenges facing the CCG financially next year.
To support the CCG in achieving full authorisation with no conditions work is underway to deliver at a more granular level a financial strategy which will demonstrate significant understanding and clear actions on how the CCG will deliver its statutory financial duties at the 31st March 2014.
All transitions matters have been completed and key documents were handed over the CCGs Governing Body on the 21st March 2013. This included the Quality handover document and the Operational legacy document.
Since early in the new year work has been underway to review the capacity of the CCGs management team in the area of Quality and Financial Management and it has been agreed that these areas need further strengthening through the introduction of two quality officers and a deputy Chief Financial Officer. All the costs of these posts are within the £25 running cost allowance.
Action: The CCG Governing Body is asked to note the transition and capacity matters
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3.0 Conflicts of Interest
NHS England have recently sent information to CCGs which updates advice on the issue of Conflict of Interest to support CCGs in demonstrating that they have systems which are transparent and open to public scrutiny in the way the CCG discharges its functions.
The documents are attached for information and include:-
• Updated guidance for Clinical Commissioning Groups • Five Appendices which help in managing identified conflict of interest issues
The Chief Finance Officer and the Lay Member for Governance have been asked to review these documents and set out proposals for how this advice can be used as part of the CCGs processes
Action: The CCG Governing Body to note the documents and ask the Chief Financial Officer and Lay Member for Governance to report back on the how this guidance could be incorporated into the CCGs systems and processes
4.0 Individual Funding Request Policy (Attached)
As part of the need to develop cohesive policies which represent the position of CCGs. The South Staffordshire IFR team hosted by South East Staffordshire and Seisdon CCG have on behalf of CCGs developed a policy for ensuring the management of individual funding requests is developed in line with the systems and processes that are now working across the four CCGs in South Staffordshire.
SSPCT has been working to develop the Cluster wide IFR policy ratified in January 2012, which receives legal input from Mills & Reeve.
There is an on-going need for CCGs to have a process in place to consider exceptional funding requests and therefore the current policy has been amended, in draft, to reflect the new NHS architecture and to meet CCG needs.
There are a number of key changes that have been made to the existing policy and these are:- • Provision is made under paragraph 2.5 to consider rarity as a basis for exceptionality. This is an addition to the current policy, but is included on the assumption that smaller CCGs are less likely to have commissioning policies for rare situations. • Under the collaborative commissioning arrangements, the IFR process is supported by the hosted team. CCGs however cannot delegate decision making responsibility and therefore a CCG representative with delegated decision making responsibility is required to be in attendance for funding decisions. Paragraph. 3.1.1 refers.
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• The addition of paragraph 4.1.6 prevents an IFR panel considering funding any intervention which does not come under their commissioning remit.( e.g. specialised commissioning) • Under the existing policy a non-executive director is the chair of the IFR panel- the revisions propose that this role is taken over by a lay- member (and deputy). • Any Appeals had previously been addressed to the Cluster Chief Exec, who will lead an independent review; from 1st April 2013 this is no longer the case. The revised review suggested the Medical Director at the NCB AT. Other suggestions include the AO of a neighbouring CCG, which is feasible but difficult to articulate in documentation. Stafford and Surrounds CCG are asked to consider their preferences on this area of policy
Action: That the CCG Governing Body approve the policy subject to confirm their preferred position with regards to the makeup of appeals panel.
5.0 111 Update NHS 111 has been implemented to replace the previous service provided by NHS Direct. The soft launch of NHS 111 commenced in Staffordshire on the 12th March 2013, this testing was successful and during soft launch the evidence was that the capacity available, through the 111 service was managing to deal with any unexpected pressures due to call volumes.
Problems started to occur once further parts of the West Midlands started to undertake soft launching alongside many other areas nationally. It was clear prior to the end of March that significant technical problems were occurring which was outside local control. To ensure a fully stable system.
A decision was taken due the April bank holiday to revert back to using Out of Hours services to manage calls. This was a significant decision as many services were due to change hands on the 1st April 2013. This was not the case in South West Staffordshire where Badger the current Out of Hours Provider continued to support out of hours call handling even though this has proved challenging. As at today work is on-going to agree a timeline for the full implementation of 111 but this may take some weeks to ensure the right level of service and call handling is in place, to ensure a fully stable system.
The CCG is monitoring closely the situation with regards any problems for patients out of hours. As of today there have been a couple of incidents where information given to members of the public seems to have been confusing. These matters are being fully investigated by the commissioning team.
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Stafford and Surrounds hosts the Emergency and Urgent Care Team for South Staffordshire CCGs and is closely monitoring the situation as well as taking part in the provision of key data to the command and control centre set up to manage the situation.
Action: The Governing Board should note the issues with 111 and the mitigating actions
6.0 Government Initial Response to Mid Staffordshire Public Inquiry
The Governments initial response to the Mid Staffordshire Inquiry was outlined at the end of March in a Department of Health report “Patients First and Foremost”. This report is 75 pages in length and the CCGs Clinical Leaders and Officers responsible for Quality and Safety will be reviewing this document in the coming weeks.
The important point is to note that the report sets out a five point plan to revolutionise care that people receive from our NHS, putting an end to failure and issuing a call for excellence in five areas:-
• Preventing problems • Detecting problems quickly • Taking action promptly • Ensuring robust accountability • Ensuring staff are trained and motivated
In each of these areas the Government has proposed a number of key actions. All organisations will be required to set out the actions they will take to deliver the above whilst responding to the 290 recommendations in the Francis Report.
This process has commenced through a joint workshop between Stafford and Surrounds and Cannock Chase CCGs Governing Bodies on the 11th April which will be reported on under item 8.
Further reports on progress in relation to the Francis recommendations will be brought back to the Governing Body as update reports within the Quality and Safety report monthly.
Action: The Governing Body to note the Governments initial response to the Mid Staffordshire Inquiry “Patients First and Foremost”.
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7.0 CCG response to the Monitor review undertaken by the Contingency Planning Team
The contingency planning team appointed by Monitor has produced a report prior to Christmas outlining that over the longer term Mid Staffordshire Hospitals Trust was neither clinically or financially sustainable.
This has been followed by a recommendation that the Secretary of State should appoint a Trust Special Administrator. This decision is expected imminently.
The report submitted by the Contingency Planning Team was made public on the 6th March 2013. This outlined the potential future services that commissioners wished to commission alongside the services outlined as ‘Protected Services’.
The CCGs response to this as follows; the CCG understand that MSFT is not clinically or financially sustainable in its present form.
The work of the Contingency Planning Team on behalf of Monitor was to identify with proposals / options that ensured a clinically and financially sustainable future for the Trust.
The CCG notes the Contingency Planning Team report sets out options for change and at this stage they are just options which a Trust Special Administrator if appointed will wish to consider.
The information contained within the report about protected services has been developed with and signed off by Commissioners, but it is important to note that Commissioners, commission many more services than the services outlined for protection.
The report reflects Commissioners views that there should be:-
• Two hospitals remaining in Stafford and Cannock • There will be a requirement for beds at Stafford for particular parts of the population (the number of beds although the report quotes a range has yet to be defined) • A 24/7 Emergency and Urgent care service (Commissioners accept that this is not an A&E Department but will provide a 24/7 service nor is it a Minor Injuries Unit). The proposed service is between the two spectrums. However the CCG wishes to see as many patients treated in the Emergency and Urgent Care Service as possible subject to clinical safety and affordability.
The proposals set out the removal of the Midwifery service (birthing element), A&E changing to an EUCS and the removal of ITU / Critical Care Beds on the grounds of clinical safety in the future and that capacity will exist elsewhere. The CCG notes that
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the debate on the options for the provision of elective care is still outstanding as is the matter of organisational form and affordability.
The CCG are pleased to note that over 80% of patient contacts will happen locally.
The CCG is clear that all the proposals are subject to review and further discussion as we await a decision on whether a Trust Special Administrator (TSA) will be appointed.
If a TSA is appointed, the CCG has noted that they will have 150 days in which to complete a range of work including 45 days to produce a report and 30 days consultation.
Any proposals have to be clinically safe and affordable. The CCG notes that at present MSFT costs circa £20million of extra funding per year from the Department of Health to keep running at current levels and this is unsustainable in the future.
To reiterate the appointment of a Trust Special Administrator will require the question of organisational form to be addressed i.e. what organisation will Stafford and Cannock Hospitals be a part of in the future. This could affect the outcome around future service provision in Stafford and Cannock and therefore there is still a significant amount of discussion and debate to occur in the coming weeks and months.
The Clinical Commissioner Group and its member practices are committed to working with the Trust, and communities to get the best possible local services that are clinically safe and financially sustainable.
Action: The Governing Body is asked to note the receipt of the Contingency Planning Team report and CCG response
8.0 Conversation Staffordshire
Conversation Staffordshire is a collaboration between Healthwatch, Engaging Communities and Stafford and Surrounds and Cannock Chase CCGs) The initial event took place during March 2013. The event was the start of an attempt to have a conversation with the residents of Stafford and Surrounds Clinical Commissioning Group about the local health service. At the event on the 12th March over 220 local people took part in a conversation either in person or online, further events have been on-going through March 2013.
Much of the debate was about the future of Stafford Hospital; however there was lots of discussion about how people can get involved in decisions about their local health service.
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All the data is being analysed from all the discussions and events and will be available before the end of April. This information will be shared with Governing Body.
Action: The Governing Board is asked to note the update
9.0 Local Health Quality Premium Scheme
Everyone Counts: Planning for Patients 2013/14 set the intention to reward quality through commissioning by the introduction of a Quality Premium which would be paid to Clinical Commissioning Groups in 2014/15 for the achievement of objectives in 2013/14.
This quality premium would be paid to Clinical Commissioning Groups for the improvement or achievement of higher standards of quality in:-
• Four measures of the NHS Outcomes Framework (Potential years of life lost from causes amenable to healthcare, avoidable emergency admissions, the friends and family test and incidence of healthcare associated infections (MRSA and C.Diff) • Three local measures (to be chosen by the CCG) • Continued delivery of NHS Constitution rights and pledges
We now know that the quality premium will be £5.00 per head and can be paid direct to practices. We do not know at this stage what, if any restrictions will apply on how that expenditure, if allocated Practices can be used.
The total amount of the quality premium across Stafford and Surrounds CCG is circa £720k.
To achieve the above is not without its challenges particularly as many of the measures relate to Acute Trust and system performance. However it is critical that we are able to see the possible benefits of good evidence based commissioning and increased benefits of integrated working with our providers as well as increased quality of care.
Local Position
At present across the Clinical Commissioning Group there are no local quality incentive schemes for commissioners in place which will enable overall, the Clinical Commissioning Group to galvanise members as a group to focus on two key matters excellent evidence based clinical practice and financial balance.
Obviously there are small Local Enhanced Services schemes in place but these are very specific and although they support effective commissioning they do not focus on the overall strategic requirements of the CCGs to increase quality.
The following sets out a proposal for the development of a Local Health Quality Premium Scheme (LHQPS), which is specifically designed to be focused, bureaucracy
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light and gives the freedom to the practices as commissioners about how they achieve the LHQPS.
The Development of a Local Quality Premium
The Clinical Commissioning Group has a significant number of responsibilities ranging from the commissioning of high quality, safe clinical care which includes the delivery of standards in the NHS Constitution as well as its own local goals for its patient population within the resources available.
Over and above this the CCG has its own Quality, Innovation, Productivity and Prevention (QIPP) targets to deliver this creates a myriad of standards and targets to be achieved. This multiplicity of standards and financial requirements can mean that the focus is more on delivering the standard or the financial target than is actually on the job in hand of commissioning high quality safe services or providing high quality safe services (i.e. the danger is we hit the standard or target but miss the point).
It is therefore proposed that we introduce a Local Health Quality Premium Scheme (LHQPS) Scheme which has two requirements:-
1. That the group of member practices delivery high quality evidence based care whether through commissioning or provision. The principle here is that cost is incurred by Practices or the patients of the practice and therefore the responsibility for increasing quality rests with the member practices. 2. That the group provide high quality evidence based patient care within the allocated resource available.
If those two objectives are met then an LHQP will be paid to the group.
How the above are delivered will be down to the group to decide, the CCG team will assist where possible and will continue to focus on other areas which deliver QIPP benefits. However the essence of the LHQP is to give control to the member practices, for delivering high quality, safe services but within the current risk limits.
How will the LQP work?
On the principle of keeping it simple an LHQP of circa £720k for Stafford and Surrounds CCG is available and payable in 2014/15 subject to the audit of the financial accounts normally (May 2014).
It is accepted as a principle that the Practices will be commissioning and providing high quality evidenced based care and this will measured through various routes throughout the year. Therefore the LHQP will be paid to the group on the following basis:-
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If the group achieve the commissioning and provision of good quality evidence based care, and achieve this within the CCGs allocated resource i.e. the costs incurred equate to the budget then a LHQP will be paid.
If the group achieve a surplus of 1% then £5.00 per head of population will be paid, if the group achieve ½% surplus then £4.00 per head will be paid. If the group miss the financial target by 1% the group would still receive £1.00 per head of population and if the group miss the target by ½% then they would receive £2.00 per head. The table below shows this in more detail. End of Year LHQP Payment Financial Position SAS March 2014 1% Surplus (£1.5m) £5.00 per head of population ½% Surplus £4.00 per head of (£0.75m) population Breakeven £3.00 per head of population ½% deficit (- £2.00 per head of £0.75m) population 1% deficit (-£1.5m) £1.00 per head of population
Subject to audit the LHQP would then be allocated to the Membership Board and they would agree how this amount was to be disbursed to Practices.
The one outstanding matter is the level of flexibility of the use of the LHQP in Practices, the proposal is that this would be worked through by a sub-group of the members with the Chief Officer and Chief Financial Officer and the Lay Member for Governance of the CCG to ensure that any use of the funds by Practices was deemed reasonable and subject to scrutiny. Key Points to note 1. There will no further measures identified over and above current measures within the LHQP. 2. This will be bureaucracy light in that the measure for the payment will be higher quality services to patients within the CCGs allocated resources. 3. The CCG team will continue to work on QIPP schemes to support the achievement of the LHQP 4. Based on assumed liberty the members will be presumed to be delivering high quality evidenced based commissioning or provision unless indicators suggest otherwise and these will be shared with the members through the performance dashboard 5. The payment of the LHQP is not based on the achievement of the National Quality Premium the LHQP will still be paid to the membership even if standards to achieve the National Quality Premium are not achieved.
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6. The members will need to ensure for themselves all Practices are signed up. 7. Any LHQP payment will be allocated to the membership for disbursement not to individual practice.
The success of the CCG will be built on the member practices leading and engaging fully in the commissioning process. They also have a significant position as providers and navigators of care on behalf of their patients and populations. Therefore it is not only appropriate to develop the local LHQP but critical if the CCG is going to be successful in transforming care within the resources available.
Action: The Governing Board is asked to approve the development and implementation of the Local Health Quality Premium Scheme
10.0 Recommendations
The Governing Body is asked to: • Note the report • Note the transition and capacity matters • Note the conflict of interest documents and ask the Chief Financial Officer and Lay Member for Governance to report back on the how this guidance could be incorporated into the CCGs systems and processes • Approve the policy subject to confirm their preferred position with regards to the make of appeals panel • Note the issues with 111 and the mitigating actions • Note the Governments initial response to the Mid Staffordshire Inquiry “Patients First and Foremost” • Note the receipt of the Contingency Planning Team report and CCG response • Note the update on Conversation Staffordshire • Approve the development and implementation of the Local Health Quality Premium Scheme
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Managing conflicts of interests: Guidance for clinical commissioning groups
1 Item: 06 Enc: 04 NHS CB INFORMATION READER BOX
Directorate Medical Operations Patients and Information Nursing Policy Commissioning Development Finance Human Resources Publications Gateway Reference: 00005' Document Purpose Guidance Document Name Managing conflicts of interests: Guidance for CCG's Author Commissioning Development, NHS CB Publication Date 28 March 2013 Target Audience CCG Clinical Leaders, CCG Chief Officers
Additional Circulation #VALUE! List
Description 0
Cross Reference Towards establishment: Creating responsive and accountable CCGs (and technical appendix 1): Code of Conduct Superseded Docs N/A (if applicable) Action Required CCGs must have regard to this guidance Timing / Deadlines N/A (if applicable) Contact Details for John Taylor further information Commissioning policy and resources Quarry House Quarry Hill, Leeds LS2 7UE (0113) 2545704
0 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled.
2 Item: 06 Enc: 04
Managing conflicts of interest: Guidance for clinical commissioning groups
First published: March 2013
Prepared by: Commissioning Development Directorate
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Table of Contents
Introduction………………………………………………………………………………………………..5 What are conflicts of interest?...... 6 Principles for managing conflicts of interest…………………………………………………………...7 Statutory requirements…………………………………………………………………………………...8 Maintaining a register of interest………………………………………………………………………..9 Declarations of interest…………………………………………………………………………………10
Managing conflicts to protect the integrity of the decision-making process……………………....12 Appendix 1 – Register of Interests template Appendix 2 – Declaration of conflict of interests for bidders / contractors template Appendix 3 – Code of conduct template Appendix 4 – 10 question checklist Appendix 5 – Conflict of interest discussion scenarios
4 Item: 06 Enc: 04 Introduction
Managing conflicts of interest appropriately will be essential for protecting the integrity of the overall NHS commissioning system and to protect the NHS Commissioning Board (NHS CB), clinical commissioning groups (CCGs) and GP practices from any perceptions of wrongdoing. Commissioners will need the highest levels of transparency so they can demonstrate that conflicts of interest are managed in a way that cannot undermine the probity and accountability of the organisation. This will be particularly important for CCGs when dealing with member practices.
The need for NHS bodies to identify and manage conflicts of interest is not new. Healthcare professionals have always had to manage competing interests, for example when having multiple roles on PCT Boards, professional executive committees and practice based commissioning groups, as well as separating their own provider and commissioning functions
It will not be possible to avoid conflicts of interest. They are inevitable in many aspects of public life, including the NHS. However, by recognising where and how they arise and dealing with them appropriately, commissioners will be able to ensure proper governance, robust decision- making, and appropriate decisions about the use of public money.
The Health and Social Care Act sets out clear requirements of CCGs to make arrangements for managing conflicts of interest and potential conflicts of interest, to ensure they do not affect or appear to affect the integrity of the CCG’s decision making processes.
This guidance meets the NHS CB’s legal duty under Section 14O (conflicts of interest) of the National Health Service Act 2006, inserted by the Health and Social Care Act 2012, to publish guidance for CCGs on the discharge of their functions under this section. CCGs must have regard to this guidance. Whilst specific to CCGs, the principles will apply also to the NHS CB itself in its commissioning function.
It draws extensively on guidance previously issued by the NHS Commissioning Board Authority on managing conflicts of interest.
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What are conflicts of interest?
Definition of a conflict of interest
A conflict of interest occurs where an individual’s ability to exercise judgement or act in one role is or could be impaired or otherwise influenced by his or her involvement in another role or relationship. The individual does not need to exploit his or her position or obtain an actual benefit, financial or otherwise. A potential for competing interests and/or a perception of impaired judgement or undue influence can also be a conflict of interest.
Conflicts can arise from an indirect financial interest (eg payment to a spouse) or a non-financial interest (eg kudos or reputation). Conflicts of loyalty may arise (eg in respect of an organisation of which the individual is a member or has an affiliation). Conflicts can arise from personal or professional relationships with others, eg where the role or interest of a family member, friend or acquaintance may influence an individual’s judgement or actions or could be perceived to do so. These are all conflicts of interest.
For a GP or any other individual involved in commissioning, a conflict of interest may, therefore, arise when their own judgment as an NHS commissioner could be, or be perceived to be, influenced and impaired by their own concerns and obligations as a healthcare or related provider, as a member of a particular peer, professional or special interest group, or as a friend or family member.
“It is crucial that an interest and involvement in the local healthcare system does not also involve a vested interest in terms of financial or professional bias toward or against particular solutions or decisions. The fact that in their provider and gatekeeper roles GPs and their colleagues could potentially profit personally (financially or otherwise) from the decisions of a commissioning group of which they are also members, means that questions about their role in the governance of NHS commissioning bodies are legitimate. Failure to acknowledge, identify and address them could result in poor decision making, legal challenge and reputational damage.”
RCGP and NHS Confederation’s briefing paper on managing conflicts of interest September 2011
CCGs will need to provide clear guidance to their members and employees on what might constitute a conflict of interest, providing examples that are likely to arise. The important things to remember are that:
a perception of wrongdoing, impaired judgement or undue influence can be as detrimental as any of them actually occurring; if in doubt, it is better to assume a conflict of interest and manage it appropriately rather than ignore it; for a conflict to exist, financial gain is not necessary.
6 Item: 06 Enc: 04 Principles for managing conflicts of interest
Conflicts of interest can be managed by:
Doing business properly. If commissioners get their needs assessments, consultation mechanisms, commissioning strategies and procurement procedures right from the outset, then conflicts of interest become much easier to identify, avoid or deal with, because the rationale for all decision-making will be clear and transparent and should withstand scrutiny;
Being proactive not reactive. Commissioners should seek to identify and minimise the risk of conflicts of interest at the earliest possible stage, for instance by considering potential conflicts of interest when electing or selecting individuals to join the governing body or other decision-making roles, and by ensuring individuals receive proper induction and understand their obligations to declare conflicts of interest. They should establish and maintain registers of interests, and agree in advance how a range of different situations and scenarios will be handled, rather than waiting until they arise;
Assuming that individuals will seek to act ethically and professionally, but may not always be sensitive to all conflicts of interest. Most individuals involved in commissioning will seek to do the right thing for the right reasons. However, they may not always do it the right way because of lack of awareness of rules and procedures, insufficient information about a particular situation, or lack of insight into the nature of a conflict. Rules should assume people will volunteer information about conflicts and, where necessary, exclude themselves from decision-making, but there should also be prompts and checks to reinforce this;
Being balanced and proportionate. Rules should be clear and robust but not overly prescriptive or restrictive. They should protect and empower people by ensuring decision- making is efficient as well as transparent and fair, not constrain people by making it overly complex or slow.
7 Item: 06 Enc: 04 Statutory requirements
Section 14O of the National Health Service Act 2006, inserted by the Health and Social Care Act 2012, sets out that each CCG must:
maintain one or more registers of interest of: the members of the group, members of its governing body, members of its committees or sub-committees of its governing body, and its employees; publish, or make arrangements to ensure that members of the public have access to these registers on request; make arrangements to ensure individuals declare any conflict or potential conflict in relation to a decision to be made by the group, and record them in the registers as soon as they become aware of it, and within 28 days; and make arrangements, set out in their constitution, for managing conflicts of interest, and potential conflicts of interest in such a way as to ensure that they do not and do not appear to, affect the integrity of the group’s decision-making processes.
The NHS CB must publish guidance for CCGs on the discharge of their functions under this section and each CCG must have regard to this guidance.
The NHS (Procurement, Patient Choice and Competition) Regulations 2013 set out that commissioners:
must manage conflicts and potential conflicts of interests when awarding a contract by prohibiting the award of a contract where the integrity of the award has been or appears to have been affected by a conflict; must keep appropriate records of how they have managed any conflicts in individual cases.
CCGs should set out in their constitution how they will comply with these requirements.
8 Item: 06 Enc: 04 Maintaining a register of interests
Statutory requirements
CCGs must maintain one or more registers of interest of: the members of the group, members of its governing body, members of its committees or sub-committees of its governing body, and its employees
CCGs must publish, or make arrangements to ensure that members of the public have access to these registers on request.
CCGs will need to keep a Register of Interests of all members. Whenever interests are declared, they should be reported to the person designated with responsibility for the Register of Interests (as identified by the CCG or its governing body), who should then update the Register accordingly.
CCGs will need to decide locally how often to update their Register, and the BMA has suggested that the register should be formally refreshed every three months. CCGs will need to have systems to check that the Register of Interests is accurate and up to date (eg annual checks). In the interests of transparency, the Register of Interests will need to be publicly available and easily accessible to patients and the public (especially those who don’t have access to the internet) and this should be set out in the CCG’s constitution. Examples include:
confirming you will make this document available upon request for inspection at your headquarters or local health premises; confirming that the document is available upon application (either by post - in which case you will need to include the postal address of your headquarters. or email – you’ll need to provide an email address); making arrangements with your local authority(ies) for copies to be made available via local libraries.
CCGs must ensure that, when members declare interests, this includes the interests of all relevant individuals within their organisation (eg partners in the GP practice), who have a relationship with the CCG and who would potentially be in a position to benefit from the CCG’s decisions.
Note that it would not be necessary for a member of a CCG’s governing body, its committees, or sub-committees (or other committees or sub-committees of the CCG) to ensure that the interest of all partners and shareholders were declared or registered.
See Appendix 1 for a registers of interest template
9 Item: 06 Enc: 04 Declarations of Interest
Statutory requirement
CCGs must make arrangements to ensure individuals declare any conflict or potential conflict in relation to a decision to be made by the group, and record them in the registers as soon as they become aware of it, and within 28 days.
CCGs will need to ensure that, as a matter of course, declarations of interest are made and regularly confirmed or updated, for example, in the following circumstances:
On appointment: Applicants for any appointment to the CCG or its governing body should be asked to declare any relevant interests. When an appointment is made, a formal declaration of interests should again be made and recorded.
Annually: All interests should be confirmed at least annually.
At meetings: All attendees should be asked to declare any interest they have in any agenda item before it is discussed or as soon as it becomes apparent. Even if an interest is declared in the Register of Interests, it should be declared in meetings where matters relating to that interest are discussed. Declarations of interest should be recorded in minutes of meetings.
On changing role or responsibility: Where an individual changes role or responsibility within a CCG or its governing body, any change to the individual’s interests should be declared.
On any other change of circumstances: Wherever an individual’s circumstances change in a way that affects the individual’s interests (eg where an individual takes on a new role outside the CCG or sets up a new business or relationship), a further declaration should be made to reflect the change in circumstances. This could involve a conflict of interest ceasing to exist or a new one materialising.
In keeping with the regulations, individuals who have a conflict should declare this as soon as they become aware of it and in any event not later than 28 days after becoming aware.
Note: CCGs will need to set out the process that they will follow if an individual fails to comply with its polices on managing conflicts of interest as set out in its constitution. This could include that individual being removed from office.
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See Appendix 2 for declaration of interest templates
11 Item: 06 Enc: 04 Managing conflicts to protect the integrity of the decision-making process
Statutory requirement
CCGs must make arrangements for managing conflicts of interest, and potential conflicts of interest, in such a way as to ensure that they do not and do not appear to, affect the integrity of the group’s decision-making.
General safeguards
The general safeguards that will be needed to manage conflicts of interest will vary to some extent, depending on which stage in the commissioning cycle decisions are being made. The following features will need to be integral to the commissioning of all services:
openness: ensuring early engagement with patients, the public and with health and wellbeing boards in relation to proposed commissioning plans; transparency: documenting clearly the approach that will be taken at every stage in the commissioning cycle; responsiveness and best practice: ensuring that commissioning intentions are based on local health needs and reflect evidence of best practice – securing ‘buy in’ from patients and clinicians to the clinical case for change; securing expert advice: ensuring that plans take into account advice from appropriate health and social care professionals, eg through clinical senates and networks; and draw on commissioning support, for example for more formal consultations and for procurement processes; engaging with providers: early engagement with both incumbent and potential new providers over potential changes to the services commissioned for a local population; creating clear and transparent commissioning specifications: that reflect the depth of engagement and set out the basis on which any contact will be awarded; following proper procurement processes and legal arrangements, including even handed approaches to providers; ensuring sound record-keeping, including an up to date register of interests: applying best practice in sound record-keeping, making appropriate information available and accessible, and maintaining a register of interest with a clear system for declaration of interests; and dispute resolution: having systems for resolving disputes, clearly set out in advance.
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These general processes and safeguards will need to apply at all key stages of the commissioning process, including:
planning which services or pathways need to be commissioned differently or de- commissioned eg engaging with a wide range of providers, securing independent clinical advice and specifying services on the basis of best practice and outcomes; agreeing which services or pathways should be commissioned or de-commissioned eg identifying potential conflicts, designing the decision making processes to avoid such conflicts and using contractual mechanisms to mitigate any residual risk; and monitoring the services commissioned, to ensure they are delivering to the agreed specification, eg securing patient involvement and independent clinical advice in monitoring the quality of the services commissioned.
These safeguards will be particularly important in relation to the key commissioning decision- making points leading up to, during, and after the actual procurement of services, and in deciding whether to go out to procurement.
Appointing governing body or committee members
CCGs will need to consider whether conflicts of interest should exclude individuals from being appointed to the governing body or to a committee or sub-committee of the CCG. These will need to be considered on a case by case basis but the CCG’s constitution should reflect the CCG’s principles on this.
The CCG will need to assess the materiality of the interest, in particular whether the individual (or a family member) could benefit from any decision the governing body might make. This will be particularly relevant for any profit sharing member of any organisation but should also be considered for all employees and especially those operating at senior or board level.
The CCG will also need to determine the extent of the interest. If it is related to such a significant area of business that the individual would be unable to make a full and proper contribution to the governing body as this interest would preclude them from so many discussions and decisions, then that individual should not become a member of the governing body.
Any individual who has a material interest in an organisation which provides or is likely to provide substantial business to a CCG (either as a provider of healthcare or commissioning support services) should not be a member of the governing body.
Excluding individuals from meetings or decision-making when a conflict of interest arises
A CCG, or its governing body, may consider that there are certain conflicts of interest that are so material that the individual concerned should be excluded from meetings, or relevant parts of meetings, during which related issues are discussed. Alternatively, there may be circumstances where it is felt appropriate for the individual concerned to attend 13 Item: 06 Enc: 04 the meeting and join in the discussion, having declared his or her interest, but not to participate in any decision-making resulting from such discussion (ie not having a vote in relation to the decision).
The chair of the meeting should have responsibility for deciding whether there is a conflict of interest and the course of action to take. In making such decisions, the chair may wish to consult the member of the governing body who has responsibility for issues relating to conflicts of interest. All decisions should be recorded in the minutes of the meeting.
CCGs will need to decide in advance who will take the chair’s role for discussions and decision-making in the event that the chair of a meeting is conflicted, or how that will be decided at a meeting where that situation arises
CCGs will need also to have arrangements in place where more than 50% of the members of a governing body or committee are prevented from taking a decision because of conflicted interests. Decisions could still be made by the remaining members of the governing body or committee (assuming that the meeting remains quorate), especially if constituted with lay or other independent members. CCGs may need to have arrangements to secure additional external involvement in these decisions, perhaps through the involvement of a neighbouring CCG. These arrangements should be set out in the CCG’s constitution.
Procuring services
CCGs will need to be able to recognise and manage any conflicts or potential conflicts of interest that may arise in relation to procurement.
The Health and Social Care Act and regulations1 set out the statutory rules with which commissioners are required to comply when procuring and contracting for the provision of clinical services, which need to be considered alongside the Public Contract Regulations 2006 and where appropriate EU procurement rules.
The regulations put on a statutory footing many of the key tenets of the present Principles and Rules for Cooperation and Competition and place requirements on commissioners to ensure that they adhere to good practice in relation to procurement, do not engage in anti-competitive behaviour that is against the interest of patients, and protect the right of patients to make choices about their healthcare. Good practice includes acting transparently, proportionately and without discrimination and treating all providers and potential providers equally, in particular from not treating one provider more favourably than another on the basis of ownership.
The NHS (Procurement, Patient Choice and Competition) Regulations 2013, which apply from April 2013, set out that commissioners must:
1The NHS (Procurement, Patient Choice and Competition) Regulations 2013
14 Item: 06 Enc: 04
manage conflicts and potential conflicts of interests when awarding a contract by prohibiting the award of a contract where the integrity of the award has been or appears to have been affected by a conflict, and keep appropriate records of how they have managed any conflicts in individual cases.
Under section 78 of the Health and Social Care Act 2012, Monitor must produce guidance on compliance with any requirements imposed by the regulations made under section 75, and how it intends to exercise the powers conferred on it by these regulations. The NHS Commissioning Board intends to issue guidance for commissioners to help them follow good practice in commissioning and is working with Monitor to ensure consistency.
The safeguards needed to manage conflicts of interest will vary to some degree depending on the way in which a service is commissioned.
Competitive tender. Where a CCG is commissioning a service through competitive tender (ie seeking to identify the best provider or set of providers for a service), a conflict could arise where GP practices or other providers in which CCG members have an interest are amongst those bidding.
Any Qualified Provider. Where a CCG wants patients to be able to choose from a range of possible providers and is therefore commissioning a service through Any Qualified Provider, a conflict could arise where one or more GP practices (or other providers in which CCG members have an interest) are amongst the qualified providers from which patients can choose. In these circumstances (and more generally), there are a number of options (see box below) for demonstrating that GP practices have offered fully informed choice at the point of referral and for auditing and publishing referral patterns. These will build on well-established procedures for declaring interests when GPs or other clinicians make a referral.
Commissioning services from GP practices on a single tender basis is covered later in this section.
There are a number of current good governance processes to ensure patients are being given appropriate choice, particularly where referring GPs have an interest in a provider service that the patient could potentially choose.
Assessing referral patterns - the CCG could monitor and publish information on referral patterns to help provide assurance that patients are receiving free choice.
A CCG (or CSS on behalf of one or more CCGs) could have a system whereby these referrals were peer-reviewed to check that the referral destination was appropriate and that patient choice was exercised.
Establishing referral management systems - there could be systems whereby, once a GP has made a decision to refer, a third party manages the discussion with the patient about which service they wish to be referred to. This would take away any perceived potential for GPs to influence patient behaviour.
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Designing service requirements
It is good practice to engage relevant providers, especially clinicians, in confirming the design of service specifications. Such engagement, done transparently and fairly, is entirely legal and not contrary to competition law. However, conflicts of interest can occur if a commissioner engages selectively with only certain providers (be they incumbent or potential new providers) in developing a service specification for a contract for which they may later bid. The same difficulty could arise in developing a specification for a service that is to be commissioned using the ‘Any Qualified Provider’ route, ie where there is not a competitive procurement but patients can instead choose from any qualified provider that wishes to provide the service and can meet NHS standards and prices.
Commissioners should seek, as far as possible, to specify the outcomes that they wish to see delivered through a new service, rather than the way in which these outcomes are to be achieved. As well as supporting innovation, this helps prevent bias towards particular providers in the specification of services.
Although designed for different types of procurements, the Office of Government Commerce has produced some helpful guidance on pre-procurement engagement with potential bidders. The same principles could be followed by CCGs in engaging with potential providers when designing service specifications.
Such engagement should follow the three main principles of procurement law, namely equal treatment, non-discrimination and transparency. This includes ensuring that the same information is given to all.
The following points should be remembered when engaging with potential service providers:
Use engagement to help shape the requirement but take care not to gear the requirement in favour of any particular provider(s). Ensure at all stages that potential providers are aware of how the service will be commissioned, eg through competitive procurement or through the ‘Any qualified provider’ route. Work with participants on an equal basis, eg ensure openness of access to staff and information. Be transparent about procedures. Maintain commercial confidentiality of information received from providers.
Engagement with potential providers should be used to:
frame the requirement; focus on desired outcomes rather than specific solutions; and consider a range of options for how a service is specified.
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Other practical steps may include:
Advertise the fact that a service design/re-design exercise is taking place widely (eg on NHS Supply2Health) and invite comments from any potential providers and other interested parties (ensuring a record is kept of all interactions) – ie do not be selective in who works on the service specifications unless it is clear conflicts will not occur. As the service design develops, engage with a wide range of providers on an ongoing basis to seek comments on the proposed design, eg via the commissioner’s website or workshops with interested parties. If appropriate, engage the advice of an independent clinical adviser on the design of the service. When specifying the service, specify desired (clinical and other) outcomes instead of specific inputs.
CCGs will need to ensure that they have systems for managing conflicts of interest on an ongoing basis, not only in developing commissioning proposals and in making commissioning decisions but, for instance, in monitoring a contract that has been awarded to a provider in which an individual has an interest.
Specific safeguards for managing conflicts of interests where GP practices are potential providers
The most obvious area in which CCGs will need to manage conflicts of interest is where a CCG commissions either healthcare services or commissioning support services from providers, including GP practices, in which a member of the CCG has a financial or other interest.
General considerations
The “code of conduct” template at Appendix 3 sets out the factors on which CCGs are advised to assure themselves and their Audit Committee – and be ready to assure local communities, Health and Wellbeing Boards and auditors – when commissioning services that may potentially be provided by GP practices. Setting out these factors in a consistent and transparent way as part of the planning process will enable CCGs to seek and encourage scrutiny and enable local communities and Health and Wellbeing Boards to raise questions if they have concerns about the approach being taken. CCGs will be expected to make completed templates, or their equivalent, publicly available. The first set of questions are intended to apply equally to:
services that a CCG is proposing to commission through competitive tender where GP practices are likely to bid; services that a CCG is proposing to commission through an Any Qualified Provider (AQP) approach, where GP practices are likely to be among the qualified providers that offer to provide the service; and services that a CCG is proposing to commission through single tender from GP practices.
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These questions, most of which are also relevant when commissioning services from non-GP providers, focus on demonstrating that the service meets local needs and priorities and has been developed in an inclusive fashion, involving other health professionals and patients and the public as appropriate. These are matters on which the local Health and Wellbeing Board will clearly wish to take a view. The question on pricing applies to the AQP and single tender approaches. There are specific questions on AQP about safeguards to ensure that patients are aware of the range of choices available to them. These requirements apply also to GP practices as providers of services, but it is essential that CCGs too satisfy themselves and others that these safeguards will be in place before commissioning the service. The remaining questions are specific to single tenders from GP practices and focus on providing assurance that:
there are no other capable providers, ie that this is the appropriate procurement route: CCGs using commissioning support services (CSSs) should ensure that they provide robust advice on this point; and the proposed service goes beyond the scope of the services provided by GP practices under their GP contract - CCGs are advised to discuss with their NHS Commissioning Board area team if they are in any doubt on this point.
Providing reassurance
CCGs are advised to address the factors set out in the code of conduct template when drawing up their plans to commission a service for which GP practices may be potential providers. This will provide appropriate assurance:
to Health and Wellbeing Boards and to local communities that the proposed service meets local needs and priorities; and to the Audit Committee and, where necessary, external auditors that a robust process has been followed in deciding to commission the service, in selecting the appropriate procurement route, and in addressing potential conflicts.
CCGs are advised to set these factors out when fulfilling their duty in relation to public involvement. The factors include involving Health and Wellbeing Board(s), in accordance with duties on CCGs.
Preserving integrity of decision-making process when all or most GPs have an interest in a decision
Where certain members have a material interest, they should either be excluded from relevant parts of meetings, or join in the discussion but not participate in the decision-making itself (ie not have a vote).
In many cases, eg where a limited number of GPs have an interest, it should be straightforward for relevant individuals to be excluded from decision-making.
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In other cases, all of the GPs or other practice representatives on a decision-making body could have a material interest in a decision, particularly where the CCG is proposing to commission services on a single tender basis from all GP practices in the area, or where it is likely that all or most practices would wish to be qualified providers for a service under AQP. In these cases, CCGs are advised to:
refer the decision to the governing body and exclude all GPs or other practice representatives with an interest from the decision-making process, ie so that the decision is made only by the non-GP members of the governing body including the lay members and the registered nurse and secondary care doctor; consider co-opting individuals from a Health and Wellbeing Board or from another CCG onto the governing body, or inviting the Health and Wellbeing Board or another CCG to review the proposal, to provide additional scrutiny, although such individuals would only have authority to participate in decision-making if provided for in the CCG’s constitution; ensure that rules on being quorate at meetings (set out in the CCG’s constitution) enable decisions to be made; and plan ahead to recognize when items on meeting agendas that require decisions to be made are coming up that the agreed processes for ensuring they remain quorate are implemented.
Depending on the nature of the conflict, GPs or other practice representatives could be permitted to join in the governing body’s discussion about the proposed decision, but should not take part in any vote on the decision. Transparency – publication of contracts
CCGs should ensure that details of all contracts, including the value of the contracts, are published on their website as soon as contracts are agreed. Where CCGs decide to commission services through AQP, they should publish on their website the type of services they are commissioning and the agreed price for each service. CCGs should ensure that such details are also set out in their annual report. Where services are commissioned through an AQP approach, they should ensure that there is information publicly available about those providers who qualify to provide the service. Role of commissioning support
Commissioning support services (CSSs) can play an important role in helping CCGs decide the most appropriate procurement route, undertake procurements and manage contracts in ways that manage conflicts of interest and preserve integrity of decision-making. CCGs are advised to ensure that any services they commission from CSSs, or that they secure through in-house provision, include this type of support. When using a CSS, CCGs should have systems to assure themselves that a CSS’s business processes are robust and enable the CCG to meet its duties in relation to procurement. Where a CCG is undertaking a procurement, it is likely to help demonstrate that the CCG is acting fairly and transparently if CSSs prepare and present information on bids, including an assessment of whether providers meet pre-qualifying criteria and an assessment of which provider provides best value for money.
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A CCG cannot, however, lawfully sub-delegate commissioning decisions to an external provider of commissioning support. Although CSSs are likely to play a key role in helping to develop specifications, preparing tender documentation, inviting expressions of interest and inviting tenders, the CCG itself will need to:
sign off the specification and evaluation criteria; sign off decisions on which providers to invite to tender; and make final decisions on the selection of the provider. The NHS (Procurement, Patient Choice and Competition) Regulations 2013 set out that where any third parties, such as another CCG or a commissioning support service, undertake procurement activity on behalf of a commissioner the commissioner must ensure that they are compliant with requirements of the regulations in the same way the commissioner must be themselves. Statement of conduct expected of individuals involved in the CCG
We recommend that CCGs set out in their constitution a statement of the conduct expected of individuals involved in the CCG, eg members of the governing body and members of committees and employees that reflect the safeguards in this chapter.
The General Medical Council (GMC) has recently updated its guidance on conflicts of interest, both in its general core guidance2 and in separate supplementary guidance3. The GMC’s guidance recommends that:
78 You must not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients. 79 If you are faced with a conflict of interest, you must be open about the conflict, declaring your interest informally, and you should be prepared to exclude yourself from decision making.
The GMC provides further advice, such as:
You must not try to influence patients’ choice of healthcare services to benefit you, someone close to you, or your employer. If you plan to refer a patient for investigation, treatment or care at an organization in which you have a financial or commercial interest, you must tell the patient about that interest and make a note of this in the patients’ medical record. Where there is an unavoidable conflict of interest about the care of a particular patient, you should record this in the patient’s medical record.
2 GMC | Good medical practice (2013)
3 http://www.gmc-uk.org/Financial_and_commercial_arrangements_and_conflicts_of_interest.pdf_51462148.pdf
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You must keep up to date with and follow the guidance and codes of practice that govern the commissioning of services where you work. You must formally declare any financial interest that you or someone close to you, or your employer has in a provider company, in accordance with the governance arrangements in the jurisdiction where you work. You must take steps to manage any conflict between your duties as a doctor and your commissioning responsibilities.
See Annex 3 for code of conduct template
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© Crown copyright 2013 First published March 2013 Published in electronic format only 22 Item: 6 Enc: 04 Appendix 1 - Register of interests template
NHS [geographical reference] Clinical Commissioning Group This Register of Interests (Register) includes all interests declared by members, employees, governing body members and members of committees or sub-committees, (including committees and sub-committees of the governing body) of NHS [geographical reference] Clinical Commissioning Group (the CCG). In accordance with the CCG’s constitution and section 14O of The National Health Service Act 2006, the CCG’s accountable officer must be informed of any interest which may lead to a conflict with the interests of the CCG and the public for whom they commission servicesin relation to a decision to be made by the CCG, that needs to be included in the Register within 28 days of the individual becoming aware of the potential for a conflict. The Register will be updated regularly (at no more than 3-monthly intervals).
Interests that must be declared (whether such interests are those of the individual themselves or of a family member, close friend or other acquaintance of the individual) include:
• roles and responsibilities held within member practices; • directorships, including non-executive directorships, held in private companies or PLCs; • ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG; • shareholdings (more than 5%) of companies in the field of health and social care; • a position of authority in an organisation (e.g. charity or voluntary organisation) in the field of health and social care; • any connection with a voluntary or other organisation contracting for NHS services; • research funding/grants that may be received by the individual or any organisation in which they have an interest or role; • any other role or relationship which the public could perceive would impair or otherwise influence the individual’s judgement or actions in their role within the CCG.
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NHS [geographical reference] Clinical Commissioning Group Register of Interests
Name Date Position/ Role Potential or actual area where Action taken to mitigate risk Comments interest could occur
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Appendix 2 - Declaration of conflict of interests for bidders / contractors template
NHS [geographical reference] Clinical Commissioning Group Bidders/potential contractors/service providers declaration form: financial and other interests
This form is required to be completed in accordance with the CCG’s Constitution.
Notes:
• All potential bidders/contractors/service providers, including sub-contractors, members of a consortium, advisers or other associated parties (Relevant Organisation) are required to identify any potential conflicts of interest that could arise if the Relevant Organisation were to take part in any procurement process and/or provide services under, or otherwise enter into any contract with, the CCG. • If any assistance is required in order to complete this form, then the Relevant Organisation should contact [specify]. • The completed form should be sent to [specify]. • Any changes to interests declared either during the procurement process or during the term of any contract subsequently entered into by the Relevant Organisation and the CCG must notified to the CCG by completing a new declaration form and submitting it to [specify]. • Relevant Organisations completing this declaration form must provide sufficient detail of each interest so that a member of the public would be able to understand clearly the sort of financial or other interest the person concerned has and the circumstances in which a conflict of interest with the business or running of the CCG might arise. • If in doubt as to whether a conflict of interests could arise, a declaration of the interests should be made.
Interests that must be declared (whether such interests are those of the Relevant Person themselves or of a family member, close friend or other acquaintance of the Relevant Person), include the following:
• the Relevant Organisation or any person employed or engaged by or otherwise connected with a Relevant Organisation (Relevant Person) has provided or is providing services or other work for the CCG; • a Relevant Organisation or Relevant Person is providing services or other work for any other potential bidder in respect of this project or procurement process; • the Relevant Organisation or any Relevant Person has any other connection with the CCG, whether personal or professional, which the public could perceive may Item: 6 Enc: 04
impair or otherwise influence the CCG’s or any of its members’ or employees’ judgements, decisions or actions.
Declarations:
Name of Relevant Organisation: Interests Type of Interest Details Provision of services or other work for the CCG Provision of services or other work for any other potential bidder in respect of this project or procurement process Any other connection with the CCG, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgements, decisions or actions
Name of Relevant [complete for all Relevant Persons] Person Interests Type of Interest Details Personal interest or that of a family member, close friend or other acquaintance? Provision of services or other work for the CCG Provision of services or other work for any Item: 6 Enc: 04
other potential bidder in respect of this project or procurement process Any other connection with the CCG, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgements, decisions or actions
To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information.
Signed:
On behalf of:
Date:
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Declaration of interests for members/employees template
NHS [geographical reference] Clinical Commissioning Group Member / employee/ governing body member / committee or sub-committee member (including committees and sub-committees of the governing body) [delete as appropriate] declaration form: financial and other interests
This form is required to be completed in accordance with the CCG’s Constitution and section 14O of The National Health Service Act 2006.
Notes:
• Each CCG must make arrangements to ensure that the persons mentioned above declare any interest which may lead to a conflict with the interests of the CCG and the public for whom they commission servicesin relation toa decision to be made by the CCG. • A declaration must be made of any interest likely to lead to a conflict or potential conflict as soon as the individual becomes aware of it, and within 28 days. • If any assistance is required in order to complete this form, then the individual should contact [specify]. • The completed form should be sent by both email and signed hard copy to [specify]. • Any changes to interests declared must also be registered within 28 days by completing and submitting a new declaration form. • The register will be published [specify how, or how otherwise made available to the public; will any information be redacted?]. • Any individual – and in particular members and employees of the CCG - must provide sufficient detail of the interest, and the potential for conflict with the interests of the CCG and the public for whom they commission services, to enable a lay person to understand the implications and why the interest needs to be registered. • If there is any doubt as to whether or not a conflict of interests could arise, a declaration of the interest must be made.
Interests that must be declared (whether such interests are those of the individual themselves or of a family member, close friend or other acquaintance of the individual) include: • roles and responsibilities held within member practices; • directorships, including non-executive directorships, held in private companies or PLCs; • ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG; • shareholdings (more than 5%) of companies in the field of health and social care; • a position of authority in an organisation (e.g. charity or voluntary organisation) in the field of health and social care; Item: 6 Enc: 04
• any connection with a voluntary or other organisation contracting for NHS services; • research funding/grants that may be received by the individual or any organisation in which they have an interest or role; • any other role or relationship which the public could perceive would impair or otherwise influence the individual’s judgement or actions in their role within the CCG.
If there is any doubt as to whether or not an interest is relevant, a declaration of the interest must be made.
Declaration:
Name: Position within or relationship with, the CCG: Interests Type of Interest Details Personal interest or that of a family member, close friend or other acquaintance? Roles and responsibilities held within member practices Directorships, including non- executive directorships, held in private companies or PLCs Ownership or part- ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG Shareholdings (more than 5%) of companies in the field of health and social care Positions of authority in an Item: 6 Enc: 04
organisation (e.g. charity or voluntary organisation) in the field of health and social care Any connection with a voluntary or other organisation contracting for NHS services Research funding/grants that may be received by the individual or any organisation they have an interest or role in [Other specific interests?] Any other role or relationship which the public could perceive would impair or otherwise influence the individual’s judgement or actions in their role within the CCG
To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information provided and to review the accuracy of the information provided regularly and no longer than annually. I give my consent for the information to be used for the purposes described in the CCG’s Constitution and published accordingly. Signed: Date: Item: 6 Enc: 04
Appendix 3 - Code of conduct template Template [To be used when commissioning services from GP practices, including provider consortia, or organisations in which GPs have a financial interest]
NHS [geographical reference] Clinical Commissioning Group
Service:
Question Comment/Evidence
Questions for all three procurement routes
How does the proposal deliver good or improved outcomes and value for money – what are the estimated costs and the estimated benefits? How does it reflect the CCG’s proposed commissioning priorities?
How have you involved the public in the decision to commission this service?
What range of health professionals have been involved in designing the proposed service?
What range of potential providers have been involved in considering the proposals?
How have you involved your Health and Wellbeing Board(s)? How does the proposal support the priorities in the relevant joint health and wellbeing strategy (or strategies)?
What are the proposals for monitoring the quality of the service?
What systems will there be to monitor and publish data on referral patterns?
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Have all conflicts and potential conflicts of interests been appropriately declared and entered in registers which are publicly available?
Why have you chosen this procurement route?1
What additional external involvement will there be in scrutinising the proposed decisions?
How will the CCG make its final commissioning decision in ways that preserve the integrity of the decision-making process?
Additional question for AQP or single tender (for services where national tariffs do not apply)
How have you determined a fair price for the service?
Additional questions for AQP only (where GP practices are likely to be qualified providers)
How will you ensure that patients are aware of the full range of qualified providers from whom they can choose?
Additional questions for single tenders from GP providers
What steps have been taken to demonstrate that there are no other providers that could deliver this service? In what ways does the proposed service go above and beyond what GP practices should be expected to provide under the GP contract? What assurances will there be that a GP practice is providing high-quality services under the GP contract before it has the opportunity to provide any new services?
1Taking into account all relevant regulations (e.g. the NHS (Procurement, patient choice and competition) regulations 2013 and guidance (e.g. that of Monitor).
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Appendix 4 - 10 questions checklist
1. Do you have a process to identify, manage and record potential (real or perceived) conflicts of interest? 2. How will the CCG make its final commissioning decision in ways that preserve the integrity of the decision-making process?
3. Have all conflicts and potential conflicts of interests been appropriately declared and entered in registers?
4. Have you made arrangements to make registers of interest accessible to the public? 5. Have you set out how you will you ensure fair, open and transparent decisions about:
priorities for investment in new services
the specification of services and outcomes
the choice of procurement route (e.g. competitive tender, AQP, single tender)? 6. How will you involve patients, and the public, and work with your partners on the Health and Wellbeing Boards and providers (old and new) in informing these decisions? 7. What process will you use to resolve disputes with potential providers? 8. Have you summarised your intended approach in your constitution, and thought through how your governing body will be empowered to oversee these systems and processes – both how they will be put in place and how they will be implemented? 9. What systems will there be to monitor and publish data on referral patterns? 10. Has your decision making body identified and documented in the constitution the process for remaining quorate where multiple members are conflicted?
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Appendix 5 – Conflict of interest discussion scenarios Adapted from the RCGP/NHS Confederation brief on managing conflicts of interest September 2011
Scenario 1
Three GPs who are members of the governing body of a CCG have recently bought a small number of shares in Company X – a company set up by an investor and 16 local GP practices to provide community health services. Company X has recently paid for two local GPs to be trained as GPs with a special interest (GPwSIs) in gynaecology and has agreed to invest in the extension of a local surgery (where a commissioning group lead is a partner) and in purchasing ultrasound equipment so that a new GPwSI service can be set up.
The CCG has recently begun developing its strategic commissioning plan, which sets out its intention to see a shift of up to 30 per cent of outpatient gynaecology services from acute hospitals to community-based settings over the next three years. The CCG intends to develop a specification for these community services to be delivered by Any Qualified Provider.
Discussion
Although the GPs are not major shareholders in GP Provident, a conflict clearly exists as they could have made personal financial gain as a result of the CCG’s commissioning strategy.
There is also a possibility that there could be a perception of actual wrongdoing. The CCG has to consider whether Company X has been given a competitive advantage over other providers or if these individuals have put themselves in a position to make a financial gain – due to access to insider knowledge about local commissioning intentions – and if it has put sufficient measures in place to avoid or remedy this. The individuals concerned should have declared their interest in Company X when they bought the shares, and again at any meeting when the CCG began to discuss its commissioning strategy.
The CCG should have a policy that clearly identifies circumstances under which members of the governing body should not participate in certain activities and considers the material nature of any conflict and whether the individuals could successfully discharge their responsibilities. The governing body will need to consider whether this policy requires them to exclude these members from certain decisions about the commissioning strategy, even if this means removing three key decision- makers from a central part of the group’s business.
Even if not excluded from discussion of the strategy, these individuals may well be excluded by the group’s policies from being involved in the development of the gynaecology service specifications (other than to the extent any other potential supplier might be involved in such service planning), or from any subsequent contract monitoring. CCGs may wish to consider whether or not involvement with a provider company likely to develop services and bid for contracts in this way is compatible with being a CCG governing body member at all, as this scenario is likely to arise again.
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This situation should have been identified and dealt with at the point when individuals were being selected to join the CCG. A decision should have been taken at that point on whether or not it would be appropriate for owners, directors or shareholders of local community service providers to be members of the governing body. If not, these individuals could not have been selected, or would have been required to resign at the point when they decided to buy the shares.
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Scenario 2
The diabetes lead of a CCG has been working on a community diabetes project for two years and has a plan to reduce diabetes outpatients activity by 50 per cent and to reinvest in education, patient education, more specialist nurses and community consultant sessions.
A cornerstone of this new service is a proposal to fund local practices for providing additional services, previously provided in secondary care, to improve prevention, identification and management of diabetes within primary care. Discussion
Rather than benefiting a particular organisation, in this scenario all GP practices/primary care providers in the area could potentially benefit from the proposals being developed by the CCG, at the expense of existing secondary care providers.
The CCG may have to deal with the perception and challenge that it is favouring its members. However, this may be an appropriate commissioning decision, provided the CCG can demonstrate that:
it is possible and appropriate to reduce the number of people being referred to hospital for the management of diabetes and related complications;
it is expected to improve overall patient experience and outcomes;
the benefits of having the service provided by GP practices – and integrating it with the services they already provide for registered patients – are so compelling that there are no other capable providers
The CCG should have set out and communicated the case for change and the rationale for the proposed service model clearly and transparently using the “code of conduct” template before taking, or recommending, the final decision to proceed.
When developing its diabetes commissioning strategy, the CCG should consult on, and then be absolutely clear about, who will have the opportunity to provide the service model. This should be consistent with its existing commissioning strategy and procurement framework and with the joint health and wellbeing strategy of the relevant Health and Wellbeing Board.
Other qualified providers should be given the opportunity to provide those elements of the new service model not specifically embedded in general practice, for example, specialist nursing and community-based consultant sessions.
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Scenario 3
Dr X is the chair of a CCG. He is married to Dr Y. Dr Y is the clinical director for Health R Us, a company that has developed risk stratification software designed to enable primary care providers to identify vulnerable patients at risk of going into hospital and help them to put measures in place to address this.
Health R Us has offered to supply the software to Dr X’s CCG free of charge for one year to help develop it. It will then be offered at a discounted price because of the work that the group would have done in developing it and acting as a demonstration site.
Discussion
There is no immediate financial gain to Drs X and Y from the decision to accept the software free of charge for a year. However, there is potential future gain to Dr Y (and therefore to her husband) as the clinical director of a company that could profit from a product that her husband’s CCG has helped to develop, and from a preferential position as an incumbent supplier to that group.
Dr X should declare an interest and he should exclude himself from any decision-making about this project.
Any decision subsequently taken by the CCG should depend on whether or not the product on offer would help it to achieve an existing, stated commissioning objective (that is to say the CCG should not accept it just because it is on offer), and whether or not the deal being offered was in line with the CCG’s existing policies for partnership working, joint ventures and sponsorship.
If the CCG has a clear, prioritised commissioning strategy and policies for working with other organisations from the outset, this decision should be fairly straightforward.
There is a question as to whether or not the group should accept this offer at all. Although it may meet an explicit commissioning objective, it may not be appropriate even then to accept the offer without some analysis of whether other companies might be willing or able to offer the same or better. The concern is not necessarily about the personal relationships involved, but more generally about whether this is an acceptable way for a public body to do business.
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Scenario 4
Dr A is a member of a CCG with a longstanding interest in and commitment to improving health and social care services for older people. She has worked closely with local geriatrician, Dr B, for many years, including working as her clinical assistant in the past. They have developed a number of service improvement initiatives together during this time and consider themselves to be good personal friends.
Recently, they have been working on a scheme to reduce unscheduled admissions to hospital from nursing homes. It involves Dr B visiting nursing homes and doing regular ward rounds together with community staff. It has been trialled and has had a measure of success which has been independently verified by a service evaluation. They would now like to extend the pilot, and the foundation trust that employs Dr B has suggested that a local tariff should be negotiated with the CCG for this ‘out-reach’ service.
The CCG has decided instead to run a tender for an integrated community support and admission avoidance scheme, with the specification to be informed by the outcomes of the pilot.
Discussion
Due to her own involvement in the original pilot, association with the incumbent provider and allegiance to her friend and colleague, Dr A has a conflict of interest She should not be involved in developing the tender, designing the criteria for selecting providers or in the final decision making even though she is a local expert. If the CCG has clear prompts and guidelines for its members, this should be obvious to Dr A, who should decide to exempt herself.
If the CCG is clear at the outset about its commissioning priorities and strategy and its procurement framework (setting out what kind of services would be tendered under what circumstances), its decision to tender for the service should not come as a surprise to the trust, or to the individuals involved.
CCGs need to ensure that they do not discourage providers, or their own members, from being innovative and entrepreneurial by being inconsistent or opaque in their commissioning decisions and activities.
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INDIVIDUAL
FUNDING REQUEST
(IFR) POLICY
Policy Folder & Number: TBC Version: 1.1 Ratified By: Date Ratified: Name & Title of Originator: South Staffordshire IFR Team hosted by South East Staffordshire and Seisdon Peninsular CCG under the collaborative commissioning arrangements. Name of Responsible Board / Committee for Ratification: Date Issued: March 2013 Review Date: March 2014 Target Audience: NHS and partnering agencies; health and care professionals; general public
This policy is available on request in other formats such as large print, Braille, audiotape or translated.
CONTENTS 1 SSCCG IFR Policy .
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1.0 INTRODUCTION ...... 3 2.0 PURPOSE ...... 3 3.0 GOVERNANCE ARRANGEMENTS ...... 3 3.1 Legal Framework ...... 3 3.2 Responsibility ...... 4 3.3 Accountability & Reporting ...... 4 4.0 POLICY PRINCIPLES ...... 4 4.1 Basic Principles ...... 4 4.2 Exceptionality ...... 5 4.3 Framework for Decision Making ...... 6 4.4 Right to Appeal ...... 7 4.5 Triggers for Service Development ...... 7 4.6 Emergency Decisions ...... 7 4.7 Support for Patients ...... 7 4.8 Requests to Continue the Funding of Care Commenced Privately ...... 8 5.0 THE REQUEST PROCESS ...... 8 5.1 Initial Determination Stage ...... Error! Bookmark not defined. 5.2 The Screening Stage ...... Error! Bookmark not defined. 5.3 The IFR Panel Stage – decision on Exceptionality ..... Error! Bookmark not defined. 5.4 IFR Panel - Membership ...... Error! Bookmark not defined. 5.5 IFR Panel - Role ...... 10 5.6 The Virtual Panel ...... 10 5.7 Fresh evidence...... 11 2 6.1 Appeal Panel - Function...... 12 6.2 Appeal Panel - Structure ...... 13 7.0 TIMESCALES ...... 13 8.0 MANAGING INFORMATION ...... 14 8.1 Patient Confidentiality ...... 14 8.2 Communicating Decisions ...... 14 8.3 Responsible Commissioner ...... 15 8.5 Other Matters Identified ...... 15 9.0 EVALUATION & REVIEW ...... 15 10.0 TRAINING SUPPORT ...... 15 APPENDIX 1 - Guidance for Panels ...... 16 APPENDIX 2 – Guidance for Patients ...... Error! Bookmark not defined. APPENDIX 3 – A Guide for referring clinicians ...... Error! Bookmark not defined. APPENDIX 4 – List of Generic Policies ...... Error! Bookmark not defined.
2 SSCCG IFR Policy .
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1.0 INTRODUCTION
1.1 This policy has been based on the legacy policy produced by the Staffordshire Cluster of Primary Care Trusts in January 2012 to govern the Individual Funding Request (IFR) process . The policy has been produced on behalf of the four South Staffordshire CCGs (Cannock Chase, East Staffordshire, Stafford & Surrounds and South East Staffordshire and Seisdon peninsular CCGs)under the collaborative commissioning arrangements. Once authorised, each CCG will be a statutory NHS commissioning body, and therefore each CCG will be required to ratify this policy.
Throughout the policy reference is made to “the CCG” which means the CCG for which the patient request under consideration is the responsible commissioner.
2.0 PURPOSE
2.1 The CCG recognises that there may be individual cases where a patient’s needs cannot be met through existing care pathways and therapies.
2.2 This Policy sets out the principles and process to be adopted when the CCG is considering any request for treatment that falls outside of national, regional or local commissioning arrangementsor service level agreements.
2.3 All requests falling within 2.1 and 2.2 will only be considered for funding on an exceptional basis, other than as provided under 2.5
2.4 This Policy is not intended to be applied to cases where the failure of a provider to provide adequate care and treatment has precipitated the need for the intervention for which funding is sought. Funding for any such intervention will be the responsibility of the provider concerned. 2.5 The IFR process will also consider requests for treatments that are considered sufficiently rare for the CCG to have developed a commissioning policy. Rarity for the purposes of this policy is defined as an incidence of no great than 2 in a population of 1 million or a prevalence not exceeding 10 cases per million population.
3.0 GOVERNANCE ARRANGEMENTS
3.1 Legal Framework
3.1.1 Each CCG is a public, statutory NHS body, with delegated responsibility from the Secretary of State for Health for commissioning healthcare for its patients and for protecting and improving the health of its population.
3.1.2 The National Health Service Act 2006 sets out a general duty to provide services to support the prevention, diagnosis and treatment of illness.1 This is a target duty, rather than a specific legal duty owed to each and every individual in the CCG’s population. In consequence, the provision of healthcare services is legitimately subject to a decision as to what is considered appropriate and affordable within the overall annual prioritisation of healthcare interventions.
1 National Health Service Act 2006, Section 3 3 SSCCG IFR Policy .
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3.1.3 The CCG has a statutory responsibility to maintain financial balance2 and, as part of discharging this obligation, has to decide how and where finite local resources are allocated.
3.1.4 In performing these functions, the CCG has regard to the NHS Constitution, in the knowledge that patients have a right to expect that the CCG will assess the health requirements of the local community and commission the services to meet those needs as considered necessary. In discharging its obligations under this Policy, in particular, the CCGacknowledges that patients also have a right to expect that local decisions on the funding of drugs and treatments which have not been recommended by the National Institute for Health and Clinical Excellence will be made rationally following a proper consideration of the evidence.
3.2 Responsibility
3.2.1 The Host CCG( South East Staffordshire and Seisdon Peninsular CCG) is responsible for ensuring that the necessary processes are in place to underpin the delivery of the IFR process in accordance with this Policy.
3.2.2 Individual CCGs have a responsibility to provide details of their duly authorised representatives to the co-ordinating team.
3.3 Accountability & Reporting
3.3.1 A formally constituted IFR panel (see S5) will be a standing committee, with duly designated CCG representatives having delegated authority to make decisions on behalf of the CCG they represent.
3.3.2 The IFR Team will produce a summary report of panel decisions no less frequently than every 6 months. These reports will be submitted to the CCG Governing Body for consideration..
4.0 POLICY PRINCIPLES
4.1 Basic Principles
4.1.1 Wherever possible, patients will be referred to services covered by an existing service level agreement and prescribing should, wherever possible, be in line with existing local and national prescribing guidelines, including guidance from the National Institute for Health and Clinical Excellence.
4.1.2 Where a particular treatment or procedure is not part of an agreed pathway or existing commissioned service, it will not be routinely funded. The patient’s request for funding for such a treatment or procedure will be considered under the terms of this Policy, only in such instances that the CCG would be deemed the “responsible commissioner” for the service under consideration.
4.1.3 This Policy is intended to govern the consideration of IFRs where, following an initial determination stage and screening stage there is deemed to be prima facie evidence of
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exceptionality as defined at 4.2 and in Appendix 1.
4.1.4 The IFR process is not a mechanism to endorse, implement or introduce new therapies, procedures or services in-year that are not routinely commissioned. These will be treated as new service developments and considered through the CCG’s annual prioritisation process. To do otherwise would risk destabilising previously identified funding priorities and would impair the responsibility for ensuring that treatments and services are offered in an equitable and consistent manner.
4.1.5 Where a patient moves into the CCG’s area, having already commenced treatment approved by their previous local primary care trust, the CCG will honour the funding decision of the originating commisioner, even where the CCG, had it been the recipient of the original funding request, may have decided that funding was not appropriate in the particular clinical circumstances.
4.1.6 The provisions of para 4.1.5 only apply under this policy for those treatments and services for which the CCG is considered the responsible commissioner. CCGs will, under no circumstance consider funding treatments and services which fall under the responsibility of the National Commissioning Board or Local Authority.
4.2 Exceptionality
4.2.1 Where the CCG considers that the IFR submitted is supported by prima facie evidence of exceptionality, the request will be further considered under the terms of this Policy and via the supporting process.
4.2.2 The request is legally that of the patient, who should provide his or her consent to involvement in the IFR process, at the outset. Although the patient may submit the request themselves, the CCG acknowledges that in most cases the IFR will be formally made, and supporting evidence provided, by the patient’s treating consultant, GP or other clinician (‘the Clinician’). Indeed, the CCG recommends this approach. The individual submitting the collated IFR information is referred to within the Policy as ’the Requester’. Where the patient lacks capacity, the Requester must disclose whether or not a best interests assessment has been undertaken. The CCG will not process the application, in such cases, until a positive confirmation has been provided that the treatment for which funding is sought is in the patient’s best interests.
4.2.3 The CCG will respond by way of correspondence to the Requester. Where the Requester is not the patient, the correspondence will be copied to the patient unless the Clinician has advised on the IFR application that direct correspondence with the patient would not be in his or her best interests for clinical reasons. Other than in such cases, the patient will receive with the copy correspondence a leaflet intended as a patient’s guide to the process.
4.2.4 Satisfaction of each of the following three criteria is one way in which exceptionality might be demonstrated:
1. That the application does not, in fact, seek to introduce a new treatment for a definable group (however small). Such cases constitute service developments and should be introduced via the CCG’s annual prioritisation process.
2. That the patient is significantly different from the general population of patients with the condition in question, at the same stage of progression, who are currently excluded from funding; and
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3. That the patient is likely to gain significantly more benefit from the intervention than the average patient with the condition, at the same stage of progression.
although this should not be regarded as the only way in which exceptional clinical circumstances can be made out and the IFR Panel will consider each case on its merits.
In respect of consideration of cases that might be considered sufficiently rare, to be considered exceptional, rarity is defined as either and incidence of no greater than 2 per million population or a prevalence of no more than 10 per million population.
4.2.5 Non-clinical social factors (for example, but not limited to, age, gender, ethnicity, employment status, parental status, marital status, religious/cultural factors) will not be taken into account in determining whether exceptionality has been established.
4.2.6 The onus is on the Requester to set out clearly for the IFR Panel (‘the Panel’) the grounds on which it is said that the patient is exceptional. Further guidance can be found at Appendix 1 to this Policy. This guidance is not intended to be exhaustive but provides more detailed information and assistance to those making and adjudicating upon IFR applications.
4.2.7 If prima facie evidence of exceptionality has been provided, the case will be referred to the next IFR Panel.
4.3 Framework for Decision Making
4.3.0 To ensure consistency in approach, all decisions on funding taken under this Policy will be made against a common framework of commissioning standards, as detailed below:
4.3.1 Evidence – clinical and cost effectiveness
The decision to fund any intervention or treatment may be taken only after the Panel has satisfied itself that there is a sound evidence base for the likely clinical effectiveness and cost-effectiveness of the proposed treatment.
Appendix 1 provides further information in respect of the evidence required to support a request for individual funding in accordance with this Policy.
4.3.2 Affordability
Each CCG has a statutory duty to achieve financial balance despite the infinite demands placed on its finite resources. The affordability of treatment is therefore an inevitable and important consideration, when the CCG decides what specific aspects of health care it will commission for its patient population. This means that some treatments will not be routinely provided, whilst the cost of supporting one funding request may mean no funding being available for another request. Within these financial constraints, the CCG seeks to commission healthcare equitably amongst its population.
4.3.3 Equity
Each CCG is continually seeking to deliver improved healthcare outcomes to its population and to promote the health of the wider community. With finite resources, however, the CCG needs to reach decisions to ensure that those resources are utilised to provide the greatest overall health benefits for patients. The needs of the community may therefore conflict with the needs of the individual patient; and treatment will not generally be commissioned solely because an individual patient requests it. 6 SSCCG IFR Policy .
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4.3.4 National standards
National guidance and policy may direct the CCG to give priority to particular categories of patients or treatments and this may influence conclusions reached and investment decisions made.
4.4 Right to Appeal
4.4.1 If the patient or Requester is not satisfied that the correct process has been followed by the IFR Panel in reaching a decision on a funding request, the patient or Requester may ask for the matter to be considered by an Appeal Panel. (See 6.1 below for the appeal process).
4.4.2 The Appeal Panel will consider whether the procedure under this Policy was correctly applied in the IFR Panel’s consideration of the request. If the Appeal Panel identifies a failure in process, the Appeal Panel will return the case to an appropriately constituted IFR Panel for reassessment (see 6.1.8).
4.5 Triggers for Service Development
4.5.1 All requests for treatments that are not routinely commissioned, where the patient fails to establish exceptionality, will be treated as service developments and will not be funded in-year unless there are compelling reasons, in terms of safety, clinical effectiveness and cost effectiveness, to consider them outside of the CCG’s annual prioritisation process.
4.5.2 If multiple IFRs are received, on behalf of different patients, for the same treatment, the IFR Panel will notify the CCG prioritisation group( CPAG). The CCG will then review the need for a commissioning policy, in the usual way.
4.6 Emergency Decisions
4.6.1 Where, in the opinion of the Clinician supporting the request, an immediate decision needs to be made for emergency treatment purposes, the CCG will support the principle that treatment should be provided and agreement then reached with the Provider on who is responsible for the costs involved.
4.6.2 If a case is deemed urgent, but not an emergency, the Requester should email or fax the proforma request form to the CCG and then follow this up with a telephone call to the IFR co-ordinator or administrator, in the first instance, to discuss and agree a reasonable timetable for the CCG to consider this request and make a decision.
4.6.3 For the purposes of this paragraph 4.6.2 and the operation of the Policy, “emergency” means “immediately life-threatening”. A case is deemed “urgent” if a decision needs to be reached more expeditiously than normal circumstances and process would allow, even though the patient’s condition is not immediately life-threatening.
4.7 Support for Patients
4.7.1 The IFR Co-ordinator can be accessed by patients and their representatives to provide general information and guidance prior to submission of a funding request,
4.7.2 If a patient is notified that their IFR will be considered by a Panel on a specific date, the notification letter will provide the name of an IFR Co-ordinator to whom all future
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enquiries about the request should be directed.
4.7.3 The patient, the Requester or the Clinician can contact the named IFR Co-ordinator at any stage throughout the process. However, the named IFR Co-ordinator will be unable to advise of the Panel decision or enter into discussions regarding the decision over the telephone with the patient, the Requester or the Clinician, other than such cases as described in 4.6.1 and 4.6.2 when any delay may compromise the care of the patient.
4.8 Requests to Continue the Funding of Care Commenced Privately
4.9.1 Patients have a right to revert to NHS care and funding at any point during their treatment. However, if they wish to exercise this right, the CCG will expect their care to be transferred to local pathways. Funding for the patient to continue to receive care in a private facility, or to transfer to an NHS provider with which a clinician consulted privately has a link, will not routinely be authorised and the patient would have to demonstrate that they were exceptional within the terms of this Policy for such funding to be considered appropriate. Private treatment is not funded retrospectively.
5.0 THE REQUEST PROCESS
5.1 Initial Determination Stage
5.1.1 Each IFR will be considered and decided on its own merits.
5.1.2 Any request for funding made under this Policy will be considered, in the first instance, by the IFR Co-ordinator (or a nominated deputy) or a senior Clinical Commissioning Group ('CCG') commissioning officer.
5.1.3 Any incomplete applications will be returned to the Requester at this stage.
5.1.4 The aim of the initial determination stage is to establish whether the request is properly categorised as an IFR, or whether it should be dealt with more appropriately through other channels (eg: a request for prior approval). To this end, the IFR Co-ordinator, a nominated deputy, or senior CCG commissioning officer will seek advice from one or more senior colleagues in Commissioning, Public Health and/or Medicines Management, as appropriate.
5.1.5 A request for an effective intervention needed for a population of patients (however small) should be referred as a service development for potential inclusion in the prioritisation process and not couched in the form of an IFR application.
5.1.6 Once the IFR & Commissioning Policy Manager or senior CCG commissioning officer is satisfied that the request is properly categorised as an IFR, the following steps will be taken:
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5.2 The Screening Stage
5.2.1 The IFR Co-ordinator (or a nominated deputy) or senior CCG commissioning officer, together with one or more senior colleagues in Commissioning, Public Health and/or Medicines Management, as appropriate, will establish whether prima facie evidence of exceptionality has been provided. The outcome of the screening process, and the reasoning on which the decision reached was based, will be documented.
5.2.3 If prima facie evidence of exceptionality has not been provided, the request will be refused and the IFR Co-ordinator will write to the Requester to give him/her the opportunity to provide such evidence. Such requests will not proceed through the IFR process, but will instead be designated as service developments and treated as such unless and until prima facie evidence of exceptionality is provided.
5.3 The IFR Panel Stage – decision on Exceptionality
5.3.1 Where prima facie evidence of clinical exceptionality has been provided by or on behalf of the patient, the request will be submitted for consideration under this Policy by the IFR Panel. Key elements of the discussion and the decision reached will be documented. Unless there are extenuating circumstances, the Panel will meet monthly. See paragraph 4.6 and 5.6 for the procedure relating to urgent and emergency decisions.
5.4 IFR Panel - Membership
5.4.1 An IFR Panel will consist of four principal members or deputies all of which must be present for the Panel to be quorate. , including a CCG lay member, who will chair the Panel.
1) A CCG Lay-member - Chair (voting),
2) A General Medical Practitioner (not responsible for the care of the individual for whom the IFR application is made, but being a member of the CCG with commissioning responsibility for the case under consideration) (voting),
To this end, a Panel considering a number of cases on behalf of different CCGs may have a number of GP representatives present to ensure the delegated decision making responsibility is adequately addressed.
Whilst all members will be entitled to enter into discussions on the cases, only the GP representing the relevant CCG will be entitled to vote.
3) A Director of Public Health or senior Public Health officer, as nominated by the Director (voting),
4) A senior representative from Medicines Management (voting),
The IFR Co-ordinator and Administrator or suitable deputies will join the Panel for administrative purposes but will not be entitled to vote on any decision.
5.4.2 Other professionals and advisors may be invited to attend, as relevant, to support and
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5.5 IFR Panel - Role
5.5.1 All evidence supporting a claim to exceptionality should be submitted in appropriate documentary form, in advance of the Panel meeting, for the consideration of the Panel members. Neither Patients nor their Clinicians will be invited to attend Panel meetings and therefore the Requester should ensure that the Panel has all the documentation necessary for an informed consideration of the case. Patients may, however, submit a personal statement for the Panel’s consideration, if they so wish, provided that this relies upon and refers only to their clinical circumstances and not to non-clinical social factors. The Panel will make its determination after careful scrutiny and discussion of the documentary evidence.
5.5.2 If the view of the voting members of the Panel is not unanimous, the decision will be carried by a majority vote. In the event of a tied vote, the Chair will have a casting vote.
5.5.3 The Panel must:
1. Confirm that there is no existing service level agreement or commissioning policy under which the treatment sought could be funded.
2. Take into account all the relevant information submitted to it by the Requester.
3. Consistently apply the decision making framework in considering applications, to ensure that all cases are dealt with fairly and equitably.
4. Give proper consideration to the expressed needs of the patient, as described and evidenced by the Clinician and the patient themselves.
5. Take into account all relevant factors, including the clinical effectiveness and cost- effectiveness of the requested treatment.
6. Ensure that any issues and concerns, identified either by the Panel or by the Requester, which are outside the remit of this Policy, are noted and passed through to the appropriate area of the CCG for further consideration and response.
7. Set out its decision and the reasons for that decision in writing to the Requester and the patient (unless such communication is contra-indicated by the Clinician - see section 4.2.3 above).
5.5.4 Any conflicts of interest or potential conflicts should be identified and declared to the IFR co-odinator( or deputy), or Chair, at the earliest opportunity once the paperwork has been sent to the members so that a substitute member may be found as soon as possible, to avoid postponement of consideration of the case. Where the conflict or potential conflict only becomes apparent at the start of or during the course of the Panel discussions, the member should declare it immediately and a decision will be taken as to whether the conflict requires the withdrawal of that Panel member, in which case consideration of the case is likely to have to be postponed.
5.6 The Virtual Panel
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5.6.1 It is anticipated that, in normal circumstances, the Panel will meet face to face. When circumstances require an urgent decision and a face to face meeting cannot be convened, a virtual meeting may be held, whereby discussions take place by telephone and/or by email (as the nature of the discussions require), with all nominated members of the Panel contributing to the discussions.
5.6.2 Any Virtual Panel will be expected to ensure that auditable standards of documentation supporting the discussions are maintained and that its meeting is conducted in accordance with the following procedure:
5.6.3 Procedure
1. All paperwork concerning the matter for decision will be emailed or posted to all members, together with any supporting documentation
2. The treatment upon which a decision is sought from the Panel will be clearly stated.
3. All queries, comments and discussion points will be shared with the members via email, or by telephone conferencing.
4. A clear deadline for the decision will be identified.
5. The Chair of the Panel will normally be a Lay member of a CCG
6. Any conflicts of interest or potential conflicts should be declared to the IFR co- ordinator, or Chair, at the earliest opportunity once the paperwork has been sent to the members or, where the conflict or potential conflict only becomes apparent during the course of the virtual discussions, as soon as the Virtual Panel member becomes aware of it.
7. If the view of the Virtual Panel is not unanimous, the decision will be carried by majority vote. In the event of a tied vote, the Chair will have a casting vote.
8. The outcome of the Virtual Panel meeting will be advised formally in writing to all members of the Panel. The decision and the reasons for that decision will be set out in writing to the Requester and the patient (unless this is contra-indicated by the Clinician -see section 4.2.3 above).
Given the confidential nature of the material to be considered under this virtual process, all emails will be marked as CONFIDENTIAL and HIGH PRIORITY and documents will be protected in line with the following CCG policies: “Confidentiality: Staff Code of Conduct” and “Information Governance Policy”.
It is recommended that all Panel members and deputies have access to NHS.Net email accounts for use in the event of a virtual panel.
5.7 Fresh evidence
5.7.1 Where a request for funding for a particular treatment has been refused by a Panel or Virtual Panel, the case will nonetheless remain on file. In the event that fresh evidence subsequently comes to light which may, potentially, be capable of demonstrating exceptional clinical circumstances, the Requester may submit this, in appropriate documentary form, to the IFR & Commissioning Policy Manager, or IFR Co-ordinator. The new material will be examined and screened in accordance with Paragraphs 5.1 and 5.2 above. If it is considered to demonstrate prima facie evidence of exceptionality, it will go before the next IFR Panel for consideration. The IFR Panel will consider the fresh 11 SSCCG IFR Policy .
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evidence in the context of the original evidence submitted rather than in isolation ie: it will consider the totality of the evidence, old and new.
5.7.2 The submission of fresh evidence should not be confused with an appeal. Where fresh evidence is submitted but the request for reconsideration is incorrectly couched as a request for an “appeal”, it will be dealt with in accordance with Paragraph 5.7.1.
6.0 THE APPEAL PROCESS
6.1 Appeal Panel - Function
6.1.1 If the Requester or patient is not satisfied that the correct process has been followed by the Panel in reaching a decision on a funding request, the patient or requester may ask for the matter to be considered by an Appeal Panel. This is the only ground on which an appeal may be requested.
6.1.2 If an IFR has been refused in accordance with the screening criteria (at 5.2 above), because no prima facie evidence of exceptionality has been submitted, an appeal cannot be requested. Instead, the Requester will be given the opportunity to provide such evidence.
6.1.3 The Requester should submit a request for an appeal, in writing, to the Medical Director of the Staffordshire & Shropshire Area Team of the National Commissioning Board within three months of receipt of the notification letter detailing the outcome of the decision of the initial IFR Panel. The Area Team Medical Director may agree to consider an appeal received outside of this timescale, if it considers that the Requester has good reasons for failing to observe the three month time limit for submission of an appeal. The decision to consider, or to decline to consider, an appeal submitted out of time is entirely within the Medical Directors discretion and will be reached after consideration of the particular circumstances.
6.1.4 The sole purpose of the Appeal Panel will be to consider whether, having regard to the appeal papers submitted by or on behalf of the patient, the decision of the initial Panel was valid, having regard to the process followed, the factors and information considered and the criteria applied.
6.1.5. It is not appropriate for an appeal to be requested solely on the grounds that an individual disagrees with the decision made by the IFR Panel. The decision itself will not be reviewed; only the process which the Panel followed in order to reach that decision. Patients who merely disagree with the decision made will be advised of their right to pursue the matter via the NHS Complaints system and thence, if appropriate, the Parliamentary and Health Service Ombudsman.
6.1.6 Given that the sole purpose of the Appeal Panel, as outlined at 6.1.4 above, is to consider whether the decision of the initial Panel is valid, having regard to the process followed, the factors and information considered and the criteria applied, patients, Requesters and their Clinicians will not routinely be invited to attend Appeal Panel hearings.
6.1.7 In deciding an Appeal, the Appeal Panel will consider whether:
1. the decision was consistent with the “Policy Principles” set out at section 4.0 above
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2. the decision was consistent with previous analogous decisions
3. in reaching the decision, the Panel had i. taken into account and weighed all the relevant evidence ii. given proper consideration to the claims of the patient and accorded proper weight to their claims against those of other groups competing for scarce resources iii. taken into account only material factors iv. acted in utmost good faith v. reached a decision that is in every sense reasonable
6.1.8 If the Appeal Panel concludes that there was a failing in the original decision-making process, it will return the case to an appropriately constituted IFR Panel for reassessment, having outlined the areas in which the panel is deemed to have failed to follow process.
6.1.9 Any conflicts of interest or potential conflicts should be indentified and declared to the IFR Co-ordinator, or Chair, at the earliest opportunity once the paperwork has been sent to the Appeal Panel members so that a substitute member may be found as soon as possible, to avoid postponement of consideration of the case. Where the conflict or potential conflict only becomes apparent at the start of or during the course of the Appeal Panel discussions, the member should declare it immediately and a decision will be taken as to whether the conflict requires the withdrawal of that Panel member, in which case consideration of the case is likely to have to be postponed.
6.2 Appeal Panel - Structure
6.2.1 Appeal Panels will have five members:
1. NCB AT Medical Director or deputy (Appeal Panel Chair) (voting)
2. Director of Quality and Nursing (voting) 3. A Lay member not involed in the original panel 4. Director of Public Health or a senior Public Health officer, as nominated by the Director. (voting)
6.2.2 If the view of the Appeal Panel is not unanimous, the decision will be carried by a majority vote. In the event of a tie, the Chair will have the casting vote.
6.2.3 The decision of the Appeal Panel will be final.
6.2.4 If the patient or Requester remains dissatisfied with the Appeal Panel’s decision, it is open to them to pursue the matter through the NHS Complaints process and subsequently, if appropriate, with the Parliamentary and Health Service Ombudsman.
6.2.5 All Appeals Panel decisions will be reported promptly to the appropriate CCG Accountable Officer, at the conclusion of the case.
7.0 TIMESCALES
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7.1 All requests for the consideration of an IFR or an appeal will be acknowledged within 3 working days of receipt.
7.2 The outcome of the screening process will be notified to the Requester within 15 working days of receipt of the initial application. Where the request has been refused, the Requester will be offered the opportunity to submit further evidence.
7.3 Where the screening process determines that prima facie evidence of exceptionality has been provided, the case will usually be considered by the next scheduled Panel (panels are usually scheduled to meet monthly). The Requester will be notified in writing of the Panel’s decision within 5 working days of the Panel meeting. PCT staff will not enter into verbal or written correspondence with the patient or their Clinician during this 5 working day period, with the exception of urgent requests where delayed communication may compromise the patients care 7.4 The Appeal Panel will meet as and when required. The Appeal Panel will be convened within 30 days of receipt of an appeal.
7.5 The IFR Co-ordinator will notify the Requester of the decision of the Appeal Panel within 5 working days of the Appeal Panel meeting.
8.0 MANAGING INFORMATION
8.1 Patient Confidentiality
8.1.1 All information received and considered under this Policy remains confidential and will be managed in accordance with the Data Protection Act 1998 and will be held, processed and shared only as required for the purposes of delivering services in accordance with the principles of the Policy.
8.1.2 A patient who has mental capacity must consent to all relevant information being shared with the IFR Panel. The IFR application form requires the Requester to confirm that the patient has consented to an IFR application being made and processed. Written permission will be obtained from the patient at any time that the sharing of identifiable data, beyond CCG or Area Team staff involved in handling the request, is envisaged.
8.1.3 Where the patient lacks mental capacity, the Clinician will be asked to confirm on the application form that a best interests assessment has been undertaken. The Clinician must be able to supply documentary evidence of the assessment and the resulting decision, should the CCG request this, although this should not be submitted with the application.
8.1.4 All patient identifiable data will be transmitted in accordance with the CCG’s policy on the handling of sensitive personal data as set out in the following PCT policies: “Confidentiality: Staff Code of Conduct” and “Information Governance Policy”.
8.2 Communicating Decisions
8.2.1 The CCG will provide the Requester and the patient (unless this is contra-indicated by the Clinician, or Requester - see 4.2.3) with an explanation of the reason(s) for any decision not to fund the treatment sought.
8.2.2 Where the Panel declines a request for funding, the Requester and patient (unless contra-indicated) will be clearly advised of the grounds on which an appeal may be 14 SSCCG IFR Policy .
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lodged.
8.3 Responsible Commissioner
8.4.1 Where the CCG receives a request for treatment that falls within a service area not directly managed by the CCG, the request will be referred to the relevant host organisation for review and consideration under their local policy and procedures.
8.5 Other Matters Identified
8.6.1 Where the Panel or Appeal Panel, in the course of considering a funding request, identifies issues which lie outside the purpose and remit of the IFR process, the Panel or Appeal Panel will formally note the concern or issue for follow up within the relevant CCG
9.0 EVALUATION & REVIEW
9.1.1 This Policy will be reviewed on a two-yearly basis, unless circumstances suggest that earlier review is appropriate.
9.1.2 The review will include an equality analysis and an audit of decisions made, to ensure that the Policy has been applied consistently and to identify any changes required to the process, in the light of existing practice and other factors such as developing legislation, reform and case law.
10.0 TRAINING SUPPORT
10.1 Training to support members of the Panels and Appeal Panels will be provided, to ensure that respective roles are understood and to provide members with the necessary skills to fulfil their role as a Panel member.
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APPENDIX 1 - Guidance for Panels
A) The determination of exceptionality
Funding will only be provided for a patient outside the CCG’s annual prioritisation process if the Requester is able to demonstrate that the patient’s clinical circumstances are exceptional.
a) What is meant by “exceptional” circumstances?
There can be no exhaustive definition of the conditions which are likely to come within the definition of an exceptional individual case. The word “exception” means “a person, thing or case to which the general rule is not applicable”3.
The Panel should bear in mind that, whilst everyone’s individual circumstances are, by definition, unique, very few patients have circumstances which are exceptional, so as to justify funding for treatment for that patient which is not available to other patients. The following points constitute general guidance to assist the Panel. However, the overriding question which the Panel needs to ask itself remains “Has it been demonstrated that this patient’s clinical circumstances are exceptional?”
• It may be possible to demonstrate exceptionality where the patient has a medical condition which is so rare that the result of the CCG’s annual prioritisation process provides no established treatment care pathway for that condition.
3 Definition in the Shorter Oxford English Dictionary. 16 SSCCG IFR Policy .
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• If a patient has a condition for which there is an established care pathway, the Panel may find it helpful to ask itself whether the clinical circumstances of the patient are such that they are exceptional as compared with the relevant subset of patients with that medical condition at the same stage of progression of the condition. • The fact that a patient failed to respond to, or is unable to be provided with, one or more treatments usually provided to a patient with his or her medical condition (either because of a generic other medical condition or because the patient cannot tolerate the side effects of the “usual” treatment) may be a basis upon which a Panel could find that a patient is exceptional.
However, the Panel would normally need to be satisfied that the patient’s inability to respond to, or be provided with, the “usual” treatment was a genuinely exceptional circumstance. For example:
If the “usual” treatment is only effective for a proportion of patients (even a high proportion), this leaves a proportion of patients for whom the “usual” treatment is not available or is not clinically effective. If there is likely to be a significant number of patients for whom the “usual” treatment is not clinically effective or not otherwise appropriate (for any reason), the fact that the requesting patient falls into that group is unlikely to be a proper ground on which to base a claim that the requesting patient is exceptional.
If the “usual” treatment cannot be given because of a pre-existing co-morbidity which could not itself be described as exceptional in this patient group, the fact of the co-morbidity and its impact on treatment options for the requesting patient is unlikely to make the patient exceptional. b) Non-clinical factors:
Patients often seek to support an application for individual funding on the grounds that their personal circumstances are exceptional. This assertion can include details about the extent to which other persons rely on the patient, or the degree to which the patient has contributed, or is continuing to contribute, to society. The CCG understands that everyone’s life is different and that such factors may seem to be of vital importance to patients in justifying investment for them in their individual case. However, including such non-clinical, social factors in any decision- making raises at least three significant problems for the CCG:
• Across the population of patients who make such applications, the CCG is unable to make an objective assessment of material put before it relating to non-clinical factors. This makes it very difficult for the Panel to be confident of dealing in a fair and even- handed manner in comparable cases.
• The essence of an individual funding application is that the CCG is making funding available on a one-off basis to a patient where other patients with similar conditions would not get such funding. If non-clinical factors are included in the decision making process, the CCG does not know whether it is being fair to other patients who are denied such treatment and whose social factors are entirely unknown.
• The CCG is committed to a policy of non-discrimination in the provision of medical treatment. If, for example, treatment were provided which had the effect of keeping someone in paid work, this would tend to discriminate in favour of those of working age and against the retired. If a treatment were provided differentially to patients who were carers, this would tend to favour treatment for women over men. If treatment were provided, in part, on the basis that a medical condition had affected a person at a younger age than that at which the condition normally presents, this would constitute direct age discrimination.
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Generally, the NHS does not take into account social factors in deciding what treatment to provide. It does not seek to deny treatment to smokers on the grounds that they may have caused or contributed to their own illnesses through smoking, nor does it deny treatment to those injured in dangerous sports in which they were voluntary participants.
In general, the NHS treats the presenting medical condition and does not inquire into the background factors which led to the condition. The policy of the CCGT is that it should continue to apply these broad principles in individual applications for funding approval. The CCGwill therefore seek to commission treatment based on the presenting clinical condition of the patient and not based on the patient’s non-clinical social circumstances.
In reaching a decision as to whether a patient’s circumstances are exceptional, the Panel is required to follow the principle that non-clinical or social factors including social value judgments about the underlying medical condition or the patient’s circumstances are never relevant.
Patients and referring Clinicians are asked to bear this policy in mind and not to refer to social or non-clinical factors to seek to support the application for individual funding.
c) Proving the case that the patient’s circumstances are exceptional.
The onus is on the Requester to set out the grounds clearly for the Panel on which it is said that this patient is exceptional. The grounds will usually arise out of an exceptional clinical manifestation of the medical condition, as compared to the general population of patients with the medical condition which the patient has.
These grounds must be set out on the form provided by the CCG and should clearly set out any factors that the patient invites the Panel to consider as constituting a case of exceptional circumstances. If, for example, it is said that the patient cannot tolerate the “usual” treatment because of the side effects of another treatment, the patient or the referring Clinician (who is often the expert with detailed knowledge) must explain how unusual it is for patients with this condition not to be able to be provided with the “usual” treatment.
If a clear case as to why the patient’s circumstances are said to be exceptional is not made out, then the Panel is obliged to refuse the application. The Panel recognises that the patient’s referring Clinician is often in the best position to provide information about the patient’s clinical condition as compared to a subset of patients with that condition. The CCG therefore requires the referring Clinician, as part of their duty of care to the patient, to explain why the patient’s circumstances are said to be exceptional.
The policy of the CCG is that there is no duty on the Panel to carry out its own investigations about the patient’s circumstances in order to try to find a ground upon which the patient may be considered to be exceptional nor to make assumptions in favour of the patient if one or more matters are not made clear in the application. Therefore, if a clear case of exceptionality is not made out by the Requester, the Panel is obliged to turn down the application.
d) Multiple claimed grounds of exceptionality.
There may be cases where patients seek to rely on multiple grounds to show their case is exceptional. In such cases the Panel should look at each factor individually to determine (a) whether the factor was capable of making the case exceptional and (b) whether it did in fact make the patient’s case exceptional. The Panel may conclude, for example, that a factor was incapable of supporting a case of exceptionality and should therefore be ignored. That is a judgment within the discretion of the Panel. 18 SSCCG IFR Policy .
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If the Panel is of the view that none of the individual factors on their own make the patient’s circumstances exceptional, the Panel should then look at the combined effect of those factors which are, in the Panel’s judgment, capable of supporting a finding of exceptionality. The Panel should consider whether, in the round, these combined factors prove that the patient’s circumstances are exceptional. In reaching that decision the Panel should remind itself of the difference between individually distinct circumstances and exceptional circumstances.
B) The determination of clinical effectiveness
It is the responsibility of the Requester to explain to the Panel the basis upon which it is said that the requested treatment would be likely to be clinically effective for that individual patient. Details should be provided of the anticipated benefits for the patient, the level of confidence that the referring Clinician has that the benefits will be shown and the likely duration of any benefit.
Reference should be made to published material including RCT trials, NICE or other Guidance, recommendations of specialist medical bodies and any other materials relied upon.
The Panel is entitled but not obliged to seek its own specialist advice about whether a treatment is likely to be clinically effective.
A case which comes before the Panel for approval for individual funding will be subject to the same principles of assessing clinical effectiveness as treatments where a population-wide approach is taken (as far as that is possible given the inherent difficulties in an individual case).
No treatment will be approved for funding by the CCG unless the Panel is satisfied that the treatment is likely to be clinically effective. If the Panel is not provided with sufficient material so that it can be reasonably confident that the treatment is likely to be clinically effective, then it must refuse the application.
C) The determination of cost-effectiveness
It is the responsibility of the Requester to explain to the Panel the basis upon which it is said that the requested treatment is likely to be cost-effective for the individual patient.
Reference should be made to published Incremental Cost-Effectiveness Ratio/Quality Adjusted Life Year (“ICER/QALY”) material or other guidance, recommendations of specialist medical bodies and any other materials relied upon. If the referring Clinician is aware of any material relating to cost-effectiveness, including any adverse observations on the cost-effectiveness of the requested treatment, he or she is required to put this material before the Panel.
The Panel is entitled but not obliged to seek its own specialist advice about whether a treatment is likely to be cost-effective.
A case which comes before the Panel for approval for individual funding will be subject to the same principles of assessing cost-effectiveness as treatments where a population-wide approach is taken (as far as that is possible given the inherent difficulties in an individual case). No treatment should be approved for funding unless the Panel is satisfied that the treatment is likely to be cost-effective. If the Panel is not provided with sufficient material so that they can be reasonably confident that the treatment is likely to be cost-effective then it must refuse the application.
19 SSCCG IFR Policy .
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20 SSCCG IFR Policy .
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Patients First and Foremost The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry
Cm 8576 Item: 6 Enc: 04
Patients First and Foremost
The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust Public Inquiry
Presented to Parliament by the Secretary of State for Health by Command of Her Majesty
March 2013
Cm 8576 £21.25 Item: 6 Enc: 04
© Crown copyright 2013 This publication is available for download at You may re-use this information (excluding www.official-documents.gov.uk and from our logos) free of charge in any format or website at www.gov.uk/dh medium, under the terms of the Open ISBN: 9780101857628 Government Licence. To view this licence, Printed in the UK by The Stationery Office visit http://www.nationalarchives.gov.uk/doc/ Limited on behalf of the Controller of Her open-government-licence/ or e-mail: psi@ Majesty’s Stationery Office nationalarchives.gsi.gov.uk. ID 2550149 03/13 28650 19585 Where we have identified any third party copyright information you will need to obtain Printed on paper containing 75% recycled permission from the copyright holders fibre content minimum concerned. Any enquiries regarding this publication should be sent to us at FrancisResponse@ dh.gsi.gov.uk Item: 6 Enc: 04
Contents
Foreword by the Secretary of State for Health 5
Statement of Common Purpose 9
Executive Summary 15
Introduction 21
1. Preventing problems 25
2. Detecting problems quickly 39
3. Taking action promptly 55
4. Ensuring robust accountability 61
5. Ensuring staff are trained and motivated 67
Conclusion 79
References 81 4 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04 Foreword by the SecretaryItem: 6 of Enc:State for 04 Health 5
Foreword by the Secretary of State for Health
“The NHS belongs to the people… It touches our lives at times of basic human need, when care and compassion are what matter most.” The NHS Constitution “The system as a whole failed in its most essential duty – to protect patients from unacceptable risks of harm and from unacceptable, and in some cases inhumane, treatment that should never be tolerated in any hospital.” Robert Francis QC “This Public Inquiry not only repeats earlier findings but also shows wider systemic failings so I would like to go further as Prime Minister and apologise to the families of all those who have suffered for the way that the system allowed such horrific abuse to go unchecked and unchallenged for so long. On behalf of the government – and indeed our country – I am truly sorry.” The Rt Hon David Cameron MP
The report of the Mid Staffordshire NHS Foundation Trust Public Inquiry makes horrifying reading. At every level, individuals and organisations let down the patients and families that they were there to care for and protect. A toxic culture was allowed to develop unchecked which fostered the normalisation of cruelty and the victimisation of those brave enough to speak up. For far too long, warning signs were not seen, ignored or dismissed. Regulators, commissioners, the Strategic Health Authority, the professional bodies and the Department of Health did not identify problems early enough, or, when they were clear, take swift action to tackle poor care. They failed to act together in the interests of patients. This was a systemic failure of the most shocking kind, and a betrayal of the core values of the health service as set out in the NHS Constitution. We must never allow this to happen again. We must make the quality of care as important as the quality of treatment. This means celebrating and spreading excellence in care; it means challenging mediocrity and those hospitals – and other providers of care – that are doing too little to learn and improve; and above all, it means protecting patients and people who use services from avoidable harm. We know that pockets of poor care exist in many parts of the NHS and this must never be acceptable. This document is a call to action for every part of the system. Every individual, every team and every organisation needs to reflect with openness and humility about how they use the lessons from what happened at Mid Staffordshire NHS Foundation Trust to make a meaningful difference for people who use their services and their staff, and on how they are transparent and honest in demonstrating the progress they make to the public. 6 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
The Public Inquiry focused on how the wider system responded to failings in one hospital between 2005 and 2009, but the whole health and care system needs to listen, reflect and act to tackle the key challenges of culture and behaviour that the report makes so clearly. This initial response focuses on hospitals, but all of us across the health and care system must challenge ourselves to embrace the lessons of such a failure – including in primary and community care and in social care. There are four key groups that are essential to creating a culture of safety, compassion and learning that is based on cooperation and openness. First, and most importantly, patients and service users, and their families, friends and advocates – these are the people who know immediately if something is not right and who must feel welcome and safe in every part of our NHS and care and support system. Second, the frontline staff who can foster change through their individual responsibilities, behaviours and values, and by working effectively together in strong teams – we know that those organisations that treat their staff well provide better care for patients. Third, the leadership teams and, in particular, the boards of each organisation – they have the principal responsibility for ensuring that care in their organisations is safe and that those who use their services are treated as individuals, with dignity and compassion. Fourth, the external structures surrounding each individual organisation, including commissioners, regulators, professional bodies, local scrutiny bodies and Government – they are there to ensure that all hospitals deliver good care, to raise concerns and to ensure action is taken. The system must get its structures, accountabilities and ways of working right to support this and to tackle any areas of poor performance rapidly and decisively. Action is needed at each level to enable the excellent care that already exists in the health and care system to become the norm, and to become what every person can expect of the NHS. We will start immediately by the Care Quality Commission appointing a new Chief Inspector of Hospitals to champion the interests of patients and make judgements about the quality of care. We will make hospital performance more transparent and easier to understand through a clear system of ratings. We will have a single failure regime that drives a coordinated and time limited response to unacceptable care. We will do this in a way that rationalises rather than adds to the bureaucratic burdens on frontline staff and on hospitals, and we will look to reward those organisations and individuals who deliver the highest quality care. We will also take steps to apply that approach beyond the hospital setting to other parts of the health and care system. The Care Quality Commission will appoint a Chief Inspector for Social Care. We will take further action to improve safety and learn the right lessons when things go wrong. We will create a system that is much more responsive to feedback from staff, patients, service users and their families, and as part of this we will ensure that everyone is able to say whether they would recommend the service they received to their family and friends. We will foster a climate of openness, where staff are supported to do the right thing and where we put people first at all times. I have written to the Chairs of all NHS Trusts asking them to hold events where they listen to the views of their staff about how we safeguard the core values of compassion as the NHS gets ever busier. I will listen to these solutions and hear directly people’s concerns and ideas. Foreword by the SecretaryItem: 6 of Enc:State for 04 Health 7
My Ministerial team and Department will do the same, as will the Chief Executives and Chairs of the organisations who together provide the leadership and assurance of the health and care system. I am grateful to Robert Francis and his team for this seminal report, which marks a crucial moment for the whole health and care system. We all need to learn from the Inquiry findings, then act with determination and tenacity to transform the health and care system to deliver the consistently safe and compassionate care we all want for ourselves, our friends and our families. Robert Francis concluded his letter to me by saying that he hoped the recommendations in his report could ‘put patients where they are entitled to be – the first and foremost consideration of the system and everyone who works in it.’ We are determined to act together to make this a reality.
The Rt Hon Jeremy Hunt MP Secretary of State for Health 8 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04 StatementItem: of 6 Common Enc: 04Purpose 9
Statement of Common Purpose
In the light of the findings of the report into patients, families, carers, staff and the the Mid Staffordshire NHS Foundation Trust public. We use this to improve the care Public Inquiry, we the undersigned make the we provide and build on our successes. following commitments. • Compassion. We ensure that 1. We renew and reaffirm our personal compassion is central to the care we commitment and our organisations’ provide and respond with humanity and commitment to the values of the NHS, set kindness to each person’s pain, distress, out in its Constitution: anxiety or need. We search for the • Working together for patients1. Patients things we can do, however small, to give come first in everything we do. We fully comfort and relieve suffering. We find time involve patients, staff, families, carers, for patients, their families and carers, as communities, and professionals inside well as those we work alongside. We do and outside the NHS. We put the needs not wait to be asked, because we care. of patients and communities before • Improving lives. We strive to improve organisational boundaries. We speak up health and well-being and people’s when things go wrong. experiences of the NHS. We cherish • Respect and dignity. We value every excellence and professionalism wherever person – whether patients, their families or we find it – in the everyday things that carers, or staff – as an individual, respect make people’s lives better as much as in their aspirations and commitments in life, clinical practice, service improvements and seek to understand their priorities, and innovation. We recognise that all needs, abilities and limits. We take what have a part to play in making ourselves, others have to say seriously. We are patients and our communities healthier. honest and open about our point of view • Everyone counts. We maximise our and what we can and cannot do. resources for the benefit of the whole • Commitment to quality of care. We community, and make sure nobody is earn the trust placed in us by insisting on excluded, discriminated against or left quality and striving to get the basics of behind. We accept that some people quality of care – safety, effectiveness and need more help, that difficult decisions patient experience – right every time. We have to be taken – and that when we encourage and welcome feedback from waste resources we waste opportunities for others. 1 As the tragic events the Inquiry investigated occurred 2. We apologise to every individual in a hospital, this statement refers to “patients”. These affected by this deeply disturbing and principles and commitments apply equally to all tragic failing in a service that means so people in other care settings. 10 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
much to us all. What happened in Mid 7. Every one of us commits to ensuring Staffordshire NHS Foundation Trust was, a direct connection to patients and to the and is, unacceptable and collectively we staff who care for them. We will ensure that take responsibility for putting things right. our organisations and our staff look outwards We recognise that while the depth, scale to the people they serve, taking decisions and duration of the failings at this hospital with patients and local communities at the were unprecedented every day the NHS forefront of their minds. We will shape care is responsible for care that is poor as well in equal partnership with the people who as care that is good or excellent. Our depend on it. We will do the business of the commitment to the NHS and our pride in patient, before that of our organisation or the the good that it does each day will not system. blind us to its failings. It compels us to 8. We will work together to minimise resolve them. bureaucracy, enabling time to care and 3. We will put patients first, not the time to lead, freeing up the expertise interests of our organisations or the system. of NHS staff and the values and We will listen to patients, striving to ensure professionalism that called them to the quality of care that we would want for serve. Caring is demanding as well as ourselves, our own families and our friends. rewarding, and depends on the personal and 4. We will listen most carefully to those professional values of everyone who works whose voices are weakest and find it in the NHS. We know well-treated staff treat hardest to speak for themselves. We will patients well, so as the NHS become busier care most carefully for the most vulnerable we need to ensure time to care and time to people – the very old and the very young, recover from caring. We will recruit, appraise people with learning disabilities and people and reward staff for their care, as well as their with severe mental illness. skills and their knowledge. 5. We will work together, collaborating 9. Healthcare is complex and we are on behalf of patients, combining and part of a complicated system. Building on coordinating our strengths on their behalf, a foundation of fundamental and inviolable sharing what we know and taking collective standards, we will build a single set of responsibility for the quality of care that nationally agreed and locally owned people experience. Together, we will be measures of success, focussed on what unfailing in rooting out poor care and matters most to patients. They must be unflinching in promoting what is excellent. credible and independently assessed so that patients, the public, Parliament and those 6. Whilst this poor care was in a hospital, who work for NHS patients have a single poor care can occur anywhere across the version of the truth about local services and health and social care system. Whether organisations and their staff have a single set in a care home, at the family doctor, in a of standards of care to which they aspire. community pharmacy, in mental health Blind adherence to targets or finance services, or with personal care in vulnerable must never again be allowed to come people’s homes, we will ensure that the before the quality of care. We need to use fundamental standards of care that public money well and we need to be efficient people have a right to expect are met and productive, but these are a means to consistently, whatever the settings. an end – safe, effective and respectful care, compassionately given. We will be balanced StatementItem: of Common6 Enc: Purpose 04 11
in what we do and what we expect, with the job. It touches the hearts of people’s lives, patient interest at the heart of it. We must can do immense good but also immense all do our best to maintain and raise quality harm – it is a matter of life or death. This is within the resources we have. both a privilege and a great responsibility. 10. We believe that patients are best served Together, we will make ourselves accountable and our values nurtured by a spirit of candour and responsible for what we do, not what we and a culture of humility, openness, honesty say, in striving to make real, for every patient, and acceptance of challenge. Things do go the values to which we recommit ourselves wrong, but when they do we must learn from today. Over the coming months, each of mistakes, not conceal them. We will seek us will set out our plans for making these out and act on feedback, both positive commitments a reality. In delivering those and negative. We will listen to patients who plans, we will be judged by the difference that raise concerns, respond to them and learn they make to the people whom we serve. from them. We will listen to staff who are 12. The organisations signing this pledge worried about the quality of care, praising have different responsibilities within our them for speaking up, even if a concern was healthcare system, but whatever our role misplaced. We have a duty to challenge we pledge to learn the lessons from Mid ourselves and each other on behalf of Staffordshire NHS Foundation Trust, help patients and we will do so. to build better care for every patient and do 11. Signing up to principles in offices in everything in our power to ensure it does national organisations is easy. Changing not happen again. We invite all organisations ourselves, our behaviour, individually and in the health and care system to join us in institutionally, is difficult, but we pledge to signing up to this statement of common do so. Health and care is not like any other purpose.
David Prior, Chair, Una O’Brien, Permanent Secretary, Care Quality Commission Department of Health
Professor Sir Peter Rubin, Chair, Sir Keith Pearson, Chair, General Medical Council Health Education England 12 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Sir Merrill Cockell, Chair, Dr David Bennett, Chair, Local Government Association Monitor
Professor Malcolm Grant, Chair, Michael O’Higgins, Chair, NHS Commissioning Board NHS Confederation & NHS Employers
Jan Sobieraj, Managing Director, Sir Andrew Dillon, Chief Executive, NHS Leadership Academy National Institute for Health and Clinical Excellence
Sir Peter D Carr, Chair, Mark Addison, Chair, NHS Trust Development Authority Nursing and Midwifery Council
Alan Perkins, Chief Executive, Professor David Heymann, Chairman, Health and Social Care Information Centre Public Health England StatementItem: of Common6 Enc: Purpose 04 13 14 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04 Item:Executive 6 Enc: Summary 04 15
Executive Summary
Introduction taken action to strengthen the focus on the quality of care and the safeguards to 1. This document sets out an initial protect patients from harm, including through overarching response, on behalf of the the work of the National Quality Board, health and care system as a whole, to the the Nursing and Care Quality Forum, the Mid Staffordshire NHS Foundation Trust improved processes for Foundation Trust Public Inquiry (the Inquiry). It details key authorisation, and the introduction of dignity actions to ensure that patients are ‘the first and nutrition inspections amongst many other and foremost consideration of the system measures. and everyone who works in it’ and to restore 4. But it is clear we now need to go further. the NHS to its core humanitarian values. It This response starts from a simple premise sets out a collective commitment and a plan and a simple goal – that the NHS is there of action to eradicate harm and aspire to to serve patients and must therefore put excellence. the needs, the voice and the choices of 2. This is a watershed moment for the patients ahead of all other considerations. NHS and a call to action for every clinician, This response to the shocking findings everyone working in health and care, and of the Inquiry sets out a five point plan to every organisation. Many thousands of revolutionise the care that people receive committed, caring and hard working staff from our NHS, putting an end to failure and deliver good or excellent NHS care every issuing a call for excellence: day of the year. Yet in one hospital from A. Preventing problems 2005 to 2009 many patients received appalling care, and the wider system failed to B. Detecting problems quickly identify the problem and then failed to share C. Taking action promptly information and act on warning signs. This D. Ensuring robust accountability was unforgivable and must never happen again. Yet whilst the case at Mid Staffordshire E. Ensuring staff are trained and NHS Foundation Trust was unique in its motivated severity and duration, pockets of poor care 5. Delivering this response will end decades do exist elsewhere and some of the features of complacency about poor care, by that contributed to the tragedy – patients and detecting and exposing unacceptable care families ignored, staff disengaged or unable quickly and ensuring that the system takes to speak up – point to wider problems. real responsibility for fixing problems urgently 3. Robert Francis’ first independent inquiry and effectively. It will drive coasting hospitals looked at what went wrong inside the Trust to improve and it will give greater freedom and reported in 2010. Since then, we have to care for the good and the excellent. It will 16 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
underpin the compassionate values of NHS culture of the NHS around a consistent focus staff with the right training and leadership on the needs of the patients it serves. needed to ensure consistently safe, effective Time to Care and respectful care. It puts in place fair and robust systems to ensure that where 9. But to do so, leaders need time to lead organisations let patients, staff and the NHS and staff need time to care. In a busier NHS, down, there is proper accountability for those we will ensure that paperwork, box ticking failings. and duplicatory regulation and information burdens are reduced by at least one third. 6. The recommendations of the Inquiry With a single version of the truth in the Chief focussed on acute hospitals like Mid Inspector’s balanced assessment, there will Staffordshire NHS Foundation Trust and be a single national hub – the Health and so too does this response to the Inquiry. Social Care Information Centre – for collecting However, we know that many of the information, and it will have a duty to seek to messages from the Inquiry are equally reduce the information burden on the service relevant to other health and care settings. year on year. Issues such as the culture of care and the vital importance of listening to and Safety in the DNA of the NHS – The being open with patients, their families and Berwick Review advocates apply across the health and 10. Professor Don Berwick, former adviser care system. These sorts of problems were to President Obama, will be working with identified not just in Mid Staffordshire NHS the NHS Commissioning Board to ensure a Foundation Trust but also in the terrible robust safety culture and a zero tolerance of failures of care at the independent sector avoidable harm is embedded in the DNA of assessment and treatment unit, Winterbourne the NHS. View.1 B. Detecting Problems Quickly A. Preventing Problems
7. Together the changes set out in this Chief Inspector of Hospitals Making document will help to secure a consistent Assessments Based on Judgement as culture of compassionate care with patients’ Well as Data interests at its very heart. At local level, 11. The Care Quality Commission will commissioners will work with hospitals appoint a powerful Chief Inspector of to identify and tackle poor care. A Chief Hospitals later this year. Armed with a Inspector of Hospitals will shine a powerful sophisticated battery of information about light on the culture of hospitals, driving hospitals from across the system, but, change through fundamental standards and crucially, informed by expert judgements national ratings which put the experience of of inspectors who have walked the wards, patients at the centre of what the NHS does spoken to patients and staff, and looked and the way in which its success is judged. the board in the eye, the Chief Inspector 8. The measures in this document – radical will make an assessment of every NHS transparency, excellence in leadership, clarity hospital’s performance, drawing on the views of accountability, consequences for failure of commissioners, local patients and the and rewards for the very best – will together public. The Care Quality Commission will put in place the action needed to revitalise the be supported by local Quality Surveillance Item:Executive 6 Enc: Summary 04 17
Groups, encompassing all the key players hospitals and the public cannot easily tell in the system, so that there are effective how well their local hospital is doing. In the arrangements in place to identify rapidly future the Chief Inspector will ensure that those hospitals where there is a risk or reality there is a single version of the truth about of poor patient care. how their hospitals are performing, not Expert Inspectors, not Generalists just on finance and targets, but on a single assessment that fully reflects what matters 12. We will bring an end to the days to patients. As in education, the Chief of generalist inspectors briefly visiting Inspector will make a balanced assessment organisations who often have little specialist of hospitals and give them a single, clear insight into the organisations they visit. rating, which could be “outstanding”, From this year, new and thorough expert- “good”, “requiring improvement” or “poor”. led inspections will get to the heart of how Outstanding hospitals will be given greater hospitals are serving their patients, exposing freedom from regulatory bureaucracy. The the poor, spurring on the complacent and Friends and Family Test for both patients and celebrating the achievements of the good staff will be a vital component of the rating. and the excellent. Just as OFSTED acts as a Everyone in the system, whether regulator or credible, respected and independent arbiter commissioner, will use the same single set of of the best and the worst in our schools, data to judge success. the Chief Inspector will shine a light on how our hospitals are serving our patients. The Chief Inspector of Social Care Chief Inspector will become the nation’s 15. There will be a new Chief Inspector of whistleblower – naming poor care without Social Care who will adopt a similar approach fear or favour from politicians, institutional to social care and will be charged with rating vested interests or through loyalty to the care homes and other local care services, system rather than the patients that it serves. promoting excellence and identifying 13. A ‘comply or explain’ approach to problems. known good practices will be used in Publication of Individual Speciality inspections. So, where there are well- Outcomes established practices that benefit patients (for 16. A new spirit of candour and example nursing rounds, supervisory ward transparency will be essential for exposing sisters, evidence-based staffing levels, and poor care. In line with the Nuffield Trust independent collection of patient experience recommendations, information about data), inspectors will expect to see these hospitals will not be limited to aggregated being used across hospitals, or a valid ratings but it will be possible to drill down explanation given if this is not the case. to information at a department, specialty, Ratings – A Single Balanced Version of care group and condition-specific level. As the Truth a starting point, the NHS Commissioning 14. We intend to give the Care Quality Board will extend the transparency on Commission the power to conduct ratings surgical outcomes from heart surgery, which at the earliest opportunity and will work has been hugely successful, to cardiology, with the Nuffield Trust to develop these vascular surgery, upper gastro intestinal proposals further. Until now there has been surgery, colorectal surgery, orthopaedic a confusing welter of information about surgery, bariatric surgery, urological surgery, 18 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
head and neck surgery and thyroid and will be in language that both the public and endocrine surgery. professionals can easily understand. Penalties for Disinformation, and a Time Limited Failure Regime for Quality as Statutory Duty of Candour Well as Finance 17. Mortality data must be interpreted with 21. In the past, when poor care was care, but it must also be accurate so that detected, it was too often put in a “too the public and patients can trust that they difficult” pile. Patients have been left with are hearing an honest and fair account. So no one acting with urgency on their behalf there will be tough penalties and we will to ensure a decent standard of care. This consider the introduction of additional legal inaction must and will stop. sanctions at corporate level for organisations 22. The Chief Inspector will identify poor that are found to be massaging figures or care in public, a call to action to the hospital concealing the truth about their performance. itself, its commissioners and the organisations A statutory duty of candour on providers responsible for their oversight. Where to inform people if they believe treatment of normal commissioner engagement with care has caused death or serious injury, and local hospitals has been unable to address to provide an explanation, will reinforce the significant concerns about patient care, a existing contractual duty. new time-limited three stage failure regime, A Ban on Clauses Intended to Prevent encompassing not just finance, but for the Public Interest Disclosures first time quality, will ensure that where 18. Contractual clauses that seek to prevent fundamental standards of care are being NHS staff from speaking out on issues like breached, firm action is taken until they are patient safety, death rates and poor care properly and promptly resolved. will come to a halt. Staff who disclose such 23. In the first stage, the Chief Inspector problems should be supported, not vilified. will require the hospital board to work with its Complaints Review commissioners to improve, within a fixed time period, but the Care Quality Commission will 19. A review of best practice on complaints not be responsible for making improvement will ensure that when problems are raised, happen. That will first be a task for the they are heard, addressed and acted upon, Board of the hospital, working with its and seen as vital information for improvement commissioners. In the second stage, if the rather than irritations to be managed hospital with commissioners is unable to defensively. resolve its own problems, then the Care Quality Commission would call in Monitor C. Taking Action Promptly or the NHS Trust Development Authority to take action. In the final stage, where Fundamental Standards fundamental problems in the hospital mean that its problems have not been resolved, the 20. The Care Quality Commission, working Chief Inspector will initiate a failure regime, with NICE, commissioners, professionals, in which the Board could be suspended or patients and the public, will draw up a the hospital put into administration, whilst new set of simpler fundamental standards ensuring continuity of care. which make explicit the basic standards beneath which care should never fall. This Item:Executive 6 Enc: Summary 04 19
24. The Care Quality Commission, the NHS Barring Failed NHS Managers Commissioning Board, Monitor and the NHS 27. To deal with the small numbers of Trust Development Authority will be required managers who let their patients and the NHS to agree together the data and methodology down through gross misconduct, and prevent for assessing hospitals. This will ensure a them from moving to new jobs in the NHS, single set of expectations on hospitals of we will introduce a national barring list for unfit what is required of them which are aligned managers, based on the barring scheme for with the way in which commissioners, led teachers. by clinicians and guided by the views of local patients, ensure high quality care in Clear Responsibilities for Tackling Failure the hospitals for which they are responsible. 28. At a national level, these proposals, Providers will demonstrate, through annual taken together, will resolve the confusion Quality Accounts, how well they are meeting of roles and responsibilities in the system, that single set of expectations. so it is clear where the buck stops on poor care beyond the action that providers and D. Ensuring Robust Accountability commissioners take themselves. The Chief Inspector will identify failing standards in Health and Safety Executive to use NHS Trusts and Foundation Trusts. Where Criminal Sanctions necessary, Monitor and the NHS Trust 25. Where the Chief Inspector identifies Development Authority will resolve them criminally negligent practice in hospitals, with hospitals and their commissioners. the Care Quality Commission will refer the The Department of Health will ensure that matter to the Health and Safety Executive everyone plays their part on patients’ behalf. to consider whether criminal prosecution of providers or individuals is necessary. The E. Ensuring Staff are Trained and Department of Health will ensure sufficient resources are available to the Health and Motivated Safety Executive for this role. HCA Training before Nursing and other Faster and More Proactive Professional Degrees Regulation 29. Starting with pilots, every student who 26. The General Medical Council, the seeks NHS funding for nursing degrees Nursing and Midwifery Council and the should first serve up to a year as a healthcare other professional regulators are hampered assistant, to promote frontline caring by an outdated legislative framework that is experience and values, as well as academic too slow and reactive in tackling poor care strength. They will also provide students with by individual professionals. As part of the helpful experience for managing healthcare implementation of the Law Commission’s assistants when they qualify and enter review, we will seek to legislate at the earliest practice. The scheme will need to be tested possible opportunity to overhaul radically 150 and implemented carefully to ensure that it years of complex legislation into a single Act is neutral in terms of costs. Health Education that will enable faster and more proactive England will work with the Nursing and action on individual professional failings. Midwifery Council, professional leaders and trade unions in developing the pilots. We will 20 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
explore whether there is merit in extending universities, we will develop an elite fast track this principle to other NHS trainees. programme for talented leaders outside the Revalidation for Nurses NHS to attract the brightest and best to top NHS jobs. In addition we will invest in MBA 30. Building on the historic introduction of style programmes to ensure that clinicians medical revalidation, which offers proactive with a talent for leadership are supported assurance of individual doctors, when the in becoming the clinical Chief Executives of Nursing and Midwifery Council turns around tomorrow. its current poor performance we will work with them to introduce a proportionate and Frontline Experience for Department of affordable national scheme to ensure all Health Staff practising nurses are up to date and fit to 34. At the centre of the system, the practise. Department of Health will need to reconnect Code of Conduct and Minimum Training with the patients it serves. Within four years, for Health and Care Assistants every civil servant in the Department will have sustained and meaningful experience 31. Camilla Cavendish is reviewing how of the frontline with Senior Civil Service and best to ensure healthcare assistants can Ministers leading the way. provide safe and compassionate care to patients. We are today publishing Next Steps standards of conduct and training for all 35. Key organisations across health and care assistants. The Chief Inspectors will care will take the action needed to make ensure that employers meet their registration this document a reality for patients and requirements that all health and care support the Government will, as Robert Francis workers are properly trained and inducted recommends, draw together a report on before they care for people. progress each year. Barring System for Healthcare Assistants 36. In addition, all NHS hospitals should 32. The Chief Inspector of Hospitals set out how they intend to respond to the will assure, as part of inspections, that all Inquiry’s conclusions before the end of 2013. hospitals are meeting their legal obligations to ensure that unsuitable healthcare assistants are barred from future patient care by properly and consistently applying the Home Office’s barring regime. Attracting Professional and External Leaders to Senior Management Roles 33. The NHS Leadership Academy, in addition to its existing work to ensure that top leaders have the right skills and the right values, will initiate a major programme to encourage new talent from clinical professionals and from outside the NHS into top leadership positions. From within existing resources, working with world class Item: 6 Enc:Introduction 04 21
Introduction
“Until the scandalous decline in standards is reversed, it is likely that unacceptable levels of care will persist and therefore it is an area requiring the highest priority. There is no excuse for not tackling it successfully. Much of what needs to be done does not require additional financial resources, but changes in attitudes, culture, values and behaviour.” Robert Francis QC
1. This document sets out an initial to provide the correct dose of medicine or response to Robert Francis’ challenge pain relief at the right time; too often failing to make patients ‘the first and foremost vulnerable people; failing to listen to what consideration of the system and everyone patients and families say or to offer a kind who works in it’. It has been developed on word or hand when one is most needed. behalf of the health and care system and 5. The essential diagnosis from the Inquiry in partnership with the signatories of the is of an NHS that had veered, or was pushed, common statement of purpose above. too far from its core humanitarian values and 2. The Inquiry’s examination of the system’s in too many places had its priorities wrong. role in the appalling failures of care between Targets and performance management in 2005 and 2009 in Mid Staffordshire NHS places overwhelmed quality and compassion. Foundation Trust offers a stark, sobering and Top down management instructions drowned unpalatable analysis of a system failing to put out patient voices. Pressure to perform patients first, a system that lost its way. and fear of failure led to a controlling and 3. At heart, Robert Francis’ report2 is a defensive approach from organisations. powerful call to action on tackling invidious Regulators, commissioners and others in the aspects of NHS culture that have arguably system became focused on their own roles become more pronounced as the health and, in some cases, lost sight of the patients service has become busier and the needs of they were there to serve. patients more complex. 6. The job now is to put the system back 4. Our NHS is rightly celebrated, performing on track and to put in place sustainable incredible feats at the cutting edge of measures to ensure that it continues to medicine and surgery. Its staff, in the vast drive improvements. This means restating majority of cases, are dedicated, skilled, clearly our common purpose and binding kind and committed people. Yet in parts it principles – that quality is as important as is failing, sometimes atrociously, in the very finance, that patient interest comes before basics of care: failing to ensure patients have institutional interest, that we all work together food they can eat and water to drink; failing in the interests of patients and are open and 22 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
transparent in our actions. Though Robert Action Since the First Inquiry Francis’ report focuses particularly on nursing and medicine, it is a call to action for the 10. The Department of Health and national whole clinical workforce and everyone who agencies have acted on many of these areas works in health and care. both during the Inquiry and since it finished hearing evidence in December 2011. For 7. Although the Inquiry and this response example: focus primarily on NHS hospitals the core messages are applicable to all staff working (a) Values and standards – the NHS throughout the health and care system, Constitution has been revised to give whatever the setting. The failures of care more prominence to values and the Care identified at Winterbourne View Hospital – a Quality Commission has increased its hospital far away from Mid Staffordshire NHS number of compliance inspectors, and Foundation Trust both geographically and in improved their training. All inspections the nature of its services – demonstrated that are now unannounced to strengthen the interests of patients need to be foremost, the assessment process for essential whatever their individual needs and wherever standards. In addition, Patient Led they are cared for. This call for action is as Assessment of the Care Environment applicable to staff working in an independent (PLACE) assessments will start in hospital or treatment unit for patients with April 2013 with local people going into mental health problems or learning disability hospitals as part of teams to assess as it is for staff in an acute hospital. how the environment supports patients’ privacy and dignity, food, cleanliness and 8. Robert Francis’ report makes clear that general building maintenance. changing organisational culture is pivotal to achieving meaningful change. Transforming (b) Openness, transparency and candour the health and care system cannot be – actions include strengthening the done from Whitehall and it cannot be done protection and support available to overnight. This response states a collective whistleblowers, including a right to raise commitment to facilitate this transformation concerns within staff contracts; the and early actions, but it is for every part of amendment of the NHS Constitution the health and care system to think, talk to include explicit rights and pledges and act with drive and ambition to tackle on whistleblowing; new guidance to avoidable harm and enable compassionate employers; the extension of the national care. In supporting this transformation, each helpline to include staff in social care; hospital in the country has been asked to the strengthening of the annual NHS hold listening events with its staff to reflect on Staff Survey, and making crystal clear Robert Francis’ report and consider how to that compromise agreements should safeguard the core values of compassion and not stop staff speaking out on matters care in a busy NHS. of public interest. In addition, the NHS Standard Contract for 2013/14 will 9. Alongside his overarching critique include a contractual duty of candour of culture, Robert Francis has drawn out on all providers to be open and honest five key themes under which the majority with patients when things go wrong with of his recommendations sit: values and penalties for breaching this duty. standards; openness, transparency and candour; leadership; compassion and (c) Leadership – the NHS Leadership care; and information. Academy was established in 2012 and Item: 6 Enc:Introduction 04 23
is already supporting system leaders mortality indicator, infection rates and through a range of programmes. In reported levels of patient safety incidents. addition, the Professional Standards More generally, the Power of Information4 Authority for Health and Social Care has sets out the Department’s ten-year published standards for members of framework for transforming information for NHS boards and Clinical Commissioning health and care. Group’s governing bodies that put 11. In addition, we have published our respect, compassion and care for response to the events at Winterbourne View patients at the heart of leadership and in Transforming Care: a national response good governance in the NHS. to Winterbourne View Hospital and a (d) Compassion and care – Compassion programme of transformation is underway in Practice3 (the nursing, midwifery and including reviewing care placements and care staff vision and strategy for England) supporting everyone inappropriately in was launched in December 2012. It is hospital to move to community-based based on the values and behaviours support. A Joint Improvement Programme of the “6Cs” – Care, Compassion, led by the Local Government Association and Competence, Communication, Courage NHS Commissioning Board has been set up and Commitment. Over the last three to support this transformation in care. months nurses, midwives and care staff, 12. There is much more to do under each as well as stakeholders at national and of Robert Francis’ themes and most of organisational level, have developed the recommendations in Robert Francis’ implementation plans to support the report we accept, either in principle or in delivery of the values and behaviours of their entirety. This report, six weeks on, the “6Cs”. In addition, the Government is not, and could not be, a full response has announced a £13 million innovation to each and every one of Robert Francis’ fund for the training and education of 290 recommendations. As he notes ‘some unregulated health professionals and recommendations are of necessity high level Skills for Health and Skills for Care have and will require considerable further detailed been developing minimum training work to enable them to be implemented.’ standards and a code of conduct for To rush ahead would mean that they healthcare support workers and adult would not be given the full and collective social care workers in England. consideration they deserve and would limit (e) Information – from April 2013, a the clinical engagement and patient and network of local and regional Quality public involvement that will be so important. Surveillance Groups (QSGs) will bring The report, therefore, provides an overarching together commissioners, regulators, response, setting out key early priorities. local Healthwatch representatives and 13. We recognised also that there are vital other bodies on a regular basis to share questions implied by the report findings information and intelligence about quality about how we ensure older people get across the system and proactively spot excellent treatment care and support when potential problems. Also from April 2013, they need it to help people stay in good Quality Accounts will include comparable health throughout their lives, maintain control data from a set of quality indicators and independence, and avoid or postpone linked to the NHS Outcomes Framework needing hospital treatment or long-term including the summary hospital-level 24 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
residential care. This response focuses particularly on urgent priorities to ensure safe, compassionate care in hospitals, and we will take forward further work later this year on improving prevention, integration and primary care to help keep more people out of hospitals. 14. Over the coming months, many of the organisations who have contributed to this response will produce their own action plans and we expect that everyone will respond to the Inquiry’s first recommendation to set out how they will act on the Inquiry’s recommendations. All NHS hospitals should also set out how they intend to respond to the Inquiry’s conclusions before the end of 2013. This autumn, we will publish a document drawing this together into a system-wide update on progress and next steps. We will continue to ensure Robert Francis’ report drives real change, reporting annually on our progress and where we need to take further action. Chapter OneItem: – Preventing 6 Enc: Problems 04 25
Chapter One – Preventing Problems
Summary
The measures in this document – radical transparency, excellence in leadership, clarity of accountability, consequences for failure and rewards for the very best – will together put in place the measures needed to revitalise the culture of the NHS around a consistent focus on the needs of the patients it serves. In particular, the creation of a new Chief Inspector of Hospitals will shine a powerful light on the culture of hospitals, driving change through national ratings which put the experience of patients at their heart. But to do this well leaders need time to lead and staff need time to care, unconstrained by a culture of compliance. In a busier NHS, we will ensure that paperwork, box ticking and duplicatory regulation and information burdens are reduced by at least one third. With a single version of the truth in the Chief Inspector’s balanced scorecard and assessment, there will be a single national portal – the Health and Social Care Information Centre – for collecting information, and it will have a key role in reducing the information burden on the service year on year. Professor Don Berwick, former adviser to President Obama, will be working with the Commissioning Board to ensure safety and a zero tolerance of avoidable harm is embedded in the DNA of the NHS. The Government will consult on amendments to the NHS Constitution to ensure that it fully reflects the findings of the Public Inquiry.
Achieving Culture Change Trust and to ensure that all care is consistently to the standard that patients, the public and 1.1 Much of this response is focussed on staff themselves wish to see, we need to new and radical approaches to identifying ensure a culture that is consistently supportive problems quickly, ensuring swift action to of this aim. address them, holding organisations to account and ensuring that staff have the skills, 1.2 Robert Francis’ report sets a profound motivation and support they need to give the challenge to change the culture of the health best to patients. But our first focus must be to and care system so that it never loses sight of prevent poor care occurring in the first place. its core values of compassion and care. This And the issue of culture is absolutely central demands “the engagement of every single to this task. To prevent a reoccurrence of the person serving patients”, from the hospital events at Mid Staffordshire NHS Foundation porter to the Secretary of State for Health. 26 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
1.3 The analysis of what went wrong 1.4 The cultural challenge faced by the shows Mid Staffordshire NHS Foundation NHS has been talked about in many ways. Trust’s leadership and board focused on the The key is that boards and leaders need wrong things – “hitting the target and missing to create environments where staff feel the point” – and a wider system where supported to cope with the day to day risks warning signs were dismissed or unheeded and challenges of health and care work. and crucial information was not shared. This also enables openness: mistakes will Robert Francis’ first independent review told sometimes happen – staff need to know horrifying stories about what this meant for it is safe to admit them. It also enables patients and their families: compassion: under stress, anyone can find “In the next room you could hear it hard to be caring – staff need to know it is the buzzers sounding. After about safe to ask for the support they need to really 20 minutes you could hear the men be there for patients. shouting for the nurse, “Nurse, nurse”, and it just went on and on. And then Common Values – the NHS very often it would be two people Constitution calling at the same time and then you would hear them crying, like shouting 1.5 Every team, within every individual “Nurse” louder, and then you would organisation, will have its own distinct culture, hear them just crying, just sobbing, but the Government agrees with Robert they would just sob and you just Francis’ conclusion that the common values presumed that they had had to wet the and cultural attributes that we seek to foster bed. And then after they would sob, across the NHS should be set out in the NHS they seemed to then shout again for Constitution5. We are publishing a revised the nurse, and then it would go quiet...” Constitution that takes account of the lessons from the Inquiry, with an increased emphasis The daughter of a patient in ward 11 on common values, and in particular the “We got there about 10 o’clock and I fundamental value of “working together could not believe my eyes. The door for patients”. We will consult on further was wide open. There were people amendments to the Constitution later this walking past. Mum was in bed with year to respond in full to Robert Francis’ the cot sides up and she hadn’t got recommendations. a stitch of clothing on. I mean, she 1.6 However, we know that publishing a would have been horrified. She was national document is not going to change completely naked … covered in faeces cultures in wards and teams across the ... It was everywhere. It was in her hair, country. What matters is whether teams are her eyes, her nails, her hands and on inspired to own and live the values set out all the cot side, so she had obviously in the Constitution. The rest of this chapter been trying to lift herself up or move considers what is needed to enable this. about, because the bed was covered The rest of this document sets out a series and it was literally everywhere and it of measures which help to ensure that the was dried. It would have been there a leaders of organisations providing care long time, it wasn’t new.” make the NHS Constitution and its values a The daughter-in-law of a 96-year-old meaningful reality for patients and staff every patient day. Chapter OneItem: – Preventing 6 Enc: Problems 04 27
The Board – Critical for a able to ensure that only people with the skills and experience needed to help meet the Compassionate Culture developing needs of these organisations are 1.7 Boards have a critical role in ensuring appointed as their chairs and non-executive that their organisations are well governed and directors, and will work directly with boards deliver the organisation’s strategic objectives. to ensure they have the support they need They are responsible for shaping those to be wholly effective in their roles. Monitor objectives, providing clear accountability will be carrying out work in parallel to ensure for their delivery and shaping a culture that that the governors and non-executives of positively promotes safety, effectiveness, NHS foundation trusts have the support they compassion, ambition, openness and need to hold their organisations to account innovation. effectively and to build and sustain the right organisation cultures. 1.8 In his report, Robert Francis recognises the urgent need for cultural 1.11 Recognising the importance of change in the NHS. Effective boards will the role of boards in the success of be essential if this requirement is to be fully NHS organisations, assessment of the realised; they will be at the helm of each performance and future capability of the NHS service provider, constantly checking board will be an increasingly important that every department, every team and every element of an NHS foundation trust individual is focused on and wants to deliver application for both the NHS Trust the best possible patient care. Development Authority and Monitor. 1.9 The 2010 publication The Healthy NHS 1.12 Importantly, the new Chief Inspector of Board5 articulated the role of boards in the Hospitals, will consider carefully the culture of NHS and made it clear that patient safety and organisations and the quality of their boards the quality of services is the key, over-arching in making judgements about their overall priority. This document is currently being ratings. reviewed by the NHS Leadership Academy, working with key partners including the Care Clinically-Led Commissioning, Quality Commission, Monitor and the NHS Focused on Outcomes Trust Development Authority to reflect the lessons learned from Robert Francis’ report. It 1.13 Robert Francis’ report provided a stark will then provide a statement of what a good account of an organisation that focused on NHS board looks like that everyone, including targets and processes at the expense of its the boards themselves and their regulators, core responsibilities to patients. All parts of can understand and work towards. the NHS must focus on outcomes rather than processes, and on what matters most: 1.10 The NHS Trust Development Authority, providing safe, effective care and a positive with its responsibility for exercising the patient experience. Secretary of State’s powers to appoint the chair and non-executive directors of NHS 1.14 There is a place for targets in the trusts, has for the first time the opportunity NHS, but they became too numerous, too to ensure that there is a direct correlation tight and their implementation too obsessive, between these important appointments and based on national political priorities rather the broader oversight of the provider. The than the views of local people and local NHS Trust Development Authority will be clinicians. Since 2010, we have started to 28 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
change the approach. We have moved from strengthen their collective voice nationally a system focused on targets and processes and locally. to one focused on outcomes, and on what • A culture of open information, active matters most to patients: safe, effective care responsibility and challenge will help and a positive patient experience. Local ensure that patient safety is put above all commissioners, led by clinicians and driven else. by the views of local patients, will be setting the priorities. The NHS Outcomes Framework • A contractual duty of candour (now to sets out the outcomes and corresponding be strengthened by a statutory duty) will indicators that will be used to hold the NHS require hospitals to be open with patients Commissioning Board to account for the when things go wrong. outcomes it secures through its oversight of • The NHS Outcomes Framework will be the commissioning of health services from used to hold the NHS Commissioning 2012/13. These new arrangements will ensure Board to account for the improvements an NHS that looks to patients, not politicians. it makes through the commissioning of 1.15 The reforms to the NHS, to be health services. introduced in April 2013, will significantly 1.18 The NHS Commissioning Board will strengthen the commissioning system provide effective new leadership for the to deliver better quality, patient-centred commissioning system. All NHS organisations healthcare. The focus of this new need to work to connect more effectively with commissioning system, made up of clinically- patients and the public. To help support this led clinical commissioning groups, supported change, the NHS Commissioning Board will by the NHS Commissioning Board, is adopt the name ‘NHS England’, a title which explicitly on improving outcomes, as defined will provide a clearer and less technical sense by the NHS outcomes framework, giving of its remit. This change will not alter in any commissioning a new clarity of purpose. way the NHS Commissioning Board’s role, 1.16 The Secretary of State’s Mandate to power, or functions. the NHS Commissioning Board sets out 1.19 As part of the process of authorising clearly the improvements in outcomes which Clinical Commissioning Groups (CCGs), the should be achieved. These include reducing Board must be satisfied that they are able the number of incidents of avoidable harm to commission safely and to exercise their and making measurable progress to embed a functions in relation to improving quality, culture of patient safety in the NHS, including reducing inequality and delivering improved through improved reporting of incidents. outcomes within the available resources. The These aims are consistent with Robert NHS Commissioning Board will also hold Francis’ recommendations. CCGs to account for the quality outcomes 1.17 Placing local clinicians in the lead for they achieve and for financial performance, commissioning represents a fundamental and will have the power to intervene where change to drive better alignment with the there is evidence that CCGs are failing, or safety and effectiveness of patient care. In the are likely to fail, their functions. Through the new commissioning system: new role of health and wellbeing boards, local • Patients will have access to the commissioners of health, care, and other information they want to make choices services will have a new opportunity to work about their care and Healthwatch will in partnership together to improve outcomes for the whole population. As a member, and Chapter OneItem: – Preventing 6 Enc: Problems 04 29
the convenor, of Quality Surveillance Groups • a strengthened leadership role in relation (QSG), the NHS Commissioning Board will to the wider local health and social care work with CCGs, regulators, providers and system, through health and wellbeing other partners to gather intelligence and boards; and information from local patients and services, • putting in place a new consumer to raise any concerns about quality, and to champion for health and care, local agree what action should be taken to address Healthwatch. them. In future, as the Chief Inspector of Hospitals is established, the Care Quality 1.23 The Government has an ambitious Commission will play the lead role in Quality programme to improve public health through Surveillance Groups in assessing quality strengthening local action, supporting problems and Monitor and the NHS Trust self-esteem and behavioural changes, Development Authority will lead on overseeing promoting healthy choices and changing action to address them. the environment to support healthier lives by empowering local communities. Local 1.20 Incentive payments that reward Government (upper tier and unitary local improvements in quality and innovation authorities) will lead for public health because to focus on outcomes now make up a of its unique potential to transform outcomes minimum of 2.5% of provider contracts, in for their local communities through: order to encourage a focus on continuously improving the quality of services for patients. • population focus; These payments (CQUIN), include a number • the ability to shape services to meet local of nationally mandated schemes aimed at needs; and improving safety and patient experience • the ability to influence the wider social across the provider, for example the NHS determinants of health – such as housing Safety Thermometer, and improvements in and employment – to tackle health the results of the patient survey. inequalities. 1.21 The NHS Commissioning Board, with 1.24 The 2012 Act also requires health and its statutory duty relating to improvement in wellbeing boards to be established in every quality, will continue to seek to create further unitary and upper tier local authority area. incentives for providers to focus on the quality Health and wellbeing boards will take an of services, learning from what has worked overview of health and care services, and well and supporting local commissioners to they will guide action to promote population develop effective quality incentives. health and wellbeing. This strengthened leadership role for local authorities, working Extending the Statutory Role of with the NHS and local communities, is Local Authorities intended both to improve outcomes and increase accountability and democratic involvement in health. Local Authorities will 1.22 The Health and Social Care Act 2012 also be members of Quality Surveillance (‘the 2012 Act’), gives local government Groups. three critical new roles in relation to health, enhancing and extending their previous role: Actions for Cultural Change • leading on local public health; 1.25 Throughout this response, we highlight case studies of things that NHS 30 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Royal United Hospital Bath NHS Trust – See it my way Using patient, carer and staff stories to inspire and motivate staff “See it my way sessions provide a time to re-connect with why we all work in the NHS – because we really care for people in need. Staff can see into the speaker’s life and hear and feel the person behind the need and they are moved from within themselves to improve the way they interact and work.” The Royal United Hospital Bath NHS Trust (RUH) has developed a powerful way of using patient stories to inspire and motivate staff. Regular events are held, open to all RUH staff at which patients, carers and staff are supported to talk about their experience of care. Each event is themed around an area that has been identified as a priority for improving patient experience. Three patients, two carers and one member of staff speak to the audience. Speakers are chosen to be as diverse as possible, and to include stories from people who are often not heard or given a platform to speak, such as people with a learning disability, dementia or a terminal diagnosis. Patients, carers and staff who have spoken say they feel truly heard and valued by the experience. Staff and patients at the RUH have been moved by the power of real life stories to inspire and motivate. As well as increasing their understanding and connection with the person behind the patient or role, staff have implemented practical changes following what they have heard. To find out more see: www.ruh.nhs.uk/get_involved/ppi/index.asp organisations are doing to build healthy the lessons to be learned from the Inquiry. organisational cultures. None of the methods It is this frontline reflection which will make and approaches described should be seen sustainable change a reality. as a “silver bullet”, but rather as part of a wider programme to drive change. The case studies throughout this document are offered to provide inspiration and prove what is possible, rather than offer a simple formula for transformation. Whilst the establishment of a Chief Inspector for Hospitals with a single clear picture of the quality of care for patients in each organisation will ensure a single set of incentives for hospitals, it will be for each board, each leader, each ward and each member of staff to find their own best way of achieving the best for patients. The Secretary of State for Health wrote to all hospitals at the time of the publication of the Inquiry report to ask leaders to reflect with their staff on Chapter OneItem: – Preventing 6 Enc: Problems 04 31
Allied Health Professions – The Big Conversation In February 2012, Karen Middleton, the Chief Health Professions Officer, met with leaders of the professional bodies, together with senior Allied Health Professionals (AHPs) leads from across the NHS to discuss professionalism. With evidence demonstrating that talking about an issue can shift the culture, the group agreed to stimulate frontline staff to have conversations about professional and unprofessional behaviour, the aim being to help develop a culture where clinicians feel as comfortable discussing values and behaviours with colleagues as they do discussing clinical issues. AHPs were asked to consider ‘What would you do if...?’ For example – if you saw a colleague texting while assessing a patient; or heard a colleague call a patient ‘darling’; or saw a colleague rush treatment to finish work on time? From this informal start, and active support from the key professional bodies, it has developed as a social movement among AHPs with discussions on professionalism in bulletins, journals and web sites, and cross-profession Twitter chats between AHP groups such as the occupational therapists (#OTalk) and nursing groups such as #WeNurses. The importance of The Big Conversation is demonstrated through the many positive reflections of staff – “we are being reminded daily that the small things make a big difference to the people we work with – both patients and colleagues.” To find out more visit http://ahp.dh.gov.uk/category/professionalism-2/
Supporting Staff to Care The Emotional Labour of Care
1.26 There is a wealth of evidence which 1.27 Working in health and care is inherently shows clearly that the key to providing emotionally demanding. To support staff safe, effective and compassionate care to to act consistently with openness and patients is supporting and valuing staff. Staff compassion, teams need to be given time wellbeing is not just a matter of culture. It and space to reflect on the challenging depends on tangible elements such as good emotional impact of health and care work. management, effective job design, education, Many organisations are already finding ways training and appropriate resources. But to do this, for example through Schwartz if boards and leaders do not engage the Center Rounds and Restorative Supervision people they lead, through their own priorities (see boxes overleaf and in Chapter 5 and their own behaviour, in a common respectively). endeavour for the patients that they serve, 1.28 The National Institute for Health then too often staff feel unsupported in their Research is launching a call for proposals for efforts to give their best for their patients. research to evaluate interventions aimed at Board behaviour and leadership will be a key increasing compassion and dignity in NHS focus for the Chief Inspector of Hospitals. care. 32 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Schwartz Rounds at the Royal Free London NHS Foundation Trust “It restores faith that you are working with colleagues who can share. There is a lot of angst and low morale in the health service but this shows there is heart here and we want to do the best for patients. It is quite uplifting.” Schwartz Rounds have been held on a monthly basis at the Royal Free since October 2009. They are a forum for clinical and non-clinical staff from all backgrounds and all levels of an organisation to come together once a month, for one hour, eat lunch or breakfast together, and explore the significant impact that their job has on their feelings and emotions. A team who have cared for a patient tell their story and this is followed by discussion, open to all, exploring issues that have arisen. It is not about problem solving – rather it is a dedicated time for reflection and a safe place to voice feelings not often shared, such as frustration, anger, guilt, sadness, joy, gratitude and pride. Joanna Goodrich, King’s Fund fellow, says “sitting in on Rounds all over the country I have been moved, time and again, by the commitment of staff, and humbled by their stories of how they have gone the extra mile for their patients – and seen what that has cost them.” For more information on Schwartz Rounds, please see: http://www.kingsfund.org.uk/ schwartzrounds
The Cultural Care Barometer Many excellent tools have been developed to help teams and organisations measure their cultural health. The Cultural Care Barometer is one example, which Robert Francis highlighted in his report. Developed by the National Nursing Research Unit at King’s College London in association with leading nurses from across the NHS, it aims to: • be short and quick to complete; • complement, not duplicate, other measures or quality programmes; • allow “ward to board” communication; • act as an early warning system to identify care culture problems; and • prompt reflection, to help identify any actions required. The tool is in the form of a short survey. However it is the conversations which the tool stimulates, for example through appraisal, which are important – both at team and board level. The barometer is currently being piloted in an acute trust, and will be piloted in a range of other settings (including community and mental health services, and to test board effectiveness) before it will be ready for wider application. Chapter OneItem: – Preventing 6 Enc: Problems 04 33
Measuring Culture Care Information Centre – for collecting information, and it will have a duty to seek to 1.29 Measuring culture is difficult, and reduce the information burden on the service needs to be approached with caution. Many year on year. tools exist to help organisations measure 1.31 To support this, the NHS their culture – but no tool in itself is “the Confederation is undertaking a review of answer” – culture is easier “to smell” than it bureaucratic burdens on NHS providers. The is to measure. What matters is how any tool initial focus of the review is to consider how is used, and what conversations take place to reduce the burden of inspection and data on the basis of it. The new Chief Inspector collection on the providers of care so that of Hospitals, in making assessments of the they can focus more on the delivery of safe, culture of institutions to inform judgements effective compassionate care. The review about their ratings, will be dependent on the will report in full in September 2013 and experience of expert inspectors with deep Government will look carefully at how best to insight into how hospitals tick, supported act on its findings. by data about complaints, whistleblowing, patient experience and staff experience. 1.32 The Health and Social Care Information Whilst indicators can be gamed, an Centre (HSCIC) collects and publishes experienced eye will be invaluable in ensuring comparable data on health and care to that boards are showing the leadership ensure that appropriate data standards are needed to shape and enable positive cultures applied to that information. New provisions in of compassionate care. the Health and Social Care Act 2012, coming into effect this April require that organisations across the health and care system must Creating Time to Care, Creating have regard to advice and guidance the Time to Lead HSCIC gives on data collection and the associated administrative burdens. Where 1.30 The measures in this document – an organisation does not comply, it must radical transparency, excellence in leadership, make public its reasons for not doing so. clarity of accountability, consequences for These arrangements will be strengthened to failure and rewards for the very best – will require organisations in the health and care together put in place the measures needed system, including the NHS Commissioning to help revitalise the culture of the NHS Board, Monitor, the Care Quality Commission, around a consistent focus on the needs of Clinical Commissioning Groups and others, to the patients it serves. But to do so, leaders comply with the HSCIC advice or guidance in need time to lead and staff need time to care, certain circumstances. This may include, for unconstrained by a culture of bureaucratic example, where an organisation is seeking to compliance with national regulations. In a carry out a new information collection itself, busier NHS, we will ensure that paperwork, rather than draw on the resources already box ticking and duplicatory regulation available to the system. and information burdens are reduced by 1.33 The Informatics Services at least one third. With a single version of Commissioning Group (ISCG), chaired by the truth in the Chief Inspector’s balanced the NHS Commissioning Board on behalf of scorecard and assessment, there will be a the health and care system, will ensure that single national portal – the Health and Social the HSCIC becomes the focal point for data 34 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
collected at the national level, so the HSCIC future need to think hard and argue hard becomes the ‘gateway’ for those seeking to about why they need more information and collect new data. The ISCG will support the consider its impact on direct care for patients. HSCIC in its duty to ensure that the burden When information is collected, the technology on front-line services from data collection is needs to be in place to make it easy for significantly reduced. organisations to provide and easy for frontline 1.34 Busy leaders and busy staff need to staff to collect, so they can concentrate on be freed up to build cultures of care and to the patients that they serve. care for patients. National and local bodies 1.35 The Government will implement in full that impact on providers and staff will in the findings of the Fundamental Review of
NHS Confederation Review of Bureaucratic Burdens on NHS Providers: Interim Report Recommendations 1. Immediately implementing the Fundamental Review of Data Returns. 2. Developing an agreed single data set for all providers aligned around a single definition of quality that is appropriately balanced across the five outcome domains and has proper emphasis on the patient and public and frontline staff view of quality. 3. Placing requirements on regulators, commissioners, and providers themselves to use this as the single source of data to support multiple uses for regulation, inspection, licensing, quality surveillance and risk assessment, commissioning and benchmarking, quality reporting by organisations, and in time, research. This could include introducing powers to restrict organisations collecting their own data. 4. Establishing the new Health and Social Care Information Centre as a world-class data hub for all health and social care information and the single major collection point. 5. Creating a system of governance at the new Health and Social Care Information Centre that engages all the key stakeholder bodies (including representation from the NHS and patient groups) and establishes a robust process of continuous challenge about what is collected. 6. Requiring the new Health and Social Care Information Centre to consult and publish annually on the scope and volume of its required returns. 7. Creating incentives on all organisations in the NHS to minimise locally driven information collections, subject to the proper management and assessment of risk. 8. Increasing and facilitating information sharing across all organisations concerned with NHS and social care to minimise duplication of data collection and underpin a safer process of integrated care for patients. 9. Creating an effective and transparent system of earned autonomy to guide the volume and frequency of external assurance and inspection activity by regulators. 10. Committing wholeheartedly to the roll-out of digital technology to reduce the burden on frontline staff collecting information by incentivising procurement and deployment of digital collection systems. Chapter OneItem: – Preventing 6 Enc: Problems 04 35
Data Returns, carried out by Department of build a modern data service, care.data, Health and the HSCIC in partnership with key in health and social care, to provide timely organisations who generate or use NHS data. and accurate data derived from information Fifty-eight data returns have already been collected as part of the care process and suspended and work will start immediately linked along care pathways. with the owners of data returns to discontinue any remaining redundant data returns. This Safety in the DNA of the NHS – will deliver a 25% reduction in the number of data returns that NHS organisations are The Berwick Review required to send to the Department of Health and its arms length bodies, freeing up time Zero Harm for hospital boards and staff to focus on 1.37 A critical component of NHS culture providing high quality, compassionate care. must be a deeply embedded culture of safety. 1.36 Drawing on the HSCIC, the NHS Whenever avoidable harm or deaths occur, Commissioning Board is leading work to these need to be treated on every occasion as an individual disaster, requiring close
NHS Safety Thermometer Monitoring the Safety of Care at the Frontline and Taking Action to Improve The NHS Safety Thermometer is the first tool to measure four high volume patient safety problems – pressure ulcers; falls in care; urinary infection (in patients with a urinary catheter); and treatment for new Venous Thromboembolism (VTE). It can be used across a range of settings, including for district nursing caseloads, in community hospitals, in nursing homes as well as in acute care. It gives immediate feedback for teams to use in their improvement work and the data collected can be viewed at the ward, organisation or national level at the push of a button. The NHS Safety Thermometer gives nurses on the front line the power to take control and make the NHS a much safer place for patients. It only takes a few minutes to complete the checklist, it can be completed as part of routine care and can save a significant amount of staff time as it means they don’t have to deal with as many preventable patient safety incidents. The tool is called the NHS Safety Thermometer because it is used to take the temperature of safety in an organisation, caseload or ward. It takes only a minimum set of data that helps to signal where individuals, teams and organisations might need to focus more detailed measurement, training and improvement. Just like a regular thermometer it can flag abnormal readings and measure changes. The power of the NHS Safety Thermometer lies in it being used by frontline teams to measure how safe their services are and to really deliver improvement locally. Use of the NHS Safety Thermometer is incentivised across the NHS through the existence of a ‘CQUIN’ (Commissioning for Quality and Innovation) payment. It is being adopted rapidly across the NHS with virtually all of the health care organisations in some areas using the tool. 36 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
scrutiny, deep learning and lasting change. A report in relation to the quality and safety of “never event” must become a “never again” patients and propose a new improvement event for every NHS organisation. A “these programme that will build capacity and things happen, let’s move on” approach capability for safety in the NHS. The Group is unacceptable in 21st century care and is will also advise on how to bring about a unacceptable to patients. genuine culture of change in the NHS so 1.38 Safe care is about both systems that staff at every level and across the entire and people: ensuring organisational healthcare system can take serious and structures, policies, procedures and profound action to make patient care and practices are delivering reliably safe care treatment as safe as it can possibly be. (such as computerised prescribing to 1.41 Following the Berwick Review, reduce medication errors or the NHS Safety the Department of Health, the NHS Barometer – see box); and ensuring that Commissioning Board and the Care staff’s decisions and behaviours and the Quality Commission will jointly consider effect of these are promoting safer care the recommendations and work with other and avoiding risk and harm. It is about stakeholders to agree the key roles and minimising harm without creating a risk- responsibilities for patient safety across the averse environment where fear overrides healthcare system. Its findings will have deep sensible decision-making. Health and care is significance for the future of our healthcare inherently a risky business and many of the system, the safety of care and public and most important developments in improving patient confidence in the NHS. medical care have relied on clinicians being 1.42 From 2012 the mechanism by which willing to break new ground and innovate. patient safety incidents are reported nationally 1.39 At Mid Staffordshire NHS Foundation transferred to the NHS Commissioning Board. Trust, patients were not receiving reliably safe This data is used to derive learning from care and treatment. The report cites many patterns and trends in incidents to prevent factors that demonstrated a systemic failure future harm. The NHS Commissioning Board at the hospital. This included compromised will develop and deliver a revised, easy staffing levels, poor nursing handover, to-use and responsive National Reporting disempowerment of medical and nursing and Learning System (NRLS) that will staff, poor clinical governance (including provide a “one-stop shop” for the NHS, poor systems for managing serious untoward clinicians, patients and the public to report incidents and not implementing national patient safety incidents and receive advice. patient safety alerts) and a failure, or even a It was Robert Francis’ recommendation refusal to listen to staff and patients when that the functions of the National Patient they had concerns. The wider system failed Safety Agency were transferred from the to detect the risks to patients at the hospital NHS Commissioning Board to the Care and intervene quickly. Quality Commission. However, given that 1.40 The Government has asked Don the NRLS was only transferred to the Berwick to lead a National Patient Safety NHS Commissioning Board in 2012, the Advisory Group to advise on a whole system Department believes that reallocating this approach to make zero harm a reality in the work at this stage would be unnecessarily NHS, reporting by the end of July. The Group disruptive. There are already good information will reflect on the findings of Robert Francis’ flows from the NRLS to the Care Quality Commission, which are analysed and brought Chapter OneItem: – Preventing 6 Enc: Problems 04 37
to inspectors’ attention through the Quality Francis has said repeatedly, the NHS and Risk Profile (QRP) to support their planning its dedicated staff do not need to wait for of inspections. In addition, the functions Government to legislate, or guidance from transferred to the NHS Commissioning Board national bodies: we urge everyone at the go further than the remit of the Care Quality frontline of care to have confidence in their Commission at this time. We will, however, caring, professional NHS values and take to keep this under review. their hearts the hard task of changing care for 1.43 Given the importance of the medical the patients that they care so deeply about. profession to good care, the General Medical The Government will do everything in its Council (GMC) has an important part to play power to support them. in shaping the culture of a system in which doctors’ behaviour and values are so vital. It has issued new guidance on leadership and management for all doctors which was sent to every doctor in the United Kingdom, saying that all doctors, whatever their role, must raise and act on concerns about patient safety. It also makes clear that doctors must not sign contracts that attempt to prevent them from raising concerns with professional regulators, nor must doctors in management roles promote such contracts or encourage other doctors to sign them. The Government expects other professional regulators to embrace this approach, as many are already doing.
Conclusion
1.44 The changes to inspection, regulatory and information burdens, transparency and accountability set out in this response will themselves help to shape a more consistently safe, effective, respectful and compassionate culture in our NHS, and these principles extend beyond health to the care system. But to be sustainable they need to change the behaviour of boards, leaders, and staff. Many already embrace this culture, but have been hampered by national targets, bureaucracy and a lack of time to care and a lack of time to lead. The Government is determined to address this, but for real to change to occur, local staff and local leaders must embrace the need for fundamental change. As Robert 38 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04 Chapter Two – DetectingItem: 6Problems Enc: 04Quickly 39
Chapter Two – Detecting Problems Quickly
Summary
The Care Quality Commission will appoint a powerful Chief Inspector of Hospitals later this year. Informed by expert judgements of inspectors, the Chief Inspector will make an assessment of every NHS hospital’s performance. Using expert-led inspections, the Chief Inspector will shine a light on how our hospitals are serving patients. Just as OFSTED acts as a credible, respected and independent arbiter of the best and the worst in our schools, the Chief Inspector will become the nation’s whistleblower – naming poor care without fear or favour, from politicians, institutional vested interests or a loyalty to the system rather than the patients that it serves. The Chief Inspector will ensure that there is a single version of the truth about how hospitals are performing, not just on finance and targets, but in a single assessment that reflects what is important to patients. As in education, the Chief Inspector will make a balanced assessment of whether hospitals are in categories such as “outstanding”, “good”, “requiring improvement” or “poor”. Outstanding hospitals will be given greater freedom from regulatory bureaucracy. The Friends and Family Test for both staff and patients will be a vital component part of the rating. A new spirit of candour and transparency will be essential for exposing poor care. As the publication of individual outcomes for heart surgery has helped to drive up standards in that field, the NHS will extend this openness on outcomes to further specialties. Mortality data must be interpreted with care, but it must also be accurate so that the public and patients can trust that they are hearing the truth. So there will be tough penalties and possibly criminal sanctions on organisations that are found to be massaging figures or concealing the truth about their performance. A statutory duty of candour will reinforce the existing contractual duty, so that patients can be assured that they are given the plain truth about the care that a hospital provides. Clauses intended to prevent public interest disclosure by NHS staff will come to a halt. Staff who speak up about problems should be supported, not vilified.
A review of best practice on complaints will ensure that when problems are raised, they are heard, addressed and acted upon and seen as vital information for improvement rather than irritations to be managed defensively. 40 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Introduction NHS Commissioning Board and the NHS Outcomes Framework set by Government, 2.1 The measures set out in Chapter One and its application will also take account will help to foster a more consistent culture of of the need to reflect local commissioner safe, effective, respectful and compassionate priorities. When assessing individual care for patients and thereby help prevent providers, the Care Quality Commission problems from arising. But in a system as will look at quality in the round, not just important to the public and to individual registration standards. While in the past patients as the NHS, there also needs to a plethora of signals and imperatives left be a robust and effective system to provide providers pulled in conflicting directions about ongoing surveillance and proportionate what was really expected of them, in future inspection to spot problems so that action there will be a clear, single nationally agreed can be taken to address them effectively and definition of success, a single assessment promptly. of achievement against that and no room for manoeuvre locally of playing one national A Chief Inspector of Hospitals supervisory body off against another. 2.4 The Care Quality Commission, the 2.2 The Care Quality Commission will NHS Commissioning Board, Monitor and become the primary assessor of quality in the NHS Trust Development Authority will the health and social care system. The Chief be required to agree together the data and Inspector of Hospitals will be the focal point methodology for assessing hospitals. This for honest and independent assessment will ensure a single set of expectations on about how well or badly hospitals are serving hospitals of what is required of them that is patients and the public. To avoid duplication aligned with the way in which commissioners, this will mean change to the existing quality led by clinicians and guided by the views surveillance responsibilities of Monitor and of local patients, ensure high quality care in the NHS Trust Development Authority. This the hospitals for which they are responsible. means that the focus for the Care Quality Providers will demonstrate, through annual Commission will widen from being merely Quality Accounts, how well they are meeting a regulator of compliance to becoming an that single set of expectations. inspector of quality. 2.5 In line with its clearer leadership on 2.3 In delivering this role, the Care quality assessment and surveillance, the Quality Commission will develop a method Care Quality Commission will over time lead of assessing the overall performance of on the assessment aspects of local Quality organisations in meeting the needs of patients Surveillance Groups and local Risk Summits, and the public. To ensure that all national and the NHS Trust Development Authority organisations are sending a single measure and Monitor will lead on enforcement. The of success to the system, the Care Quality Chief Inspector will become the leader in Commission will agree this with Monitor, the the system that coordinates national bodies NHS Trust Development Authority and the for a single set of quality expectations, a NHS Commissioning Board. Building on the single assessment of performance against work of Lord Darzi, there will be one agreed them and ensuring that nationally and locally national definition of quality. The method everyone works together to detect poor care will be consistent with the Mandate to the and ensure appropriate action is taken. Chapter Two – DetectingItem: 6Problems Enc: 04Quickly 41
2.6 For NHS trusts and foundation trusts, of the single failure regime and the national to reduce duplication, the Chief Inspector will ratings for hospitals. focus on exposing problems and requiring 2.10 We will also consider whether there action, with enforcement action overseen by should also be a Chief Inspector of Primary Monitor for Foundation Trusts or the NHS Care, with the Care Quality Commission Trust Development Authority for NHS trusts. consulting with the public, patients, health In line with that, the Care Quality Commission professionals, commissioners and others on will formally delegate its enforcement powers whether the broad approach which applies (those beyond warnings) to Monitor and the to hospitals could be extended to primary NHS Trust Development Authority. We will and community services. In doing so it will be ensure Monitor retains sufficient powers of important to ensure that the new inspection Foundation Trust oversight. We will discuss regime reduces regulatory burdens whilst with the three bodies concerned the detailed enhancing public confidence and builds on practical arrangements for this. the role of Clinical Commissioning Groups in 2.7 For the time being, the Care Quality driving up the quality of primary care. Commission will retain all its current enforcement powers for social care, general Expert Inspectors practice, social enterprises and independent sector providers. However, we recognise fully 2.11 As with clinical practice, inspection the differences between health and social is both a science and an art, based on care provision, we will look carefully at the knowledge, experience and judgement. To options for enforcement, either by the Care have authority and credibility, inspection Quality Commission or other bodies, in the must be led by individuals with deep insight same way as we are doing for hospitals. and specialist experience in the areas for which they are responsible, with the close Chief Inspectors involvement of patients, staff and others. The new Care Quality Commission leadership 2.8 The new Chief Inspector of Hospitals is developing a model of inspection that will will take the lead across the system on secure thorough and insightful inspections assessing the quality of care in hospitals. which combine first-hand expert experience The Chief Inspector will provide oversight to with data and feedback from patients and the Care Quality Commission’s inspections, staff. The Care Quality Commission will set assessments and ratings of providers, out their proposals in their new strategy in identifying both good and poor performance. more detail shortly. He or she will communicate these findings to the public. Ratings – A Single Balanced 2.9 Robert Francis stressed the Version of the Truth importance of physical inspections. The Chief Inspector will lead an expert team that 2.12 We intend to give the Care Quality conducts inspections and actively engages Commission the power to conduct ratings at with other organisations including Monitor, the earliest opportunity and we will work with the NHS Trust Development Authority and the the Nuffield Trust to develop these proposals NHS Commissioning Board as a pivotal part further. Whilst there is a significant amount of information available on organisations 42 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
providing health and social care in England, services to seek better performance. Subject there is currently no aggregated rating to to the conditions outlined in the Nuffield Trust summarise and compare the performance report regarding larger and more complex of organisations or the services provided by organisations, which we accept, ratings them. Just as OFSTED offers clear reports on will be compiled using both judgement and local schools, a new regime is needed to give data to ensure there is a system wide ‘single patients and the public a fair, balanced and version of the truth’. Award of the bottom easy to understand assessment of how well a category rating in itself will automatically provider is doing relative to its peers. trigger action. We will work with the Care 2.13 To this end, the Secretary of State for Quality Commission and the Nuffield Trust to Health commissioned the Nuffield Trust to develop these proposals further. carry out an independent review of whether 2.15 The Department of Health will an aggregate rating of provider performance commission an independent evaluation of should be used in health and social care, the operation of the new ratings system, and and if so how best this might be done. The this will inform future adaptations. Subject to Nuffield Trust report, Rating Providers for the findings of the evaluation, changes will be quality: a policy worth pursing?7, published kept to the minimum necessary, to provide last week, has set out advice on an aggregate stability for providers and facilitate meaningful rating for GP practices, hospitals and care comparison over time. homes based on information that matters to patients and service users. It suggests Working Together to Focus on an overall approach to ratings that allows complex organisations, particularly hospitals, Quality to be assessed not just at an organisational level, which could be misleading on its own, 2.16 The National Quality Board (NQB), but at different levels with service-specific established in 2009, brings together ratings where possible. While a range of the national organisations tasked with commercial organisations currently offer safeguarding and improving quality. Following benchmarking data or provider ratings, the publication of the first Inquiry into Mid the report highlights a clear place for an Staffordshire NHS Foundation Trust, the NQB aggregate rating based on inspection as well published a Review of early warning systems 8 as data. In the light of this advice, aggregate in the NHS and Quality in the New Health 9 ratings will be developed and published by System that began to assess how systems, the Care Quality Commission, independently values and behaviours could better support of Government. The Care Quality Commission the detection and prevention of serious will also work with Monitor, the NHS Trust failures against basic standards. Development Authority and the NHS 2.17 From April 2013, a network of local Commissioning Board to agree an overall and regional Quality Surveillance Groups approach to provider assessment, which will (QSGs) will bring together commissioners, aim to minimise duplication, reduce burdens regulators, local Healthwatch representatives and join-up intelligence. and other bodies on a regular basis to share 2.14 Aggregated ratings of provider information and intelligence about quality performance will be of value to the public in across the system, including the views of helping to choose the right services, and to patients and the public, and proactively those organisations providing or purchasing spot potential problems early on. QSGs will Chapter Two – DetectingItem: 6Problems Enc: 04Quickly 43
be supported and facilitated by the NHS Care and Support Commissioning Board and will foster a culture of open and honest cooperation. This will 2.20 In care and support, the system support many of the recommendations made will apply the same lessons to ensure by Robert Francis in relation to the sharing problems are identified early and resolved of information. They will also help support quickly. Providers of care have the primary the coordination of any action that is needed accountability for the quality of the care to respond where risks to patients are people experience, but commissioners and identified. Over time, as the Chief Inspector the regulators have important roles to play, as role becomes established, the Care Quality set out in Bringing Clarity to Quality.10 From Commission will assume a leading role in April 2013, NHS Choices will include new these quality oversight and surveillance care and support information, including online arrangements. public comments to compare care from 2.18 Where concerns arise of a serious different providers. This will include the ability failure, members of the QSGs will be able to submit and view comments from users to act quickly by triggering a “risk summit”. and their families giving the public greater All QSG members relevant to the provider transparency of people’s experiences of care, in question attend these summits so that and giving providers the chance to act on they can, together, give specific, focussed what they hear. consideration to the concerns raised and 2.21 Local authority commissioners of care develop a joined-up response. In Autumn are leading the drive to improve the quality 2013, the National Quality Board will review of the care and support they provide for their how the QSGs have worked, taking into communities. The Towards Excellence in account relevant recommendations made Adult Social Care programme, led by the local by Robert Francis, and update guidance to government sector, combines strengthened ensure that all QSGs can learn from best transparency on councils’ performance practice. with a robust programme of peer-to-peer 2.19 We need to do more to ensure challenge and review, supporting councils effective joint working, including with to identify and act upon areas of concern. coroners, building on the recommendations A key focus of the programme has been about better information sharing. Monitor and to enhance the information available both the Care Quality Commission have reviewed to councils, to support their improvement their working arrangements to ensure that efforts, and to local people, making councils they work better together to share information genuinely answerable to the people they about the performance of foundation trusts. serve. Currently, available information on The Care Quality Commission already councils’ performance is being used to good receive many of the rule 43 reports which effect, with most local authorities already are issued where a coroner believes that publishing local accounts, which set out action should be taken to reduce the risk of councils’ progress and priorities, supporting future deaths. However, the Chief Coroner an active dialogue with local communities on will issue guidance to Coroners Offices, as performance. The Care Quality Commission recommended by Robert Francis, to promote will want to review these arrangements in the sharing of these reports with the Care discussion with key partners when the Chief Quality Commission and its Chief Inspectors. Inspector of Social Care is appointed. 44 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
University Hospital of North Staffordshire – Proud to Care North Staffordshire have worked hard to embed a safety and quality culture. One aspect of their Proud to Care programme is the use of patient stories to inspire staff. Stories of excellent patient-centred care are highlighted in a regular staff bulletin. One story is about Margaret, 74, who had recently lost both her husband and daughter to cancer. Margaret needed a blood transfusion but felt unable to attend her appointment, which was in the same building where her daughter had been treated. Hospital staff tried hard to arrange for Margaret’s appointment to take place in a community setting, but due to the specialist equipment needed, it was not possible. On the day of the transfusion, a dedicated nurse met her at the entrance of the building to help her overcome her anxiety, and cared for her throughout the day. The Matron also spent some time talking to Margaret to ensure her needs were met. Staff ensured that Margaret was not left alone, and received the emotional support she needed during this difficult time. Following her treatment, Margaret specifically asked to speak to the Matron to praise the team and pass on her thanks to all involved. For more information, please see http://www.uhns.nhs.uk/ForPatients/ProudtoCare.aspx
Transparency to cardiology, vascular surgery, upper gastro intestinal surgery, colorectal surgery, 2.22 The Government’s mandate11 to the orthopaedic surgery, bariatric surgery, NHS Commissioning Board set an objective urological surgery, head and neck surgery to shine a light on variation and unacceptable and thyroid and endocrine surgery. practice, to inspire and help people to learn 2.23 All hospitals are required to produce from the best. The Government wants to Quality Accounts, an annual statement of see a revolution in transparency – so that their performance on quality with the same the NHS leads the world in the availability importance as annual financial accounts. of information about the quality of services. From April 2013, Quality Accounts will also From 2015, the NHS Commissioning Board include comparable data from a set of quality will ensure that data on services at speciality indicators linked to the NHS Outcomes level is increasingly available. To do this they Framework. This will include the summary will work with providers, patient groups, hospital-level mortality indicator, infection speciality level organisations and those rates and levels of patient safety incidents. bodies such as the Health and Social Care Quality Accounts are already made available Information Centre and the Care Quality to the lead commissioner, Overview and Commission that have an interest in the Scrutiny Committees and local Healthwatch collection, use and publication of such data. organisations prior to publication. Any As the publication of individual outcomes comments that these organisations make for heart surgery has driven up standards in must be included in the Quality Account. that field of medicine, as a starting point, the The Department of Health will lead work on NHS will extend this openness on outcomes Chapter Two – DetectingItem: 6Problems Enc: 04Quickly 45
further standardising quality accounts to Quality and Risk Profiles increase their impact and reduce burdens. 2.24 Complaints information, along with 2.27 The Care Quality Commission has comments and feedback, is also a key part developed Quality and Risk Profiles (QRP) of ensuring the quality of services provided as its main information tool to support its by NHS providers. In February 2013, the inspectors to target their inspection activities. Department announced that a review of The profiles draw together and analyse complaints would be undertaken this year. information from a wide range of internal It would include how the information from and external data sources. To ensure that complaints is shared and used to protect the Care Quality Commission is focusing on patients. It will report in the summer. the things that matter most for the different settings that it regulates, it has commenced a major piece of work to develop the way in Mortality indicators which it uses and analyses information. This work will be used to identify, predict and 2.25 Since October 2011, the Health and respond to varying standards of care and will Social Care Information Centre has published help drive the Care Quality Commission’s new as an experimental national statistic, the inspection methodology. The Chief Inspector Summary Hospital-level Mortality Indicator and the Care Quality Commission will review (SHMI). This followed from a review in 2010 how this sits within the overall surveillance of Hospital Standardised Mortality Ratios systems set out in this document. (HSMR) in response to the publication of the first Inquiry12 SHMI data can be used by 2.28 The Department of Health and the trusts, as part of a wider set of information Care Quality Commission will look at ways to that identifies risks to patients, to review make their analyses about standards of care performance and consider where action may publicly available (and the methodologies need to be taken to protect patients. used) as recommended by Robert Francis. This will allow patients to be better informed 2.26 Professor Sir Bruce Keogh is about risks to the outcomes of their care and investigating the quality of care and treatment treatment. provided by those NHS trusts and foundation trusts that are persistent outliers on mortality Duty of Candour indicators. The investigation will look at 14 trusts that have been outliers for the last 2.29 A spirit of candour will be critical two consecutive years on either the SHMI to ensuring that problems are identified or the HSMR. The investigation will seek quickly and dealt with promptly. Openness to determine whether there are sustained is a key element of healthy organisational failings in the quality of care and, where there cultures in health. There is a requirement are, if actions already taken by these trusts to be open in the professional codes of are sufficient or whether further support practice for managers, doctors and nurses or regulatory action is required to protect and the principles are also covered in the patients. The review will report by the end of NHS Constitution and the Care Quality summer 2013. Commission’s guidance. In addition to clinicians and other health and care professionals, it is also the responsibility of boards and leaders in provider organisations 46 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
to support openness and deliver high quality Criminal Sanctions care. Clear guidance exists on how to disclose patient safety incidents to patients 2.33 Robert Francis’ report makes a in the form of Being Open13 published by the number of recommendations in relation to National Patient Safety Agency in 2010. the use of criminal sanctions when things go 2.30 Patients also need proper advocates. wrong, or where there is wilful misleading of They can help patients when things go the public or regulators by individuals. We wrong but they are also part of a system recognise that attaching criminal sanctions that provides support to patients, particularly to key areas of public service delivery can vulnerable patients, when they need send an important message about the assistance. Advocacy is being considered as expected standards of care and duty to part of the review of complaints. the public. However, before we introduce 2.31 The NHS Standard Contract for criminal sanctions at an individual level for 2013/14 will include a contractual duty of staff providing NHS services we would want candour on all providers to be open and to ensure that this does not unintentionally honest with patients when things go wrong create a culture of fear. This in turn could with penalties for breaching the duty. The prevent lessons being learned and could rationale for a contractual duty is that make services less safe. However, we agree individual clinical commissioning groups (as that in the unusual situation where staff opposed to a single national body) are best deliberately allow fundamental standards to placed to examine their own local providers be breached or are obstructively dishonest, and take action where required. A contractual robust action should be taken. We will duty placed upon organisations is also the consider the conclusions of Don Berwick’s best approach for encouraging staff to be review of safety and what further action open and report incidents, and thereby might be taken by the Nursing and Midwifery promote a positive safety culture. This is Council, the General Medical Council and because the onus is on the organisation to other professional regulators before deciding create a supportive culture in which people on the appropriateness of criminal sanctions can admit mistakes – a challenging, but below board level. We will also review nonetheless essential task when it involves whether existing criminal sanctions could be a needlessly injured patient or relatives who applied more effectively. have been bereaved. 2.34 There can be no excuse for boards 2.32 We intend to go further and introduce who knowingly supply wrong information a statutory duty of candour on health and about key indicators such as mortality rates, care providers to inform people if they believe or deliberately withhold information from treatment or care has caused death or patients or families about serious harm serious injury, and to provide an explanation. or death. So where organisations wilfully We will need to carefully consider the scope generate misleading information or withhold of this duty on all providers. We will also information they are required to provide, we work closely with professional regulators will consider the introduction of additional to examine what more can be done to legal sanctions at a corporate level. encourage professionals to be candid with their patients at all times. Chapter Two – DetectingItem: 6Problems Enc: 04Quickly 47
A Ban on Clauses Intended to too easily permit the persistence of poor and Prevent Public Interest Disclosures unacceptable care.’ 2.38 The Secretary of State for Health has 2.35 Robert Francis makes clear the announced that the era of gagging NHS staff important role that whistleblowers played in from raising their real worries about patient uncovering the events at Mid Staffordshire care must come to an end. Staff who show NHS Foundation Trust but also highlighted the professionalism and personal courage the challenges they faced being heard and to speak out in the public interest – which is believed. He recommended that any ‘gagging difficult even in an open culture – must be clause’ that seeks to limit legitimate disclosure celebrated and rewarded, even if, following of problems with patient safety and care investigation the concern turns out to be should be prohibited. misplaced. 2.36 Contracts of employment and 2.39 We will update our guidance to make severance are determined between the clear that any compromise agreements employing organisation and its employee. We must include an explicit statement making acknowledge that the use of confidentiality clear that ‘nothing within the agreement clauses within compromise agreements has prevents the parties from making a protected a right and proper place, to ensure that both disclosure in the public interest’. parties end the employment with a clean 2.40 The Government has already taken a break. We have consistently made clear that series of steps to enhance the protections where confidentiality clauses are used, they available to whistleblowers – including a should go no further than is necessary to right to raise concerns within staff contracts; protect matters such as patient confidentiality amending the NHS Constitution to include and commercial interest. Under no explicit rights and pledges on whistleblowing; circumstances should clauses ever seek to issuing new guidance to employers; and prevent the departing employee from making extending the national helpline to include a disclosure in the public interest. In practice, staff in social care settings for the first time. all such clauses are unenforceable in law. We In addition, the annual NHS Staff Survey are clamping down to make sure that the law asks staff if they are aware of how to raise is observed. a concern, if they feel safe to do so and if 2.37 The Secretary of State for Health wrote they believe their organisation would take to all Trusts on 15 February 2013 reminding action on a concern. Responses to the them again of their obligations to have Public questions can be broken down by trust, Information Disclosure Act (PIDA) compliant professional and demographic group, whistleblowing policies and asking that they allowing benchmarking of performance. All ‘check that the confidentiality clauses in your staff survey data is publicly available. contracts (and compromise agreements with 2.41 Those changes mean that NHS staff departing employees) do indeed embrace have professional duties and contractual the spirit of [this] guidance. I would also ask rights to raise concerns and, if need be, to you to pay very serious heed to the warning whistleblow where they believe that the basic from Mid Staffordshire that a culture which standards of quality of patient care are not is legalistic and defensive in responding to being met. The NHS Constitution contains reasonable challenges and concerns can all a corresponding pledge that Trusts and other providers of NHS services will actively 48 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Whistleblowing: Advice to all NHS Staff (extract from NHS Constitution Handbook 2012 edition) • If you have a concern about a risk, malpractice or wrongdoing at work, you should normally raise it first in confidence with your line manager or lead clinician, either verbally or in writing if you are able to do so. • If you feel unable to do this, you may raise it with the designated officer within your employing organisation. You should find details of the designated officer in your employer’s whistleblowing policy. • If you have raised your concern with the designated officer or your line manager, but feel it has not been addressed properly, or that inadequate action has been taken, you should raise your concern via the dedicated whistleblowing helpline which provides a free, independent and confidential service, staffed by legal experts, which can support staff who need advice. The freephone helpline number is 08000 724 725. • If your concern is related to a detected or suspected incidence of fraud or corruption, you should follow your local whistleblowing policy or the reporting procedure prescribed by NHS Protect by reporting directly to the Local Counter Fraud Specialist, Director of Finance, or via the fraud and corruption line or online reporting form where you are able to. You will still be entitled to make a whistleblowing complaint and receive protection under the Public Interest Disclosure Act. • In certain circumstances, wider disclosures to bodies or persons other than your employer or a Minister of the Crown may also be protected by PIDA. A number of additional tests (aside from reasonable belief and good faith) will apply to assess whether such a disclosure is a “protected disclosure”. Those additional tests will vary from case to case and may include consideration of the following factors: • the identity of the body/person to whom the disclosure is made (generally disclosures to the media are unlikely to be covered), and the seriousness of the alleged breach and whether it is “an exceptionally serious” concern; • there is a risk that evidence could be destroyed or concealed if the disclosure is made to the employer or another prescribed person; • the disclosure amounts to a breach of confidence with the employer; • the matter has already been raised • there is a good reason to believe that the individual will be the subject of a detriment by their employer if the matter were raised internally or with another prescribed person; and • disclosure was reasonable given the circumstances. Staff considering such a disclosure are advised to take advice from the helpline, their trade union or their regulatory body before taking this step Chapter Two – DetectingItem: 6Problems Enc: 04Quickly 49
Florence Nightingale School of Nursing and Midwifery, Kings College London Research – Experience-based co-design “We were all together. There was that terrific sense of an equal playing field. Anybody could speak. There was no sense of fear, there was no hanging on status or using it. It was quite incredible really.” Experience-based co-design (EBCD) uses the experiences of patients, carers and staff to redesign all or part of a particular health care process, to make it more efficient, safe and a better overall experience for both patients and staff. EBCD starts by filming patients telling their stories and carrying out observation of routine care, to help staff to ‘see the person in the patient’. Patients and staff then sit down and redesign services together, the focus being on designing the human experience and not just impersonal systems or processes. Research shows the approach can lead to: • practical, tangible quality improvements felt by patients and staff • a significant legacy in terms of patient-centred working, support groups, and information for patients • cultural change, for example, greater and more open team working and better communication across departments, clinicians and staff of different grades. “I have done lots of surveys and I often feel that my experience isn’t reflected on there. I want to tick a box that’s not there. EBCD gave me, as a patient, a chance to say what was actually happening” Experience-based Co-design toolkit: http://www.kingsfund.org.uk/ebcd/ support them by promoting a culture where that if staff who raise concerns about poor the raising of concerns is valued as a means care are harassed by their colleagues, their of improving the quality of care. employer is liable for this conduct. 2.42 The Government has agreed an amendment to the Enterprise and Regulatory Reform Bill, securing Public Interest Disclosure Act (PIDA) protections for all NHS staff by adding other NHS contractual arrangements to the extended definition of “worker” in section 43K of the Employment Rights Act 1996. We have recently welcomed proposals from the Department for Business Innovation and Skills to introduce vicarious liability into employment law to provide even greater whistleblower protections. This means 50 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
The Friends and Family Test in NHS Midlands and East Since April 2012, providers in NHS Midlands and East cluster have been piloting a friends and family question as part of their feedback mechanisms, and the lessons and experience from this pilot area has fed substantially into the development of the national Friends and Family test. It has had considerable impact in the Midlands and East area as local teams have embraced the opportunity to hear feedback from their patients, in better time than is currently provided by existing national survey mechanisms. It has led to local changes being implemented on a practical level for patients, and has increased ownership of the patient experience from ward staff, who are now keen to see the latest weekly scores. For more information read, The Patient Revolution: The continuing journey from across the Midlands and East. See http://www.strategicprojectseoe.co.uk/uploads/FNL%20-%20 Patient%20Revolution%20Continuing%20Journey%20Feb%202013(1).pdf
2.43 We have considered with regulators their treatment and care. This is a particular and staff the need for an independent concern for older people and other groups authority to which staff could turn when their whose voice can sometimes be harder to hear own organisation is not listening alongside and where we need to listen more carefully. the wider recommendations made by Robert 2.45 The care system requires a genuine Francis. The Care Quality Commission has shift to placing patients at the centre, shaping considerably improved its service since services around people and their preferences, 2010, and the new process includes a “track involving them at all stages of service and trace” team to ensure no concerns get delivery from assessing population needs to lost in the system. We will therefore not be commissioning and service design to patient creating a new body, but will work to ensure feedback. In the future patient feedback and all organisations work together to learn from information on patient experience will be an whistleblowers and make sure that action is even more important influence on shaping taken when people raise concerns. policy and the delivery and regulation of care services. Involving people in decisions about Engaging and Involving patients their health, care and services should be the norm, not the exception. 2.44 A key theme running through the Francis Report was the observation that 2.46 All key organisations within the health patients, their carers and families were not and care system need to ensure that they listened to during and after their care. The are listening to and understand the views of reason for this is not something that can be people who have experience of using the changed through an organisational restructure NHS and care services so that the work but is one of culture – listening to patients, they do is properly informed by the voice of their carers and families, considering and patients and citizens. responding to their views, and treating 2.47 The Department of Health will ensure patients as equal partners in decisions about that it connects with the voice of patients, Chapter Two – DetectingItem: 6Problems Enc: 04Quickly 51
Northumbria Healthcare NHS Foundation Trust Northumbria Healthcare NHS Foundation Trust has some of the most satisfied staff and patients in England and firmly believes the two must go hand in hand for a healthy organisational culture. Staff are listened to, empowered to instigate change and own quality improvements with support from the very top of the organisation. The Trust recruits staff based on values, attitudes and behaviours, as well as skills and expertise, and invests heavily in nurturing its staff – which means leaders are born at all levels of the organisation, rather than relying on old fashioned hierarchies. The Trust was one of the first in England to appoint a Director of Patient Experience at Board level and they run an award winning patient experience programme. Feedback from patients is shared openly within 24 hours of receipt – not to judge or criticise – but to initiate change and encourage teams to lead improvements and foster a positive mindset to make things even better. Every month, a patient and their family come and tell their story at start of the Trust’s board meeting. The Chief Executive regularly takes part in shadowing frontline staff, in different settings, to hear first hand feedback from staff and patients. The Trust has a feedback channel for staff, patients, visitors and members of the public to actively encourage ideas for quality improvement, with feedback on improvements and changes implemented shared widely. For more information please see: www.northumbria.nhs.uk/patients-and-visitors/what our-patients-say citizens and communities. It will gather that timely, easy-to-review feedback on NHS evidence of needs, views, aspirations and services becomes the norm. experiences in relation to health and care 2.49 A key aim of the NHS Commissioning from citizens and communities to inform its Board, working with commissioners and work and to understand how effectively the providers, is to ensure that all NHS funded system is delivering improvements to health patients will have the opportunity to leave and care. feedback in real time on any service by 2015, starting with the roll-out of the Friends Patient and Staff Feedback and Family Test from April 2013. This is reflected through a new pledge in the 2.48 The Government is committed to NHS Constitution: “The NHS commits to improving patients’ experiences of NHS encourage and welcome feedback on your services and only by listening and responding health and care experiences and use this to to the views of patients, their families and improve services.” carers will the NHS know that it is delivering 2.50 Every patient and member of staff high quality care in the eyes of patients and will, in the future, be able to say whether the public. This will mean making it easier for they would recommend their hospital to their patients and carers to give feedback on their friends or family through the Friends and care and see reviews by other people, so 52 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Family Test. The Friends and Family Test is a complaints and concerns raised by patients, simple and comparable tool that can provide service users, families and carers. Complaints a mechanism to identify poor performance can be an early symptom of a problem early. Alongside the results of patient surveys within an organisation. We need to make and feedback through complaints, it will help the complaints procedure much easier. As to improve services based on what patients Robert Francis highlights: “Complaints, their and staff say. From April 2013, all providers source, their handling and their outcome of NHS Accident and Emergency and acute provide an insight into the effectiveness of inpatient services will collect from patients, at an organisation’s ability to uphold both the discharge or up to 48 hours later, information fundamental standards and the culture of on how likely they are to recommend the caring. They are a source of information provider’s services to their friends and family. that has hitherto been undervalued as a From October 2013, the test will be rolled out source of accountability and a basis for to women who have used maternity services, improvement. Learning from complaints must and the NHS Commissioning Board will be effectively identified, disseminated and continue to work with providers to determine implemented, and it must be made known how the test can be rolled out further. to the complainant and the public, subject to 2.51 The NHS staff survey also provides suitable anonymisation”. important information about organisations’ 2.54 The Department has established an health. It asks whether staff would independent review to consider the handling recommend their place of work to a family of concerns and complaints including relevant member or friend as a high-quality place to recommendations from Robert Francis’ receive treatment and care, equivalent to report. This Review will report in the summer. the ‘Friends and Family Test’. However, staff The Review is being led jointly by the Rt. are only asked this question annually, and Hon. Ann Clwyd, MP for Cynon Valley, and the NHS Commissioning Board will work to Professor Tricia Hart, Chief Executive of ensure that much more regular staff feedback South Tees Hospitals NHS Foundation Trust. on the ‘Friends and Family Test’ becomes the It will consider how patients, their carers and norm. families are listened to, how what they say is acted upon, and will identify key components 2.52 The feedback patients provide can also of good practice and how to improve its help doctors understand what they do well adoption. It will also look at how complainants and where they can develop their professional can be supported more effectively during the skills. Revalidation now requires all doctors complaints process through, for example, to take part in an independently administered advice, mediation and advocacy; and include feedback questionnaire from both colleagues the handling of concerns raised by staff, and patients. With their appraiser, doctors will including the support of whistleblowers. need to review and reflect on this feedback, It will review the role of trusts’ boards and as well as any additional complaints and senior managers in developing a culture that compliments they have received from patients takes the concerns of individuals seriously. and relatives. In carrying out its work, the Review will Complaints engage with patients and their carers and representatives, staff and managers to hear 2.53 The system must learn and improve and understand their experience of the way from general feedback and from any Chapter Two – DetectingItem: 6Problems Enc: 04Quickly 53
concerns and complaints are managed and local Healthwatch network. This training acted on. will support both the leadership of local 2.55 Where complaints cannot be resolved Healthwatch organisations, and volunteers satisfactorily by a trust, they may be referred and others who might get involved in the to the Parliamentary and Health Service work of local Healthwatch. Ombudsman. The Ombudsman is changing 2.58 Local Healthwatch organisations will the way it works to start investigations be established in upper-tier and unitary local sooner and complete them more quickly. The authority areas in England from 1 April 2013. Ombudsman will publish summaries of all A key role of local Healthwatch organisations investigations to publicise both good and bad will be to promote the local consumer voice practice, so that the public can make better to ensure that the views of patients, service informed choices about their care. It will users and the public are fed into improving focus on identifying systemic issues arising local health and care services. The primary from individual and clusters of complaints task of local Healthwatch organisations will and publish more thematic case reports to be to gather evidence from the views and highlight big or repeated complaints and to experiences of patients, service users, carers build confidence in the value of complaints. and the public about their local health and It will make it easier for people to complain care services and to provide feedback based to them and will work with regulators to drive on that evidence. better information sharing about complaints 2.59 Local Healthwatch will be able to ‘enter to gain earlier insight into concerns about and view’ local health and care services to quality. observe how effective those services are Healthwatch to help them gather a rounded picture of how services could or should be improved. 2.56 The creation of Healthwatch will be Healthwatch England will be providing a key part of ensuring that the voice of the training to local Healthwatch organisations to patient is listened to within the new system. support them to use effectively their ability to Healthwatch England works at the national ‘enter and view’ health and care services in level providing leadership, support and advice order to observe activities carried out there to the local Healthwatch network. It will use and provide recommendations or escalate evidence based experiences to highlight concerns. national issues and trends to influence 2.60 It is important that local Healthwatch national policy. Through the network and by organisations are diverse and inclusive of receiving views directly, Healthwatch England local people and communities. There is will ensure that the voices of people who use potential for all different types and levels health and social care services are heard by of involvement of local people within local the Secretary of State for Health, the Care Healthwatch organisations. Quality Commission, the NHS Commissioning Board, Monitor and local authorities in 2.61 Local Healthwatch organisations will England. build on the knowledge and experience of existing Local Involvement Networks (LINks), 2.57 Healthwatch England will deliver a so ensuring continuity, and will reach out into full offer of training and guidance over the parts of the community that do not currently next financial year to ensure and support have a voice. Robert Francis heard a lot of the development of a vibrant and effective evidence about the experiences of Patient 54 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
and Public Involvement Forums (PPIFs) and LINks (predecessors to local Healthwatch) in Stafford. He has set out a number of recommendations based on the evidence he heard and we are considering how best to address these. 2.62 In care and support, we will take forward the Caring for Our Future White Paper14 commitment to test out different approaches to make care homes more open to their local communities by encouraging different forms of lay visiting and also supporting visitors to know how to link to their local Healthwatch where they have concerns.
Sharing Information
2.63 As the Inquiry highlighted, the effective collection, analysis and dissemination of relevant information is essential for swift identification and prevention of substandard service, facilitating accountability, provision of accessible and relevant information to the public, and supporting patient choice of treatment. 2.64 The Chief Inspector needs to be able to consider data from a range of sources quickly to identify issues or trends that could indicate risks to quality. The Care Quality Commission needs to be alert to the signals from data and qualitative feedback, including from staff and patients, service users, their families and carers. Important early warning signs include intelligence from complaints and comments, and patient and staff surveys where changes to key scores can be an indicator that services are deteriorating. Differences between various parts of a hospital can also provide insights into which wards may be providing a lower quality of care for their patients. Chapter ThreeItem: – Taking 6 Action Enc: Promptly 04 55
Chapter Three – Taking Action Promptly
Summary
The Care Quality Commission, working with the National Institute for Health and Clinical Excellence (NICE), commissioners, patients and the public, will draw up a new set of simpler fundamental standards which make explicit the basic standards beneath which care should never fall. This will be in language that both the public and professionals can easily understand. In the past, when poor care was detected, it has too often been put in a “too difficult” pile. Patients have been left with no one acting with urgency on their behalf to ensure a decent standard of care. This inaction will stop. Freed up from the conflict of having to resolve poor hospital care through delegating Care Quality Commission enforcement powers to Monitor and the NHS Trust Development Authority, the Chief Inspector will identify poor care in public, and issue a call to action to the hospital itself and the regulators responsible for their oversight. A new time-limited three stage failure regime, encompassing not just finance, but for the first time quality, will ensure that where fundamental standards of care are being breached, firm action is taken until they are properly and promptly resolved. In the first stage, the Chief Inspector will require the hospital board with its commissioners to improve within a fixed time period, but it will not be responsible for making it happen. In the second stage, if the hospital with its commissioners is unable to resolve its own problems, then Monitor or the NHS Trust Development Authority would step in to take action. In the final stage, where fundamental problems in the hospital mean that its problems cannot be resolved, the Chief Inspector will initiate a failure regime in which the Board is suspended or the hospital is put into administration.
Fundamental Standards Already the system rightly has a focus on ‘never events’ – the errors that should never 3.1 A key recommendation from Robert happen. These fundamental standards Francis’ report related to setting fundamental represent the basic requirements that should standards. We accept this recommendation. be the core of a quality services and they These standards will help to set the context need to have a similar status to ‘never’ for delivering compassionate, safe care. events. 56 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
3.2 As Robert Francis recommended, • Safe: such as avoiding pressure ulcers, these standards must be developed MRSA, wrong site surgery, medication with public involvement and consultation errors with staff. Department of Health will • Responsive: such as waiting times, start work immediately with the Care A&E waits and ease of access for Quality Commission, Monitor, NHS appointments Trust Development Agency, the NHS Commissioning Board and NICE and then • Effective: such as mortality rates, consult with the public to develop a small complications and readmissions; number of fundamental standards focusing recovery rates; management of long term on key areas of patient care. The Chief conditions Inspector will use these standards, and • Well led: such as visible leadership, the evidence from inspections, to make organisational culture, helpful staff, judgements about the quality of a hospital’s openness and transparency. services. 3.5 As Robert Francis envisaged, the 3.3 We will incorporate fundamental fundamental standards will be complemented standards into the Care Quality Commission’s by enhanced and developmental standards. registration system, which provides the To implement this approach, NICE will extend independent assessment of quality. The the scope of its quality standard programme standards are likely to include things like: to provide guidance on known good practice • People are getting the medicines they in providing excellent care. have been prescribed at the right time and the right dose, including appropriate Time Limited Failure Regime for pain relief; Quality as Well as Finance • People are getting food and water, and help to eat and drink if they need it; 3.6 A critical finding from Robert • People are being helped when they need Francis’ report was the significant failures it to go to the lavatory and not left in wet of accountability and transparency in the or soiled clothing or beds; role of system managers and regulators. He found that their focus was directed at • People are being asked to consent to financial and organisational issues rather treatment and all staff communicate with than the protection of patients and ensuring patients effectively about their care and that patient safety and quality standards treatment; and were being observed. He attributed this to • The environment is clean and hygienic. poor communication, misaligned methods 3.4 The fundamental standards, together of assessment, and an over-reliance on with other important aspects on which assurances given by other organisations. A inspections will focus, will sit within some of key recommendation was that there should the five areas below: be a ‘single regulator dealing with both corporate governance, financial competence, • Caring: such as dignity, compassion, or viability and compliance with patient safety pain relief and quality standards for all trusts’. 3.7 Since 2009, Monitor and the Care Quality Commission have worked to develop Chapter ThreeItem: – Taking 6 Action Enc: Promptly 04 57
a better working relationship and improve the regime we will consider the recommendations coordination of their regulatory activities. This from the NHS Confederation’s Review of was strengthened by the Health and Social Bureaucratic Burdens outlined earlier in this Care Act 2012, which makes Monitor and the document. Care Quality Commission subject to stronger 3.11 The single failure regime will deliver duties of cooperation and requires them to a clear and co-coordinated regulatory operate a joint application process for the approach to identifying and tackling failures Care Quality Commission registration and a of quality. There will be three elements to the Monitor licence. However, the public still lacks proposed failure regime: clarity over who in the regulatory system will take action when there are serious failures of • It is essential that there is a common care in hospitals. understanding of provider performance amongst regulatory bodies and 3.8 The Government agrees that commissioners – a ‘single version of regulators and commissioners should ensure the truth’. There will be a single rating they have a shared picture of provider of providers led by the Chief Inspector performance, and that there should be of Hospitals at the Care Quality greater transparency in identifying those that Commission which draws on information are failing to meet fundamental standards. In and assessments from Monitor and addition, the Government agrees that better the NHS Trust Development Authority communication and greater co-ordination on finance. The Chief Inspector of is required between the Care Quality Hospitals will champion excellent Commission and Monitor. care. The regulatory bodies and the 3.9 We believe there continues to be a NHS Commissioning Board will agree strong case for maintaining the Care Quality a single national definition of quality, Commission and Monitor as separate consistent with the Mandate and the organisations fulfilling distinctly different NHS Outcomes Framework. This agreed functions. Assessing quality and highlighting quality framework will include consistent failures of care should not be conflated use of data to support assessment. with the responsibility for overseeing the The application of the national method turnaround of failing NHS providers. So, will take account of the need to reflect, rather than merging the responsibilities of and not crowd out, local commissioner the regulators, we will deliver Robert Francis’ priorities. The Care Quality Commission vision through a single failure regime that will have an increasingly prominent role in will place the same emphasis on addressing Quality Surveillance Groups in assessing failures in quality of care as there is on the quality of providers. financial failure. • Where quality is poor, the Chief Inspector 3.10 In delivering this regime, the Care will require the board of the provider with Quality Commission, Monitor and the NHS its commissioners to improve, within Trust Development Authority will work closely a fixed period. But the Care Quality with each other and with commissioners, Commission will not then be responsible who will have a role in driving improvement for making it happen. The principle and service change. We are mindful that this that responsibility for dealing with the approach should not increase the overall level problem lies with the provider, rather than of regulatory burden, and in developing the external bodies, will not change. If the 58 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
provider is unable to resolve the situation We have made quality improvement a in partnership with commissioners, and statutory duty for commissioners. In the case problems persist, Monitor or the NHS of Mid Staffordshire NHS Foundation Trust, Trust Development Authority would step the pursuit of foundation trust status became in, potentially following a request from the a distraction from this goal. Acquiring the Chief Inspector. Monitor and the NTDA badge of foundation trust status became an retain their current ability to intervene at end in its own right and patient care suffered their discretion if urgent regulatory action as a result. Moreover, the foundation trust is required. The same level of intervention assessment process at that time paid too will be possible in response to quality little attention to the quality of care, meaning failings as for finance and governance Mid Staffordshire NHS Foundation Trust’s failings. tragic loss of focus was not challenged. We • In some cases, however, it may are determined to ensure these mistakes become clear that more fundamental cannot happen again. issues prevent an NHS foundation 3.14 Robert Francis argued for a single trust or NHS trust from making the regulator, the Care Quality Commission, necessary improvements in quality of taking on responsibility for foundation trust care. For these rare cases of clinically authorisation. We agree that the delivery unsustainable providers, we will ensure of good quality and safe care should be a there is a suitable mechanism to ensure central requirement on any trust wishing to that the local population can access a attain foundation trust status, but we do not comprehensive range of safe, sustainable think that the foundation trust authorisation health services. role should rest with the Care Quality 3.12 In care and support, we similarly Commission. We think it should remain with need a single and consistent approach to Monitor. Through changes to the processes failure that can give people the confidence undertaken by Monitor, much has already that quality failings will not be tolerated. been done to ensure that the foundation The Government has recently consulted trust assessment process now has quality of on a new approach to overseeing financial care at its heart. This includes a clearer role performance and managing financial for the Care Quality Commission. Monitor failure in the care and support market. The will not authorise a trust as a foundation Government will set out its detailed plans trust unless the Care Quality Commission shortly. The new Chief Inspector of Social indicates that they are content that the trust Care will have an important role in ensuring is compliant with basic standards of care. that judgements about the quality of care is a Furthermore, with the creation of the new central consideration, in any new future failure NHS Trust Development Authority, there system for providers of social care. is an opportunity to strengthen further the focus on quality in the way that NHS trusts are overseen and prepared for foundation Foundation Trust Status trust status. The NHS Trust Development Authority will have a clear focus on improving 3.13 Robert Francis’ report makes clear that the quality of care in NHS trusts and the first priority for all provider organisations, ensuring that only high quality providers are and for the bodies that oversee them, should considered for foundation trust status, in line be to secure high quality services for patients. Chapter ThreeItem: – Taking 6 Action Enc: Promptly 04 59
with the recommendations in Robert Francis’ report. 3.15 The NHS Trust Development Authority will set out initial plans to address the recommendations that it is leading on, including some of those relating to the foundation trust application process and the approach to oversight and performance management of providers, through its Accountability Framework for NHS Trust Boards, which will operate from April 2013. 3.16 The Government’s ambition is clear. We want NHS trusts to improve the quality and sustainability of services as quickly as possible. It is vital that the focus on improving quality cannot be compromised by a focus on the pursuit of foundation trust status for its own sake. So where time is needed to make the necessary improvement, it is important that the process is not rushed and that risks to patient care are not created. 3.17 The 2014 deadline for reaching foundation trust status has done much to galvanise the NHS trust sector and drive improvement. However, in light of Robert Francis’ report, we have allowed the NHS Trust Development Authority to agree trajectories for NHS trusts to reach foundation trust status that go beyond 2014 on a case by case basis. In so doing, we will ensure that the primary focus of the NHS Trust Development Authority and of NHS trusts themselves is on improving the quality and sustainability of services for patients. 60 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04 Chapter Four – EnsuringItem: Robust 6 Enc:Accountability 04 61
Chapter Four – Ensuring Robust Accountability
Summary
Where the Chief Inspector identifies criminally negligent practice in hospitals, he or she will refer the matter to the Health and Safety Executive to consider whether criminal prosecution of individuals or boards is necessary. The General Medical Council, Nursing and Midwifery Council and the other professional regulators are hampered by an outdated legislative framework that is too slow and reactive in tackling poor care by individual professionals. As part of the implementation of the Law Commission’s review, we will radically overhaul 150 years of complex legislation into a single Act that ensures much faster and more proactive action on individual professional failings. To deal with the small numbers of managers who let their patients and the NHS down, and prevent them from moving to new jobs in the NHS, we will introduce a national barring list for unfit managers, based on the barring scheme for teachers. The Chief Inspector of Hospitals will assure, as part of inspections, that all hospitals are meeting their legal obligations to ensure that unsuitable healthcare assistants are barred from future patient care by properly and consistently applying the Home Office’s barring regime. It is primarily for providers and commissioners to identify and resolve problems, working together for the patients that they serve. But at a national level, these proposals will resolve the confusion of roles and responsibilities in the system, so it is clear where the buck stops on poor care. The Chief Inspector will identify failing standards. Monitor and the NHS Trust Development Authority will resolve them. The Department of Health will act as the patients’ champion in the system to ensure that everyone plays their part on patients’ behalf.
Introduction desirability of criminal sanctions for individual members of staff below board level in the 4.1 Clear accountability for boards light of the Berwick Review and potential and organisations is essential so that they enhancements to professional regulation, understand their responsibilities to patients. it agrees that there needs to be stronger Whilst the Government will assess the accountability for boards. 62 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Health and Safety Executive to regulatory purpose and has built in public protection at the centre of what they do. use Criminal Sanctions Since 2009 the Nursing and Midwifery Council has: 4.2 If the Chief Inspector finds a potential breach of health and safety requirements, • published new standards for pre the Care Quality Commission would refer registration nursing education in 2010 the matter immediately to the Health and which place significant emphasis on care Safety Executive, which in serious cases and compassion of patients; could use its existing powers to prosecute. • introduced a helpline for directors of The Department of Health will work with the nursing as the first point of contact to Department for Work and Pensions and the discuss fitness to practise issues; Health and Safety Executive to ensure that the Health and Safety Executive has the • run employer’s roadshows and events to necessary capacity to act. raise profile amongst employers; • developed a new case management tool Faster and Proactive Professional to encourage early resolution of cases and a new voluntary removal process; Regulation • developed greater transparency by 4.3 Robert Francis made a number of ensuring details of nurses and midwives recommendations directed at the professional who have been struck off or suspended regulators for doctors and nurses: the in the last five years are visible through General Medical Council and the Nursing and searching our online register; and Midwifery Council, in particular to ensure they • begun work on an appropriate model act quickly on concerns, share information of revalidation, to ensure continuing with other regulators more proactively and fitness to practise, of nurses could be put greater emphasis on protecting patients introduced. and the public. These principles affect all 4.6 More recently the Nursing and professional regulators. Midwifery Council has embarked on a 4.4 The General Medical Council and the programme of work to respond to Robert Nursing and Midwifery Council, together with Francis’ specific recommendations, other professional regulators, will consider considering how they can raise their public these recommendations further before profile, ensure resources are effectively making a fuller response. However, both targeted, improve joint-working arrangements regulators are already taking further action to with other professional and systems act more quickly to address concerns raised regulators and review their education and with them about the fitness to practice of professional standards. individual clinicians. They are also engaging 4.7 The General Medical Council is more actively with other parts of the system, engaged in programmes of work to: in sharing and using information, for example through the National Quality Board’s Quality • embed revalidation for doctors; Surveillance Groups. • change its relationship with doctors and 4.5 For example, the Nursing and patients; Midwifery Council has refocused its core • develop a stronger local presence; Chapter Four – EnsuringItem: Robust 6 Enc:Accountability 04 63
• support doctors at all stages of their Regulatory Excellence (now the Professional careers; Standards Authority) also raised concerns • provide leadership and guidance to the in relation to the Nursing and Midwifery profession; Council in its report, Strategic Review of the Nursing and Midwifery Council, July • work with others and share data; 2012.15 The legal framework relating to the • reform fitness to practice procedures, regulation of healthcare professionals, and for example with the introduction of the in England social workers, is currently under Medical Practitioners Tribunal Service in review by the Law Commission. The Law 2012; and Commission has issued a consultation paper making provisional proposals that seek to • in cooperation with Government, develop simplify and modernise the law and establish further language controls in relation to a streamlined, transparent and responsive foreign doctors. system of regulation. Amongst other things, 4.8 Robert Francis’ report marks a period the review will consider legislation on the of increased scrutiny for the professional investigation and adjudication of fitness to regulators. The former Council for Healthcare practise cases.
The Teaching Agency – Example of a Barring Scheme The agency supports the quality and status of the teaching profession by ensuring that in cases of serious professional misconduct, teachers can be barred from teaching. The regulatory function includes all teachers and instructors in all maintained schools, non-maintained special schools, academies and free schools, sixth-form colleges, independent schools and relevant youth accommodation and children’s homes in England. To this end, the agency: • screens and sifts all cases of serious professional teacher misconduct referred to the Secretary of State to determine whether the case should be formally investigated; • investigates cases and, where appropriate, passes to a Professional Conduct Panel hearing, which will recommend to the Secretary of State whether a prohibition order is appropriate; • puts interim prohibition orders in place where there are extremely serious allegations that can be substantiated; • organises and administers Professional Conduct Panels; • administers and manages the list of prohibited teachers; • compiles and evaluates evidence, seeking expert advice (legal, medical etc) as appropriate; • liaises and shares information as appropriate with devolved administration GTCs, the police, other regulators and the Disclosure and Barring Service (DBS); and • organises and considers cases of whether a prohibition order should be set aside. 64 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Directors and Senior Leaders arrangements will continue to apply, the Government is concerned to ensure that 4.9 Good leadership is critical to ensuring severance payments for senior managers that patients receive excellent care from well- should be proportionate. We are considering supported and well-motivated staff, working the options and will make an announcement in a culture focussed on patients’ needs. shortly on these matters. Chapter Five sets out how we will help ensure 4.12 The Department will also discuss the NHS can recruit and develop its leaders with the profession whether an assured – from within the NHS, from the clinical voluntary register would help give effect to the professions and from outside the health and Professional Standards Authority’s recently care system. The Inquiry also identified the published standards and code of conduct for need to ensure that, for the small number senior NHS leaders. of leaders who let down their patients, their staff and the NHS, there is a mechanism in 4.13 In the meantime, Monitor, the Care place which prevents unsuitable board level Quality Commission and the NHS Trust executives and non-executives from moving Development Authority will be developing to new senior positions elsewhere in the proposals on a fit and proper person test for system. board level directors, covering basic issues such as bankruptcy and criminal convictions. 4.10 The Government agrees and will establish a barring mechanism to ensure that individuals whose conduct or competence Barring System for Healthcare makes them unsuitable for these vital roles Assistants Enforced by Chief are prevented from securing them. However, Inspectors such a scheme needs to be developed very carefully so that it enhances professional 4.14 The Chief Inspectors will assure, as esteem for the vast majority of senior leaders part of inspections, that all hospitals and care and does not discourage capable and homes are meeting their legal obligations to experienced individuals from serving in both ensure that unsuitable health and social care executive and non-executive roles. Whilst assistants are barred from future care by patients and the public will want to have properly and consistently applying the Home confidence that the mechanism is robust, Office’s barring regime. equally senior leaders will need to be assured that it is fair, independent and has effective safeguards. The Department of Health will Clear Responsibilities for Tackling work with staff representatives, patients and Failure the public to draw up consultation proposals to meet these aims and seek to legislate 4.15 At a national level, these proposals when time is available for Parliament to will resolve the confusion of roles and consider the Law Commission’s proposals responsibilities in the system, so it is clear on professional regulation. We will consult on where the buck stops on poor care when whether the scheme should extend beyond commissioners and providers are unable to board level to other managers. do so quickly. The Chief Inspector will identify 4.11 While for redundancy payments, failing standards. Monitor and the NHS Trust normal statutory and contractual Development Authority will resolve them. The NHS Commissioning Board will support Chapter Four – EnsuringItem: Robust 6 Enc:Accountability 04 65
Disclosure and Barring Service The Disclosure and Barring Service (DBS) took over the functions of the Criminal Records Bureau and the Independent Safeguarding Authority in December 2012, and issues criminal records certificates and makes independent decisions about who should be placed on the barred lists. http://www.homeoffice.gov.uk/agencies-public-bodies/dbs/ There is a legal duty for providers, including NHS organisations, care homes and domiciliary care agencies, to refer people to the DBS. They must refer if they think a member of staff or volunteer has harmed, or poses a risk of harm to service users and, because of that risk, they have stopped them providing care. Making these referrals will ensure that people who are barred because they pose an ongoing risk to service users are prevented from moving from one provider to another. In addition to the legal duty to refer, it is an offence to knowingly employ people who are barred from certain activities, and organisations can apply to the DBS for an enhanced DBS disclosure with barred list check to ensure they are not doing so. The activities are: • healthcare • personal care • social work • assistance with cash bills or shopping because a person needs that assistance because of their age, illness or disability • assistance with the conduct of an adult’s own affairs, including powers of attorney • transport for adults in certain circumstances.
Clinical Commissioning Groups in improving commissioning. The Department of Health will ensure that everyone plays their part on patients’ behalf. 66 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04 Chapter Five – Ensuring Staff areItem: Trained 6 Enc:and Motivated 04 67
Chapter Five – Ensuring Staff are Trained and Motivated
Summary
Starting with pilots, every student who seeks NHS funding for nursing degrees should first serve up to a year as a healthcare assistant, to promote frontline caring experience and values, as well as academic strength. Building on the historic introduction of medical revalidation, which offers proactive assurance of individual doctors, when the Nursing and Midwifery Council turns around its current poor performance, we will introduce a national scheme for already qualified nurses to ensure all nurses are up to date and fit to practise. Camilla Cavendish is reviewing how best to ensure healthcare and care assistants can provide safe and compassionate care to patients. We are today publishing standards of conduct and training for all care assistants. The Chief Inspectors will ensure that all employers are meeting their requirements to ensure that all healthcare and care assistants are properly trained and inducted before they care for people.
The NHS Leadership Academy, in addition to its existing work to ensure that top leaders have the right skills and the right values, will initiate a major programme to ensure new talent from the clinical professions and from outside the NHS is drawn into top leadership positions. Working with world class universities, we will develop a fast track programme for Chief Executives to attract the brightest and best to top NHS jobs. At the centre of the system, the Department of Health, with its new role as champion of the patient, will need to reconnect radically with the patients it serves. By 2016 every Department of Health civil servant will have real and extensive frontline experience of caring for patients and will bring this essential experience to their policy advisory role and to the Department’s stewardship of the health and care system.
Treating staff well be aspiring to excellence in recruitment, induction, training and appraisals for all 5.1 Organisations need to have a clear staff and tackle any inconsistencies in good aspiration to create the right conditions practice. There is already good evidence to that enable their staff to deliver high quality, show organisations that treat their staff well effective and compassionate care. Across deliver better outcomes for patients16, 17. health and social care, organisations should 68 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Staffing Levels 5.4 Local NHS organisations are best placed to take responsibility for the skill mix 5.2 Staff need capability and capacity of their workforce because they are best to do their job properly – clarity about roles placed to assess the health needs of their and responsibilities, team structures, team local health community and must have the working and cooperation. Key to enabling freedom to deploy staff in ways appropriate staff to deliver high quality care is ensuring we for local conditions. We support Robert have the right staff, with the right values, skills Francis’ call for evidence-based guidance and training available in the right numbers to and tools to inform decisions made by local support the delivery of excellent care. This professional leaders on appropriate staffing depends on the needs of patients on each levels for high quality and we will work with ward at any time. NICE, the Care Quality Commission and the NHS Commissioning Board on this 5.3 Right staffing in terms of numbers recommendation. and skills is vital for good care, but minimum staffing numbers and ratios risk leading to a 5.5 The Care Quality Commission will lack of flexibility or organisations seeking to require that evidence-based tools are used achieve staffing levels only at the minimum to determine staffing numbers. Compassion level. However adequate staffing levels are in Practice2 recommends that the trust board essential to provide proper care and the receives, publishes and endorses information new Chief Inspector will have a clear remit to on staffing at least twice a year. inspect staffing levels and report if they are 5.6 The majority of hospitals have inappropriate. introduced hour by hour nursing rounds on
Compassion in Practice – “The 6Cs” Care, Compassion, Competence, Communication, Courage and Commitment. Compassion in Practice (the nursing, midwifery and care staff vision and strategy for England) was launched in December 2012 at the Chief Nursing Officer’s Conference. Compassion in Practice was developed with nurses, midwives and care staff up and down the country. There was an eight week engagement period prior to the launch of Compassion in Practice when spoke to over 9,000 people including nurses, midwives, care staff, patients, people we care for and stakeholders. We also used social media to engage people in the 6Cs and had over three million twitter impressions. As well as the clear focus on the 6Cs, Compassion in Practice sets out six areas of action to concentrate our effort and create impact for our patients and the people we support. These six areas of action will be delivered together as one programme to achieve the values and behaviours of the 6Cs. Over the last three months nurses, midwives and care staff, as well as stakeholders at national and organisational level, have developed implementation plans to support the delivery of the values and behaviours of the 6Cs. To find out more and to see the implementation plans visit: www.commissioningboard. nhs.uk/nursingvision Chapter Five – Ensuring Staff areItem: Trained 6 Enc:and Motivated 04 69
The Nursing and Care Quality Forum In January 2012, the Prime Minister created the Nursing and Care Quality Forum, bringing together patients, voluntary organisations, front line staff and leaders in the field, asking them to take on a national leadership role in promoting excellent care and ensuring good practice is adopted across the NHS and social care. The Forum has been active in highlighting the issues which need to be addressed in improving care on the national level. They have promoted the use of technology to reduce bureaucracy, emphasised the need for better leadership and recruiting health and care staff based on their values. their wards. The forthcoming Compassion in them to input patient observations at the Practice action plans will urge the remaining bedside or point of care and for community hospitals to do so within a year. nurses to input data when they are away from their base. The Fund will be available Making Time to Care during 2013/14 and 2014/15. Following further consultation with internal and external 5.7 A key to improving working lives for stakeholders, further details on the roll out of staff is to reduce the volume of paperwork the Fund will be released at the start of the they are required to fill in so that they can new Financial Year. focus the vast majority of their time on their patients. Over the next ten years, technology Rewarding High Quality Care will transform the experiences of staff enabling them to spend more time caring for 5.9 We know that high performing staff people. can improve the outcome for patients. It is 5.8 In addition to the measures already therefore right that we recognise this in the described in Chapter 1 to tackle bureaucracy, way we reward staff. Pay progression should the NHS Commissioning Board has be more closely linked to performance and committed to supporting commissioners to delivering high quality patient care. We will provide staff with digital technology that helps strongly encourage employers to use the full them manage health and care work and to flexibilities in existing pay contracts so that support a move to paperless referrals in the pay progression is linked to quality of care, NHS by March 2015. In October 2012, the not time served. Government announced the establishment 5.10 NHS Employers will support this by of a £100m technology fund to help equip working with the service on new model nurses and midwives with latest technologies performance frameworks, which will place designed to help them to provide safer, more greater emphasis on the quality of care, effective and more efficient care to patients including the important NHS values of and service users. The types of technologies compassion, dignity and respect. this fund will help the NHS to embrace 5.11 We will also ensure that medical pay include digital pens for use in many different rewards current excellence, rather than settings and mobile or handheld devices historical performance. for hospital based nurses which will allow 70 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
South Warwickshire – Restorative supervision Restorative supervision was designed to address the emotional demands of nursing and health visiting staff, supporting them to build resilience and reduce their own stress and burnout levels. It is a sustainable, low-cost model: staff meet with a trained supervisor for a series of six sessions. Research has found that restorative supervision increased compassion satisfaction (the pleasure staff derive from doing their job) as well as reducing burnout and stress by over 40%. Sarah, a 45 year-old midwife had worked on an acute ward for 19 years. When she came for her first session of restorative supervision her physical presentation suggested that she was washed out. She looked exhausted and spent a lot of the time within the session sighing heavily and explaining why everything was so difficult and nothing could be done to change things for her. Following the process, she commented: “Today, I felt great – I was prepared to tackle anything that came my way. I remember going back to the office as if it was my first day as a midwife feeling full of energy – thank-you.” To find out more, please see: www.restorativesupervision.org.uk
Listening to Staff based recruitment for all students entering NHS-funded clinical education programmes. 5.12 Ensuring effective staff engagement is This will include testing for values, face also crucial to promoting better outcomes for to-face interviews and scenario testing patients and their care. There is a need for to assess candidate’s attitudes towards mutual value and respect between different caring, compassion and other necessary staff groups and all organisations across professional values. Health Education health and care need to focus on listening to England will also work with NHS Employers staff and enabling them to influence decisions on aptitude tests which can be used more that affect the services and care they deliver. widely. In addition, the Department will Organisations should be actively using discuss with Health Education England information such as the NHS Staff Survey and the nursing profession options to make results to review and improve staff experience it easier for healthcare assistants to train so that staff can provide better care. and qualify as nurses, with their vocational experience counting towards their degree. Recruitment and Training – Health 5.14 Starting with pilots, every student Education England who seeks NHS funding for nursing degrees should first serve up to a year as a healthcare 5.13 Robert Francis recommended that assistant, to promote frontline caring the NHS should recruit and train staff to experience and values, as well as academic demonstrate the right values and behaviours strength. They will also provide students with – and to challenge colleagues who do not – helpful experience for managing healthcare so that we can ensure the quality of care is as assistants when they qualify and enter important as the quality of treatment. Health practice. The scheme will need to be tested Education England will introduce values- and implemented carefully to ensure that it Chapter Five – Ensuring Staff areItem: Trained 6 Enc:and Motivated 04 71
is neutral in terms of costs. Health Education which the Nursing and Midwifery Council will England will work with the Nursing and examine in the light of revaluation proposals. Midwifery Council, professional leaders and 5.18 The Royal College of Nursing has an trade unions in developing the pilots. We will important role in developing and promoting explore whether there is merit in extending the art, science and practice of nursing. The this principle to other NHS trainees. Government believes a clearer distinction between its professional and trade union Revalidation for Nurses roles, both important, would enhance the authority of its work. 5.15 The Nursing and Midwifery Councils’s current focus must be to ensure that the recent improvements in its performance are Nursing Supervisory Ward sustained and that public and professional Managers confidence is restored. When that is secured, the Chief Nursing Officer and the Department 5.19 There is a good body of evidence to of Health’s Director of Nursing will work demonstrate that supervisory roles for Ward with the Nursing and Midwifery Council Managers (including Sister, Charge Nurse in developing an effective and affordable andTeam Leader) are important to delivering approach to revalidation appropriate and oversight to all aspects of care on a ward and proportionate to nursing and midwifery in a community, from cleanliness to allocation professions. Should legislative change be of staff18, 19. Moreover, nurse leadership at required to strengthen the powers of the ward level provided by a Ward Manager is Nursing and Midwifery Council, this would be important to the delivery of safe high-quality taken forward in line with the Government’s care to patients. legislative programme. 5.20 A ‘supervisory’ role is about having 5.16 In the interim, appraisals will be the time to lead, support staff in their clinical strengthened, made more consistent and role and ensure patients are having a good explicitly include values and behaviours. The experience of care. We recognise that many Department will work with health and care ward managers currently have the same services to ensure that the organisation’s caseload as other nurses on the ward, which director or lead for nursing and care lead does not always allow them time to perform this process and act upon the training and the full scope of the supervisory role. support needs identified. 5.21 Having sufficient nurses trained and 5.17 The Department of Health agrees with the capacity to respond to ensure the in principle to the recommendations but delivery of safe, patient focused care is needs to do more work with the Nursing and currently a core standard requirement of the Midwifery Council and other stakeholders Care Quality Commission. Compassion in to consider how the proposed model to Practice commits to ensuring we have the ensure continuing fitness to practise for right staff, with the right skills in the right nurses and midwives can be developed place. This includes supporting leaders to be to work. The concept of the Responsible supervisory, giving them time to lead action Officer for nursing raises issues about the plans by December 2013. role of directors of nursing in trusts or any organisation’s lead for nursing and care, 72 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Supervisory Nurse Ward Managers Wrightington, Wigan and Leigh NHS Foundation Trust found that it is imperative that the Ward Manager role becomes supervisory to clinical practice. In a review of Nursing Establishment (2012), the Trust Board approved the requested uplift in establishment, which equates to the current level of temporary spend, and forecasted outturn of £2.1 million. Within the report, the Trust Board recognised the need to strengthen the role of the Ward/Departmental Manager in driving quality and safety; provide active and visible clinical leadership; provide reassurance for service users and staff in all care settings reflecting the proposed changes announced by the Prime Minister on 6 January 2012. County Durham and Darlington NHS Foundation Trust reported ward sisters spending 80% of their time on supervising wards and 20% delivering care. Recruiting 40 band 5 nurses enabled ward sisters to devote their time to leadership and management roles. The trust approved £800,000 per year to support the establishment and ward manager education and training. Central Manchester University Hospitals NHS Foundation Trust report ward managers spending half their time in a supervisory role and the remainder as part of the direct care- giving team, which means that they can devote their leadership time to budget setting, managing sickness, recruiting and retaining staff, meet patient expectations, reduce complaints and deliver additional duties that are pivotal to good care . Salford Royal NHS Foundation Trust highlighted a number of initiatives that demonstrated an excellent track record with nursing care, including the Nursing Assessment and Accreditation System (NAAS) which enables the ward matron to operate at a higher level of autonomy. Ward matrons have led quality improvements through the SCAPE (safe, clean and personal every time) status, approved by Board of Directors, to deliver 92% patients harm free as measured by the safety thermometer, 78% reduction in C Difficile, 71% reduction in cardiac arrests, 56% reduction in pressure ulcers, and 17% reduction in falls.
Health and Care Support Workers ensuring they have the right processes in place to ensure they have the right staff with 5.22 The idea of compulsory, statutory the right skills to deliver the right care in the regulation can seem an attractive means of right way to patients. ensuring patient safety, yet Rober Francis’ 5.23 Arrangements for induction, training report demonstrates that regulation does and performance managing healthcare not prevent poor care. Regulation is no assistants are uneven between trusts and substitute for a culture of compassion, safe sometimes underdeveloped. Because each delegation and effective supervision. Putting trust implements its own way of induction it is people on a centrally held register does not very difficult to know just how much training guarantee public protection. Rather it is about a healthcare assistant has had before dealing employers, commissioners and providers with patients. This is not acceptable and Chapter Five – Ensuring Staff areItem: Trained 6 Enc:and Motivated 04 73
Proper induction and training for staff to support quality and safety As part of its inspection regime, the Care Quality Commission expects providers to comply with standards of quality and safety. People should be cared for by staff who are properly trained and supervised, have the chance to develop and improve their skills, and are properly qualified and able to do their job. CQC requires providers to be managing quality and safety by employing the right people, staff who are: • competent and have the required qualifications, knowledge, skills and experience to carry out the roles which they have been assigned; • appropriately trained to provide safe and quality care, treatment and support; • appropriately supervised and supported. Building on this Skills for Health and Skills for Care have published a code of conduct and national minimum training standards for healthcare support workers and adult social care workers in England. Those standards of training provide the foundation for safe and effective practice, and should form the basis of the Care Quality Commission’s assessment of training standards for all staff. www.skillsforhealth.org.uk/codeofconductandtrainingstandards this is one of the reasons we asked Camilla healthcare support workers and adult social Cavendish to carry out her review (see later). care workers in England. The Chief Inspector of Hospitals will ensure 5.25 Further work is underway on recruiting, that all hospitals are acting to ensure that all training, support and progression for health healthcare assistants are properly trained and care support workers, including: and inducted before they care for people. The new Chief Inspector for Social Care • An independent review undertaken by will also ensure that all unregulated social Camilla Cavendish to look at how the care support staff have the induction and training and support of healthcare and training they need to meet their employers’ care assistants can be strengthened so registration requirements. that they provide safe and compassionate care to all people using NHS and social 5.24 We have already announced further care services; measures to support health and care support workers, such as the £13 million • The Government’s mandate to Health innovation fund for the training and education Education England which will set an of unregulated health professionals, and objective for the new organisation to the development by Skills for Health and work with employers to improve the Skills for Care in developing minimum capability and training standards of training standards and a code of conduct for the care assistant workforce. Health Education England will develop a strategy 74 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
and implementation plan to achieve this, Mandate to the NHS Commissioning Board, building on the Cavendish review and the and the Outcomes Frameworks for health, work by Skills for Health and Skills for social care and public health. Care on minimum training standards and 5.28 Robert Francis recommended the engaging with other relevant partners; creation of a separate registered older • Care Quality Commission inspections person’s nurse role. However, many older of induction training for health and care people in hospitals are under the care of support workers will enable it to focus its specialist teams (for example orthopaedics energies where it is most effective and or cancer services) and require nurses to most needed. have those specialist skills. Additionally care 5.26 As these work programmes of older people with many conditions and develop, their outputs will further inform the frailty can take place in their own home and Department of Health’s thinking and action care homes as well as in hospitals. Therefore, on how the public protection is ensured instead of setting up this specific role we will most effectively through a workforce that go further. We will strengthen the focus on is appropriately recruited and developed to the complex physical and emotional needs provide care that is dignified, respectful and of frail older people throughout nursing and compassionate. other healthcare training to ensure that older people needing nursing care will benefit from Caring for Older People a nursing workforce that is trained to deal with their needs. 5.27 Caring for older people is core to 5.29 We will work with Health Education the job of many nurses working in wards England, Higher Education Institutions and throughout hospitals and across community the Nursing and Midwifery Council to review settings. Providing high quality care and the content of Registered Nurse Adult support to older people means removing the branch pre registration education to ensure barriers to integration of care services, both all new nurses have skills to work with the national and local, to provide responsive, large numbers of older people in all parts of appropriate, person-centred care. The hospital and beyond. We will also work with Care and Support White Paper contains a Health Education England to develop specific commitment to ‘taking integration further’ post-graduate training for nurses caring for that will start to tackle barriers at a national older people with complex needs and frailty level. The Department of Health will work in care settings. with the NHS Commissioning Board, Health Education England, Monitor, Public 5.30 We are also committed to improving Health England, Skills for Care and Skills for education and training on dementia. A wide Health, the Local Government Association programme of work is underway including and the Association of Directors of Adult work with e-learning for healthcare to Social Services to establish the best ways develop a series of ten e-learning sessions to promote and enable integration of local on dementia for health and social care staff, services and will jointly publish in May a the provision of £2.4m Dementia Workforce common purpose framework. We have also Development Fund to support the completion set out clear obligations in the Health and of accredited qualifications on dementia by Social Care Act 2012 and are reinforcing social care staff, a survey of the dementia these messages in the NHS Constitution, the content of medical school curricula and work with Skills for Care and Skills for Health Chapter Five – Ensuring Staff areItem: Trained 6 Enc:and Motivated 04 75
“Barbara’s Story” – Increasing Awareness of Dementia A quarter of patients in UK hospitals have a dementia many of whom will be older people, and this number is growing. In September 2012 , Eileen Sills, Chief Nurse at Guy’s and St Thomas’ NHS Foundation Trust (GSTT), began a campaign to raise awareness of dementia for staff working in hospitals and in the community. All 12,500 staff will be attending an innovative training session, where staff watch Barbara’s story – a powerful film that was created by GSTT about a woman with dementia, and her experiences during a hospital visit. The video focusses on the care of older people with dementia, although the principles apply to all patients. Initial training sessions have prompted positive feedback from staff. One staff member commented that, “It is a powerful reminder of just how important everyone’s contribution is when it comes to creating a safe and positive environment across the organisation.” This initiative is run in partnership with The Burdett Trust. For more information, please see: www.guysandstthomas.nhs.uk/education-and-training/staff-training/Barbaras-story.aspx to develop Common Core Principles for 5.33 To ensure the system has leaders Supporting People with Dementia. with the right values, behaviours and competencies, we are developing leaders Attracting Professional and and leadership at every level to influence the External Leaders to Senior culture and values of the NHS from ‘ward to board’. The NHS Leadership Academy Management Roles which has already been established can 5.31 There is a wealth of evidence and fulfil Robert Francis’ recommendation for a understanding about what is required to leadership college, working with a range of deliver safe, compassionate, high quality care. academic and private sector partners. The The challenge of translating understanding NHS Leadership Academy’s development into reality is primarily one of leadership. programmes will see a range of NHS staff, including doctors, allied health professionals, 5.32 Cultural change is not something that nurses, midwives, pharmacists and can be undertaken lightly or half-heartedly. healthcare scientists learn to lead their teams, It is one of the hardest things that leaders services and organisations to achieve better, can do, and needs their wholehearted more compassionate patient care. Up to £40 commitment. It is vital that attempts to million will be invested in nurse leadership change culture do not simply focus on at all stages of the nursing career. We will surface-level observable behaviours. ensure that the investment in development of Meaningful change is only possible if deeply general managers includes the importance of ingrained beliefs and assumptions are front-line work with patients. brought into the light and discussed. This is necessarily an uncomfortable process, and 5.34 We want to build the capacity and requires courageous, authentic leadership. diversity of our top leaders and we will ensure that the work of the NHS Leadership 76 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
Academy gives very strong attention to bring a fresh vision and impetus to leadership developing senior clinical leaders, with the in social care. The Forum will bring together right masters-level support to bring them up expertise from the best inspirational leaders to speed with the managerial and business from the private, public and voluntary sectors requirements of leadership. We will invest to develop the transformational leadership in MBA style programmes to ensure that required. The National Skills Academy, clinicians with a talent for leadership are in conjunction with the Department, has supported in becoming the clinical Chief developed a support programme for front Executives of tomorrow. line, registered managers. 5.35 As well as promoting better senior 5.37 The Professional Standards Authority leadership through the NHS Leadership for Health and Social Care in November Academy, we know that highly experienced 2012 published Standards for Members of senior leaders from other sectors want NHS boards and Clinical Commissioning to join the NHS and that the NHS would Bodies Governing Bodies20 that put respect, benefit from their talents. It is crucial to offer compassion and care for patients at the heart them the support they need, allowing them of leadership and good governance in the to understand quickly the complexities NHS. This for the first time brings together of delivering high quality compassionate the essential skills that are expected of all healthcare as they blend their expert NHS executive and non–executive leaders knowledge, skill and experience from other providing the basis for individuals to take sectors with those in the NHS. We will responsibility for their own behaviour and develop a programme that will enable these challenge the behaviour of others. leaders to enter the NHS more easily through 5.38 Many of the measures set out in this a fast-track programme which will combine document make significant changes to the the very best of healthcare know-how with development and oversight arrangements knowledge and support from prestigious for senior managers. In taking each measure academic institutions. Key components forward, we will have in mind the cumulative will include working with patients and staff impact on non-executive leaders, and will from across health and social care settings, seek to ensure that the arrangements enable support for managing change and bringing the NHS to attract and retain high quality innovation to healthcare delivery. non-executives from all walks of life. 5.36 The National Skills Academy for 5.39 We are transforming nursing, building Social Care and the Department are working and strengthening leadership at every together to improve the quality of leadership level of the health and social care system. in adult social care. The Department of Through implementation of Compassion in Health launched the Social Care Leadership Practice, this includes creating a system of Qualities Framework in October 2012 to accreditation for leaders in nursing, reviewing help drive high quality, integrated care. the role and function of Directors of Nursing, The National Skills Academy is developing and appointing more former nurses as non- assessment tools that can be used in executive directors. A network of caremakers, conjunction with the Framework that will who are students and newly qualified nurses help manager’s identify where they can and midwives, will promote the values of the improve. The Department is also setting up a “6Cs” and Compassion in Practice. Leadership Forum, chaired by the Minister of State for Care and Support, that will seek to Chapter Five – Ensuring Staff areItem: Trained 6 Enc:and Motivated 04 77
Frontline Experience for Department of Health Staff – Culture Change Within The Department of Health and Across the System
5.40 The need for cultural change applies equally to the Department of Health and other national bodies across the health and care systems. The behaviour of the Department has an important impact on the culture of the health and care system. We need to inspire everyone within the Department to model the same caring values and behaviours that we seek to foster across the wider system. This means ensuring that we build a healthy, open organisational culture within the Department and beyond. 5.41 The Department is reflecting on how to respond to this challenge. We understand that a sustained programme of organisational development is needed, with authentic commitment from senior leadership. At the same time, there are things we are doing right now to kick start change. We are considering how to ensure that clinical advice is at the heart of the Department’s work. As recommended by Robert Francis, we are developing a structured programme of activities to help Department of Health staff reconnect to frontline staff and service users. Within four years, every civil servant in the Department will have sustained and meaningful experience of the frontline with the Senior Civil Service and Ministers leading the way. 78 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04 Item: 6 Enc:Conclusion 04 79
Conclusion
The measures set out in this document represents the Government’s initial response to the key elements of Robert Francis’ recommendations. Over the coming months and year we will consider the recommendations further and set out our intentions. The Department of Health will be consulting on many of the measures set out here to ensure that in their detailed design and implementation they continue to reflect the spirit of the Inquiry, putting patients first and foremost. Whilst these national measures will provide a new and powerful framework to assure safe, effective and respectful care, consistently and compassionately given, to have real effect, it will be for every board, every ward and every member of staff to reflect on what they can do to ensure this, drawing on their best instincts and their professional values. As Robert Francis has made clear, the NHS and its staff do not need to wait for Government to act to make the aims of his Inquiry a reality. That work can, and must, start now. 80 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04 Item: 6 Enc:References 04 81
References
1. Transforming Care: A national response to Winterbourne View Hospital, Department of Health (December 2012) 2. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, chaired by Robert Francis QC. See http://www.midstaffspublicinquiry.com/report 3. Compassion in Practice, Nursing, Midwifery and Care Staff. Our Vision and Strategy, Jane Cummings, the Chief Nursing Officer for England (CNO), NHS Commissioning Board, and Viv Bennett, Director of Nursing at the Department of Health (December 2012). See http://www.commissioningboard.nhs.uk/files/2012/12/compassion-in practice.pdf 4. The Power of Information, Department of Health (May 2012). See http://www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_134205. pdf 5. The Healthy NHS Board, A review of guidance and research evidence, Angus Ramsay, Naomi Fulop, Adrienne Fresko and Sue Rubenstein (2010). See http://www.kingspssq. org.uk/assets/files/the_healthy_nhs_board_literature_review_13052010.pdf 6. NHS Constitution (March 2013), see http://www.dh.gov.uk/nhsconstitution 7. Nuffield Publication Rating providers for quality: A policy worth reviewing? Nuffield Trust (March 2013). See http://www.nuffieldtrust.org.uk/sites/files/nuffield/130322_ratings_ providers_for_quality_full_report.pdf 8. Review of Early Warning Systems in the NHS, Acute and Community Services, National Quality Board (2010). See http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh _113021.pdf 9. Quality in the New Health System – Maintaining and improving quality from April 2013, National Quality Board (January 2013). See https://www.wp.dh.gov.uk/publications/ files/2013/01/Final-NQB-report-v4-160113.pdf 10. Bringing Clarity to Quality in Care and Support, Department of Health (July 2012). See http://www.dh.gov.uk/health/files/2012/07/2900021-BCTQTLAP-2012-07-11-V3.pdf 11. The Mandate, A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015, Department of Health (November 2012). See http://publications. dh.gov.uk/files/2012/11/mandate.pdf 12. Mid Staffordshire NHS Foundation Trust Public Inquiry, see http://www. midstaffspublicinquiry.com 82 The Initial Government Response to the Report of The Mid Staffordshire NHS Foundation Trust PublicItem: Inquiry 6 Enc: 04
13. Being Open: communicating patient safety incidents with patients, their families and carers, National Patient Safety Association (2009) see http://www.nrls.npsa.nhs.uk/ alerts/?entryid45=65077 14. Caring for Our Future: reforming care and support, Department of Health (July 2012). http://www.dh.gov.uk/health/files/2012/07/White-Paper-Caring-for-our-future-reforming care-and-support-PDF-1580K.pdf 15. Strategic Review of the Nursing and Midwifery Council, Final Report, Council for Healthcare Regulatory Excellence (July 2012). See http://www.ukipg.org.uk/meetings/ professional_regulation_working_party/120702_CHRE_Final_Report_for_NMC_ strategic_review_(pdf)_1.pdf 16. Employee Engagement and NHS Performance. Michael A West and Jeremy F Dawson (2012). See, http://www.kingsfund.org.uk/sites/files/kf/employee-engagement-nhs performance-west-dawson-leadership-review2012-paper.pdf 17. Culture and behaviour in the English National Health Service from the blunt end to the sharp end: findings from a large multi-method study. Mary Dixon-Woods, Richard Baker, Kathryn Charles et al (2013). Submitted for publication. 18. Breaking down barriers, driving up standards, The role of the ward sister and charge nurse. Royal College of Nursing (2009). See http://www.rcn.org.uk/__data/assets/pdf_ file/0010/230995/003312. 19. Making the business case for ward sisters/team leaders to be supervisory to practice, Royal College of Nursing (2011). See http://www.rcn.org.uk/__data/assets/pdf_ file/0005/414536/004188.pdf 20. Standards for members of NHS boards and Clinical Commissioning Group governing bodies in England. Professional Standards Authority (November 2012). See, http://www. professionalstandards.org.uk/docs/psa-library/november-2012---standards-for-board members.pdf?sfvrsn=0 Item: 6 Enc: 04
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Item: 6 Enc: 04
Monitor - Contingency Planning Team Mid Staffordshire NHS Foundation Trust
Recommendations of the CPT
March 2013
Item: 6 Enc: 04 Contents
Contents
1. Executive summary ...... 2 1.1 Introduction ...... 2 1.2 MSFT must change to ensure sustainable high quality services for patients...... 3 1.3 Change at MSFT must involve other local healthcare providers...... 4 1.4 …and fulfil the intentions of local healthcare commissioners ...... 5 1.5 The CPT’s recommended clinical service model ...... 5 1.6 Why are the proposed changes better for patients? ...... 8 1.7 The implications of the CPT’s recommended clinical model ...... 9 1.8 Delivering the CPT’s recommended clinical model ...... 11 1.9 Next steps ...... 12 2. Introduction and context ...... 13 2.1 Mid Staffordshire NHS Foundation Trust ...... 13 2.2 Monitor’s appointment of the Contingency Planning Team ...... 14 2.3 Trust sustainability ...... 15 2.4 Structure of this report ...... 17 3. The local health economy ...... 19 3.1 Defining the local health economy ...... 19 3.2 Delivery of healthcare within the MSFT’s local health economy ...... 23 3.3 Commissioning within the local health economy ...... 26 3.4 Stakeholder views on what change could look like ...... 27 4. Protecting services currently delivered by MSFT ...... 31 5. Developing options for change ...... 35 5.1 CPT advisory groups ...... 35 5.2 The process for developing a short list of options ...... 37 5.3 Step One: Potential service configuration models ...... 38 5.4 Step Two: Developing the long list of options ...... 40 5.5 Step Three: Establish a shortlist of options ...... 41 6. Clinically evaluating the shortlist of options ...... 44 6.1 Clinical evaluation ...... 44 7. The CPT’s recommended clinical model ...... 50 7.1 The recommended clinical service model for Stafford and Cannock ...... 50 7.2 What are the implications of this recommendation for patients? ...... 51 8. The financial evaluation of the CPT’s recommended clinical model ...... 59 9. How should the preferred solution be implemented? ...... 65 9.1 Options for restructuring ...... 65 9.2 Recommendation on restructuring approach ...... 67 10. Delivering the recommended solution ...... 69 10.1 Elements of the recommended solution requiring further development ...... 69 10.2 Transition costs ...... 72 10.3 Managing the transition to the new clinical model ...... 73 10.4 Management of the risks and challenges ...... 74 11. Conclusion and next steps ...... 76 11.1 What happens now ...... 76 Appendix A: Outline of the services included in the shortlisted options...... 77 Appendix B: Additional risks associated with the CPT’s recommendations...... 79 APPENDIX C: Glossary of terms ...... 80
Ernst & Young i
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1. Executive summary
1.1 Introduction Mid Staffordshire NHS Foundation Trust (‘MSFT’ or ‘the Trust’) is a 344 bed acute trust comprising Stafford and Cannock Chase hospitals. It was authorised as a Foundation Trust (FT) on 1st February 2008.
In the following year, the Healthcare Commission called for a review at the Trust because of reportedly high levels of patient mortality and poor standards of care. A number of further reviews followed, including two inquiries, led by Robert Francis QC, into serious failings at the Trust and the commissioning, supervision and regulation of the Trust. These inquiries reported in 2010 and 2013.
In response to these reviews, the Trust has focused on improving the quality of care for patients. It has invested heavily in more staff, leading to significant gains in quality of care. But the Trust increased its spending during a period of tightening financial constraints on NHS organisations. As a result, the Trust has been in financial deficit since 2009 and will require significant external financial support from the Department of Health to pay its debts as they fall due.
Despite repeated attempts to turn itself round, the Trust remains financially challenged. It requires constant financial support to continue operating. For this reason, since March 2009 the Trust has been in significant breach of its terms of authorisation as a Foundation Trust on both financial and governance grounds.
In October 2012, Monitor appointed a Contingency Planning Team (CPT) to assess the sustainability of MSFT and develop a long-term plan to ensure that local patients will continue to receive excellent healthcare services if the Trust proves unsustainable.
The CPT’s interim report1, published by Monitor in January 2013, concluded that, despite the Trust’s success in improving clinical performance, its small scale means it is both clinically and financially unsustainable in its current form.
Having established a clear need for the MSFT’s form to change, the second phase of the CPT’s work has entailed developing an evidence-based plan for reconfiguring local healthcare services that will deliver high quality, sustainable healthcare services to the population served by the Trust. Together with local clinicians, patient representatives, healthcare commissioners and providers, the CPT has generated and considered a wide range of reconfiguration options.
The CPT’s recommended that patients would benefit from the establishment of local hospitals in both Stafford and Cannock. This would offer local access to regularly used services, enabling the majority of patients to access most services in the same locality as they access them today. In addition, the CPT is recommending
1 Mid Staffordshire NHS Foundation Trust sustainability report, Monitor Contingency Planning Team, January 2013 Ernst & Young 2
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the consolidation of emergency and specialist services into larger more specialist hospitals in the area, and the introduction of services that will support closer integration of acute, community, primary and social care for the population currently served by MSFT. These changes will improve the quality and safety of patient care, whilst ensuring that future services for MSFT patients are both clinically and financially sustainable.
1.2 MSFT must change to ensure sustainable high quality services for patients The people of Stafford, Cannock and the surrounding areas, rightly expect their local health services to be the very best; with the best standards of care, delivered with compassion by appropriately qualified staff. The CPT acknowledges the performance improvements at MSFT that have been achieved in the last 18-24 months, which reflect both significant financial investment and the hard work and commitment of the Trust’s leaders and staff.
In reviewing the options for the local population, the CPT and its Clinical Advisory Group were guided by the need to retain local services whenever possible, but to ensure that the services are safe and appropriately staffed. Therefore, moving services out of the localities of Stafford and Cannock was only considered where necessary to ensure patients can access high quality, safe and sustainable services.
MSFT is a 344-bed acute hospital trust with an annual turnover of about £155m. It is a relatively small acute trust in that it serves a catchment population well below the Royal College guidelines for hospitals providing a full range of acute medical and surgical services. The CPT does not believe that the levels of activity seen at the Trust’s two sites are of a sufficient scale to ensure clinical sustainability in the long term. Specifically, the estimated catchment population is c210,0002 compared to Royal College guidance for a full emergency service provider of 450,000 – 500,0003 and a minimum for a district general hospital of 300,000. Small hospitals such as MSFT face challenges in meeting Royal College standards and guidelines due to lower patient volumes, and, as a result, lack the ability to support the number of senior staff required to maintain a consultant presence twenty-four hours a day, seven days a week. In addition, MSFT faces material recruitment and retention challenges, with a higher proportion of temporary staff than other trusts. These challenges have a knock-on effect on clinical sustainability.
2 Staffordshire Public Health estimated the catchment population to be 190,000 and 212,000 and this was validated by the CPT (‘Assessment of Sustainability’ MSFT CPT, January 2013)
3 The preferred catchment population size, as recommended in previous reports, for an acute general hospital providing the full range of facilities, specialist staff and expertise for both elective and emergency medical and surgical care would be 450,000–500,000." The Royal College of Surgeons of England. Delivering High-quality Surgical Services for the Future. . March 2006. Ernst & Young 3
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The CPT has also found that the Trust is insolvent. It will need more than £70m over the next five years to cover the cost of its operations, whilst at the same time finding efficiency savings of more than 7% each year in order to break even at the end of this period.
NHS providers in financial difficulties have sometimes continued to receive subsidies from the Department of Health and/or local commissioners while they implement a realistic cost improvement plan. However, the CPT believes that delivering cost savings of this magnitude over a period of five years would most likely have a detrimental impact on clinical services and MSFT should not aim to do so. Pressure to introduce drastic cost cuts to services that were already clinically and financially sub-scale was one of the underlying causes of the serious failings in quality of care previously experienced by MSFT patients and must be avoided.
The CPT therefore concluded that MSFT is neither clinically nor financially sustainable and that there is no safe and credible means of making it both clinically and financially sustainable over the next five years in its current form.
1.3 Change at MSFT must involve other local healthcare providers... The evidence suggests that the future clinical and financial sustainability of services currently delivered by MSFT depends on reconfiguring services across the local health economy. The CPT’s analysis suggests that reforming services across the local health economy will enable the local population to continue to receive care locally, where it is most appropriate, whilst having access to high quality specialist care: delivered by the right specialists for their needs; at larger more specialist centres; where there are sufficient resources to deliver this care twenty- four hours a day, seven days a week.
The CPT is recommending that some services currently provided by MSFT should move to other providers and that there should be a fundamental change in the clinical service models in Stafford and Cannock. The CPT is also recommending that there should continue to be hospitals in both Stafford and Cannock.
The CPT has worked with local commissioners and senior leaders from all of the providers in the local health economy since the start of its work. All of these organisations acknowledge they have a role to play in making sure the population of Stafford, Cannock and the surrounding areas continue to receive high quality healthcare services. All parties also acknowledge that the local health economy is currently experiencing many challenges and the CPT’s proposed changes cannot happen immediately. Therefore change cannot be isolated to Stafford and Cannock and must take place across the local health economy in order to deliver the changes in services that the patients deserve.
The CPT believes that pursuing the options it proposes will strengthen all the providers in the local health economy and make the local health economy as a whole more sustainable.
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1.4 …and fulfil the intentions of local healthcare commissioners The CPT’s recommendations also need to conform with the commissioning intentions of the commissioners charged with purchasing NHS-funded healthcare on behalf of the local population. To that end, the CPT has worked closely with the Stafford & Surrounds and Cannock Chase Clinical Commissioning Groups (CCGs).
Both CCGs have stated their intention, where appropriate, to shift care away from acute hospitals into community and home based services through their commissioning. ‘Care closer to home’ has been a recurring theme in recent national health policy and has been judged to “significantly improve patient satisfaction with healthcare services, as well as improving patient attitudes to and knowledge of their individual conditions and treatments”4. The local commissioners are already working with local providers to redesign clinical pathways, which will change some elements of where and how patients access the treatment and care they require without having to go to an acute hospital. The CPT believes its recommended reconfiguration will enable commissioners to better fulfil their intentions.
The recommended reconfiguration should also meet regulatory requirements related to commissioning. One of Monitor’s new roles, under the Health and Social Care Act 2012, will be to support commissioners to ensure that, in the rare event that a healthcare provider fails, patients will continue to access the care that they need. Monitor has released draft guidance for commissioners concerning their role in securing continued healthcare services for their local population. This guidance explains how a CPT should support commissioners in defining ‘protected services’ for their local population in circumstances where a local provider is failing financially5. The guidance defines ‘protected services’ as services for which “there is no acceptable alternative” to the struggling provider.
The CPT has supported local commissioners in drafting a list of protected services for MSFT, which is set out in this report. The CPT has taken this list into account in developing and evaluating its options for change and making its recommendations. The CPT’s recommended clinical service model for Stafford and Cannock continues to deliver all of the services protected by local commissioners.
1.5 The CPT’s recommended clinical service model The CPT’s primary objective is to develop a set of options that are clinically sustainable in the long term, ensuring the people of Stafford, Cannock and the surrounding areas can access the clinically safe and high quality services they rightly expect. Critically, the CPT is looking at long term solutions rather than a short term fix to the clinical sustainability issues it has identified.
4 ‘Care closer to home’ narrative report – Royal College of Physicians, 2012 5 The draft guidance (“Ensuring continuity of health services and designating Commissioner Requested Services and Protected Services”) is to be finalised in the near future and it is likely that the terminology in the guidance will be updated and that the phrase ‘protected services’ will be replaced by ‘Location Specific Services’. For the purposes of this report, the phrase ‘protected services’ is retained. Ernst & Young 5
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This means that some services would have to be relocated, in order that they can be delivered by specialists in their field, at hospitals with the facilities to deliver the highest quality care and best outcomes possible.
The CPT developed and evaluated options for the clinical service model, unconstrained by the possible organisation form (i.e. who is running the hospital and services) or the costs of transitioning to the new model. The reason for taking this approach was to make sure the CPT met its primary objective of identifying a clinically sustainable service model.
To help the CPT to generate and evaluate a list of options, and to ensure these options had the appropriate clinical input, the CPT formed a Clinical Advisory Group (CAG), comprised of the Medical Directors from all of the providers and commissioners in the local health economy and chaired by an independent clinical advisor, Hugo Mascie-Taylor. This CAG has advised the CPT throughout its work.
This report sets out in detail the process that the CPT followed to evaluate how services could be delivered to patients. This process resulted in the initial identification of 32 options for the clinical service model which have been evaluated to produce a final shortlist of three. These three options are all derivations of a ‘Local Hospital’ and it is this model that the CPT is recommending should be established in both Stafford and Cannock.
1.5.1 The local hospital Medicine is becoming increasingly specialised, and there is a national trend towards centralising specialist services in order to improve patient outcomes, patient safety and quality of care. This creates a growing need for local hospitals, to maintain patients’ access to more commonly needed and less specialised services, and several local hospitals are developing as a result of reconfigurations elsewhere in the NHS (for example, in NW and SE London, and in Hertfordshire).
The local hospital is consistent with the principles of:
► “localise where possible” - a local hospital provides access for a local population to a range of services for common conditions that are used frequently, notably some emergency and urgent care services, clinically appropriate outpatient appointments and clinically appropriate day case procedures;
► “centralise where necessary” – as medicine and surgery gets increasingly specialised, establish or enhance larger more specialised centres of excellence that provide specialist care, delivered by specialist physicians using specialised equipment;
► “deliver better integration of care” – a local hospital will be part of a clinical network, with close links to the local ambulance service, primary care providers (i.e. GPs), larger more specialised acute providers, community providers (who provide healthcare out of acute hospitals, e.g. district nursing, health centres Ernst & Young 6
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and community hospitals) and social care providers. A local hospital creates the opportunity to drive this integration, for example, by co-locating some of these services.
1.5.2 The CPT’s recommendations for services within the local hospitals in Stafford and Cannock The CPT is proposing that local hospitals in Stafford and Cannock provide access for the local population to a range of frequently used services, such as common low risk procedures and outpatient appointments. This means specialised services that require specialist expertise and technology should be moved to appropriate centres within the local health economy.
Although more detailed work needs to be undertaken to finalise the detail for some of the services the CPT’s proposal is:
► Stafford services would include: a clinically appropriate 24/7 Emergency and urgent care service (see Section 1.5.3 for more explanation); specialty outpatient services (including ante and post-natal); clinically appropriate medical and surgical day cases; intermediate care beds; therapies (including physiotherapists and occupational therapists); diagnostics (including ultrasound, plain film X-Ray, MRI and CT scans); and, some clinical support services (including pharmacy and phlebotomy).
► Cannock services would include: Minor injuries unit; specialty outpatient services (including ante and post-natal); clinically appropriate medical and surgical day cases; therapies (including physiotherapists and occupational therapists); diagnostics (including ultrasound and plain film X-Ray); and, some clinical support services (including pharmacy and phlebotomy).
In addition, the CPT has concluded that retaining clinically appropriate elective inpatient care is likely to be sustainable if consolidated into a single location, but this will require further consideration as part of the TSA process.
The CPT also believes that the two local hospitals could be further developed to be part of a hub, co-located with some primary and community care services (for example, health centres, GP practices, community beds). This has not been evaluated in detail by the CPT, but is an option that the CPT would recommend for further exploration.
1.5.3 The CPT’s recommendations for services moving away from Stafford and Cannock What this does mean, is that some services could move away from Stafford and Cannock, notably those services dependent on critical care.
The CPT has concluded that emergency surgery is not viable in Stafford, due to insufficient general surgeons to cover a 24/7 service. Without emergency surgery
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on site, it makes critical care unviable due to the size of the unit that would remain. This has a number of consequences, notably:
► Any 24/7 Emergency and urgent care service in Stafford would not be an appropriate setting to treat patients with major urgent care needs. The CPT has assessed that at least 50% of the patients currently attending A&E in Stafford would still be appropriate to attend the proposed new service, but those with major needs should be treated at a larger more specialised A&E/trauma centre.
In January 2013, the NHS Commissioning Board commenced a review (being led by Sir Bruce Keogh, the Medical Director of the NHS) into the model of urgent and emergency services in England. The CPT believes this very timely review should significantly inform the final proposals for the service in Stafford and the local health economy.
► Having no critical care service on site means it would be unviable to operate an obstetrician-led maternity service. Furthermore, the CPT does not believe there will be sufficient activity to support a viable midwifery-led maternity unit. Therefore, the CPT is recommending that the maternity service in Stafford should be limited to non-complex pre and post natal outpatient appointments only.
1.6 Why are the proposed changes better for patients? The CPT has worked closely with the local clinicians and the CAG to develop solutions that improve care for the local population and deliver better outcomes not only today but also in the future, in line with the standards for high quality services as defined by the Royal Colleges.
Clinical evidence demonstrates that early and consistent input by consultants for non-elective and emergency care enables rapid and appropriate decision making. This ensures that patients receive correct diagnoses; are treated on the right pathway of care; leading to better patient outcomes including reduced mortality rates and improved physical functioning and quality of life6.
Larger more specialist centres are able to attract and retain a greater level of consultant cover and associated teams. Greater centralisation of specialist services in such centres allows the consultant cover to extend to seven days a week and up to 24 hours a day which meets the Royal College guidelines7. Studies have shown that centres with a higher level of consultant presence achieve better outcomes for patients. At these larger more specialised centres, consultants and their teams see a wider range of patients that provides them with the experience to
6 National Confidential Enquiry into patient Outcome and death, 2007. Emergency admissions: A step in the right direction, NCEPOD; London Health programmes, 2011. Adult emergency services: case for change, London Health programmes
7 Seven Day Consultant Present Care December 2012. Academy of Medical Royal Colleges Ernst & Young 8
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maintain their skills and enables them to invest in the latest technology and treatments.
At MSFT today, the relatively small number of patients8 being treated does not provide consultants with the range and frequency of experience they need to maintain their skills and the number of consultants available means that it is often not possible to have seven day a week or up to 24 hours a day specialist consultant presence in many services.
The consolidation of services in Staffordshire has already taken place for some services. Currently patients with symptoms of stroke or heart attack go to UHNS or Wolverhampton, with patients requiring vascular surgery also going to UHNS. This is because both trusts are better placed to provide consultant delivered service on a 24/7 basis and have the necessary expertise and equipment that enables them to save patient lives. The CPT’s recommendations are an extension of this, to ensure the population of Stafford and Cannock can continue to get an excellent service at units which are closer to achieving the best practice guidelines.
That said, the CPT recognises that where possible services should be delivered locally. The local hospital models proposed have been developed with this in mind and the CPT has assessed that over 80% of the current patient attendances to either Stafford or Cannock hospitals will remain within the same locality.
In addition, given the needs of the local population, the CPT recognises the need to have access to intermediate care beds locally and to improve the provision of out of hospital care and care integration. Intermediate care is a range of services which are designed to help patients to avoid admission to an acute hospital (‘step up’), or to rehabilitate after discharge from an acute hospital (‘step down’). Intermediate care services are typically staffed by multi-disciplinary teams, including nurses, physiotherapists, occupational therapists and care assistants. Intermediate care provides more appropriate care to the needs of a growing elderly population than acute hospital care. The introduction of intermediate care services in Stafford and Cannock should reduce the length of time spent in an acute hospital bed.
1.7 The implications of the CPT’s recommended clinical model The CPT has concluded that the proposal of a local hospital in both Stafford and Cannock would be clinically sustainable. In evaluating the clinical service model it has also made the following conclusions:
1.7.1 Access
► More than 80% of current patient attendances to the hospitals in Stafford or Cannock would be retained in the same locality. The reason for this is that about 55% of current attendances are for adult outpatient appointments, and
8 Mid Staffordshire NHS Foundation Trust sustainability report, Monitor Contingency Planning Team, January 2013 Ernst & Young 9
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over 90% of these would be retained in the same locality under the CPT’s proposals.
► The remaining patient attendances would be at a different location, meaning that patients would sometimes need to travel further to receive the specialist care required. The West Midlands Ambulance Service would therefore be an integral part of any solution and may require additional resources.
In these circumstances:
Average travel times for those services that are relocated would increase but remain in line with typically used standards. The average ambulance journey time for those living in the Stafford and Surrounds CCG catchment area (from their homes) would increase from 8 to 15 minutes. The average ambulance journey time for those living in the Cannock Chase CCG catchment area would increase from 13 to 14 minutes. Private car travel times would increase, but remain comparatively low.
Public transport travel times are important drivers of health inequalities and these would increase. This is the primary reason why the CCGs have protected several services, including outpatients. The CPT and the CCGs acknowledge that patient transport services would need to be enhanced in order to mitigate the impact of the changes for patients using public transport. This must be factored into the plans for change.
1.7.2 Finance
► The operation of local hospitals in Stafford and Cannock can be financially sustainable. However, this can only be achieved with significant reduction of the current cost base and in line with the proposed clinical models.
► Reducing the current cost base to a sustainable level will require a significant reduction in overheads, including significant remodelling or changes to the current estate. The consequence of reducing the cost base means that it is most likely that these local hospitals would need to be operated by an alternative provider with an established management structure.
1.7.3 Deliverability
► The assessment of the CPT is that the proposed reconfiguration could make a positive financial contribution to other providers in local health economy – that is the revenue associated with the increase in activity will cover the cost of delivery. It should be stated that improving the financial health of other providers in the local health economy is not a driver for the CPT recommending these changes.
► There are currently some capacity constraints across the local health economy that would need to be addressed to accommodate the proposed service changes. This additional capacity would need to be developed over time and services moved when the required capacity is available. The timescale would
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vary by service, but may take 2-3 years for full implementation, although a detailed implementation plan will need to be developed by the TSA. The CCGs have reflected this by protecting some services until capacity is available.
► Ideally, much of the required capacity could be created through redesigning services across acute, community, primary and social care, leading both to lower demand and improved length of stay in hospitals. There may also be opportunities for other providers to utilise the MSFT sites for some of their activity, particularly for elective care, although this is not a core assumption. However, it may be necessary for additional capacity to be developed at other sites in order to deliver the recommended changes.
1.8 Delivering the CPT’s recommended clinical model MSFT is operating within a challenged local health economy. Some local providers are experiencing clinical challenges of their own, others are forecasting significant financial problems for the foreseeable future. This is compounded by local commissioners undergoing a significant (national) restructuring and a county-wide community provider that has recently taken on responsibility for integrating community care with adult social care - an integration exercise that is still ongoing.
The CPT has focussed on developing a solution where the services currently delivered by MSFT can be delivered in a clinically and financially sustainable way in the future. The work of the CPT has therefore primarily focussed on the clinical service model and it is evident change cannot be isolated to just Mid Staffordshire.
Therefore, the CPT has recommended that: given the nature of its preferred solution; the instability in the local health economy; and, the urgency of the case for change, Monitor appoints a Trust Special Administrator (TSA). In a TSA-led restructuring, the TSA assumes the role of the Trust board and accounting office holder for the Trust, whilst preparing their own report for the Secretary of State for Health on how to deliver sustainable services for the public of Mid Staffordshire.
Any changes to services will require a statutory public consultation to be undertaken. If a TSA is appointed, it is expected that this consultation will commence nine weeks after the first day of the administration period and will last 30 days.
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1.9 Next steps The TSA process will take up to six months to complete and will include a public consultation on any proposed changes. The CPT’s recommendations will be passed to the TSA, who is at liberty to consider all options, including those ruled out by the CPT.
Some of the changes proposed by the CPT – if adopted by the TSA - could be implemented reasonably quickly after the end of the TSA process. However, the CPT believes implementing its recommendations in full could take up to three years, at an estimated cost that could exceed £60m, subject to: the development of plans for the future use of the estate; the determination of the appropriate organisational form for the future delivery of services; and, excluding the cost of funding the ongoing deficit of MSFT during that period.
The changes proposed by the CPT would require a significant investment of time and money, but are absolutely necessary to ensure high quality, clinically and financially sustainable services for the population of Stafford, Cannock and the local health economy as a whole.
Although the full implementation of the proposed changes would take time, it is imperative that the local public and GPs bear in mind that the CPT has not identified any factors to indicate the current delivery of services is clinically unsafe. The Trust has improved over the last 24 months, is continuing to improve, and the hard work and commitment of the Trust’s leaders and staff is not in question. Under a TSA, Stafford and Cannock hospitals will continue to operate as now and patients should continue to use the services as they do now.
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2. Introduction and context
2.1 Mid Staffordshire NHS Foundation Trust Mid Staffordshire NHS Foundation Trust (‘MSFT’ or ‘the Trust’) is a 344 bed acute Trust located on two sites: Stafford Hospital (built in 1984) and Cannock Chase Hospital (built in 1992). MSFT has an annual turnover of about £155m.
The Trust was authorised as a Foundation Trust (FT) on 1st February 2008. In the following year, the Trust was subjected to a review by the Healthcare Commission into reported high levels of patient mortality and poor standards of care.
Following this review there have been three further reviews and a public inquiry that has recently reported. Figure 1 sets out a timeline of these reviews.
Figure 1: High Level MSFT external reviews from 2008 to 2013
1st February 2008 September 2011 Mid Staffordshire CQC lifted July 2012 authorised as FT condition on Trust Remaining CQC March 2009 HCC February 2010 registration. 1 conditions lifted Report published Robert Francis moderate & 3 1st Year for MSFT Report minor remain April 2009 Colin April 2008 June 2010 Thomé & Alberti December 2011 February 2013 Public Inquiry HCC review Reports Public Inquiry Robert Francis commences commenced published ended Report Mar 2011 Mar Pre 2008 Pre Mar 2012 Mar Mar 2008 Mar 2009 Mar 2010 Mar
In response to the recommendations of these reviews concerning the quality of patient care, the Trust invested significantly in additional staff during 2009 and 2010 at a time when increasing financial constraints were being placed on NHS organisations. The Trust was also affected by decreasing patient referrals over the period, which in turn led to a reduction in the Trust’s income.
To address some of the clinical challenges associated with being a small hospital, and in line with a national move to larger more specialist centres of excellence, the Trust has reconfigured some clinical pathways with the result that MSFT is not providing certain specialised and/or urgent services on a standalone basis, e.g.
► Urgent cardiology care (Acute coronary syndrome, or ST elevated myocardial infarction) – provided by UHNS and Wolverhampton;
► Urgent stroke care – provided by UHNS and Wolverhampton;
► Vascular surgery – networked with UHNS.
The strategic and tactical changes the Trust has made have had a direct impact on improving both quality and performance. However, the investment in additional resources at a time when revenue is reducing has been one of the primary factors behind the Trust being in a position of financial deficit. The Trust has therefore
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required significant external financial support from the Department of Health in order to pay its debts as they fall due.
Despite repeated attempts to turn around its financial position, the Trust remains financially challenged and is expected to require further financial support to continue operating. Accordingly, the Trust has been in significant breach of its terms of authorisation as a Foundation Trust on financial and governance grounds since March 2009.
2.2 Monitor’s appointment of the Contingency Planning Team MSFT has been working closely with Monitor to improve its performance in recent years, and has made significant improvements in the clinical care provided for patients. The Care Quality Commission (CQC), the quality regulator, has said it no longer has outstanding concerns about the care delivered by MSFT.
However, the Trust is still losing money, and had to be given significant financial support from the Department of Health last year in order to maintain provision of services for patients. These circumstances cannot go on indefinitely.
Under the Health and Social Care Act 2012, Monitor has a primary duty as the new sector regulator to protect and promote the interests of people who use healthcare services. To carry out this new duty, Monitor also acquired new powers to ensure the continuity of services for patients if a provider’s financial viability puts them at risk.
In order to ensure the continuity of services for patients, Monitor needs to be assured that the clinical improvements are sustainable for the long-term. It therefore appointed a Contingency Planning Team (CPT), led by Ernst & Young and supported by McKinsey & Company, to develop a plan for the long-term to ensure services are provided for local patients on a sustainable basis.
2.2.1 Objectives of the Contingency Planning Team The terms of reference for the CPT were published in October 2012 and are available on Monitor’s website (http://www.monitor-nhsft.gov.uk/home/news- events-and-publications/latest-press-releases/terms-reference-–-contingency- planning-team-).
The core objectives for the CPT are to:
1. make an independent assessment of the financial, clinical and operational sustainability of MSFT in its current form;
2. work with commissioners to identify those services which need to be maintained in the event of provider failure, in order to ensure there is no significant adverse impact on local health or health inequalities;
3. engage with local commissioners and providers to explore the options for the future provision of all of the services currently provided by MSFT;
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4. evaluate whether proposed changes should be delivered through solvent restructuring or as part of Monitor’s Trust Special Administration framework;
5. make a recommendation on the future configuration of the services currently supplied by MSFT to ensure that they are delivered on a sustainable basis for the benefit of the local population. The CPT has already assessed the Trust’s sustainability (objective 1) and its conclusions are summarised in Section 2.3 below. The rest of this report addresses objectives 2-5.
2.3 Trust sustainability During the period October 2012 – December 2012, the CPT conducted an independent assessment of MSFT to determine whether there was a plan that, if successfully implemented, would sustain the delivery of services over the short, medium and long term. The focus of this assessment was on the actions that the provider can take that are within its own control.
The CPT assessed sustainability from three perspectives – operational, clinical and financial. Whilst there are clear relationships between the three, the CPT assessed each in isolation and presented separate conclusions from each perspective.
2.3.1 Operational sustainability The CPT acknowledged that the Trust has made significant improvements in its operational structures and processes over the last 18 to 24 months. This has resulted in improvements in key performance measures, such as CQC ratings, A&E waiting times, Hospital Standardised Mortality Rates (HSMR) and 18-week waiting times. During this period, there has also been significant investment in additional staff.
The CPT concluded that if a plan could be identified to deliver long term financial and clinical sustainability, then the Trust’s operating model is fit for purpose. To that extent, the CPT concluded that MSFT is operationally sustainable.
2.3.2 Clinical sustainability While there have been notable improvements in the quality of care at the Trust, the Trust faces a substantial challenge of scale when comparing the volume of activity at MSFT with other trusts in England. MSFT is a comparatively small trust, for example, it is 132nd out of 150 trusts in England, in terms of A&E attendances, and 135th in terms of births. Due to the size of the catchment population there is limited opportunity for growth, even allowing for predicted demographic and population changes.
Furthermore, with many acute surgical services becoming increasingly specialised, the Trust serves a size of population which is insufficient to provide exposure to enough conditions, treatments and procedures for many of its current complement of specialist consultants to achieve national standards and maintain their professional expertise. Ernst & Young 15
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Small hospitals such as MSFT face challenges in meeting Royal College standards and guidelines due to lower patient volumes, and, as a result, lack of ability to support the number of senior staff required to maintain a consultant presence twenty-four hours a day, seven days a week. This is particularly true for acute specialties where consultant presence may be required at short notice any time of the day or week, such as emergency surgery, A&E and maternity.
While many smaller hospitals face similar pressures there are several additional challenges that MSFT faces due to its recent history and reputational issues. In particular, MSFT has faced persistent difficulty in appointing medical staff and the Trust has had to rely heavily on non-permanent appointments. It has also had to pay a premium for the staff it does recruit.
Bearing in mind the available evidence, the CPT has concluded that although there have been substantial clinical improvements to the quality of care over the last three years, the Trust is clinically unsustainable in the long term, especially for emergency care, in light of established national standards.
2.3.3 Financial sustainability The Trust is forecast to make a deficit for the fourth consecutive year, and required £21m cash support in financial year 2012/13. The Trust is forecast to make a deficit for the foreseeable future.
While MSFT has achieved £16.6m efficiencies in 2011/12 and 2012/13, the efficiencies required to break even by 2018 would be a minimum of 7% each year for the next five years. This level of savings exceeds realistic targets and would still require an estimated £73m in additional support from the Department of Health and local commissioners over the same period.
The CPT has concluded, and the Trust has agreed, that this required level of extra savings and additional income is very unlikely to be delivered and sustained over the five year period
On the basis of the evidence reviewed, the CPT concluded that the Trust cannot achieve financial sustainability within the next five years without significant external intervention. Moreover, without cash support the Trust is unable to pay its debts as they fall due and as such is deemed insolvent. The Trust has needed and will continue to require substantial cash support for the next five years.
2.3.4 Sustainability conclusion The CPT has therefore concluded that MSFT is neither financially nor clinically sustainable and there is not a credible plan to deliver sustainability over the next five years in the Trust’s current form. On this basis, the CPT believes there is a clear and evident case for change with regards to the services currently delivered by MSFT.
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► MSFT is one of the smallest trusts in the country with the volume CPT Conclusion of activity below the national average for every service, and in One: some of the major acute services it is one of the smallest trusts in the country. A major acute ► MSFT has had a persistent difficulty in appointing career grade hospital in medical staff Stafford will not be clinically ► Even if sufficient career grade, e.g. consultant, medical staff were sustainable recruited to operate a 24/7 service in line with Royal College standards, there is insufficient volumes of activity to maintain their skills and capabilities CPT Conclusion Two: ► MSFT will need to achieve over 7% efficiency for the next five years to break even A major acute ► MSFT will also need over £70m of financial support to fund its hospital in deficit during this period Stafford will not be financially ► Employing the number of consultants required for 24/7 cover sustainable would worsen the financial position of the Trust
2.4 Structure of this report This report presents the CPT’s recommendations to Monitor on what changes it has assessed will ensure the sustainable delivery of the health services currently delivered by MSFT to the population of Stafford, Cannock and the surrounding area. The remainder of this report is structured as follows:
► Section 3 - The local health economy: Describes the local health economy for the population of Stafford, Cannock and the surrounding area.
► Section 4 – Protecting services currently delivered by MSFT: Provides an overview of the process and the outputs of the process that the CPT has facilitated with local commissioners to define protected services in Stafford and Cannock.
► Section 5 – Developing options for change: Provides an overview of the process the CPT has followed for establishing a shortlist of options for the future service configuration in Stafford and Cannock.
► Section 6 – Evaluating the short list of options: Presents the outcomes of the clinical evaluation of service configuration options.
► Section 7 – The CPT’s recommendations: Details the recommendations on the service configuration and the implications for patients.
► Section 8 – The financial evaluation of the CPT’s recommendations: Provides an overview of the financial evaluation conducted by the CPT.
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► Section 9 – How the recommended solution should be implemented: Sets out an evaluation of the restructuring mechanism most likely to succeed in implementing the CPT’s recommendations.
► Section 10 – Delivering the recommended solution: Outlines the considerations that will need to be taken into account in delivering the recommended solution.
► Section 11 – Conclusion and next steps: Briefly explains the next steps for Monitor and MSFT.
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3. The local health economy
Every hospital operates within a local health economy (LHE). This includes health commissioners, healthcare providers, social care providers and public health programmes that seek to positively influence, manage and treat the healthcare needs of a local population.
Having determined that there is no course of action that MSFT could pursue on its own to deliver sustainability in its current form, it is necessary and appropriate for the CPT to explore options for change across the LHE.
There are two primary reasons for doing so:
1. The CPT must identify services that could be delivered across the LHE to can ensure the sustainable delivery of services for the population of Stafford, Cannock and the surrounding areas.
2. Any changes made to the delivery of services in Stafford and Cannock will have effects on other providers in the LHE, both positive and negative. It is essential that the CPT understands any potential negative effects of its recommendations across the LHE so that any risk to another provider is mitigated.
This section therefore provides an overview of the LHE, the health providers and commissioners and the views of key stakeholders within the LHE as to the changes that could be undertaken.
3.1 Defining the local health economy The CPT has worked on the basis that the LHE was the:
1. health commissioners who currently purchase the majority of the services for their local population from MSFT;
2. health providers that were likely to be directly and significantly affected by changes to the services delivered in Stafford and Cannock.
3. health commissioners who currently purchase a significant amount of services from other providers who may be directly impacted (e.g. Stoke, North Staffordshire, Wolverhampton)
3.1.1 Commissioners in the local health economy Approximately 95% of the activity for MSFT is for patients in the catchment area of the former South Staffordshire PCT. From April 2013 the PCT will cease to exist and is being replaced by four Clinical Commissioning Groups (CCGs). Of the four, the Stafford and Surrounds CCG (S&S CCG) and the Cannock Chase CCG (CC CCG), commission the majority of the activity historically provided by MSFT.
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General Practitioners (GPs) within these two CCGs made over 18,000 new referrals to MSFT in 2010/11, although the volume of referrals had dropped by >7% since 2008/09 (see Table 1) as patients have chosen to have their care delivered by an alternative provider.
Table 1: MSFT referrals from primary CCG catchment areas during 2008-11 Year 2008/09 2009/10 2010/11
S&S CCG new referrals 20,476 19,273 18,939
% of S&S CCG total 85% 80% 78% referrals that go to MSFT
CC CCG new referrals 20,497 19,099 18,624
% of CC CCG total referrals 82% 75% 73% that go to MSFT
3.1.2 Healthcare providers within the LHE At the start of the CPT’s work, it was necessary to form a hypothesis and then agree on which other providers should be deemed as within the LHE of MSFT.
The CPT started with the hypothesis that up to seven NHS Acute Hospitals could form part of the LHE9, in addition to the Staffordshire and Stoke-on-Trent Partnership NHS Trust, (which runs community and social care services across Staffordshire) and the West Midlands Ambulance Service.
It then followed a three step process to rule in or rule out each of these hospitals as acceptable potential alternative providers of services to patients currently served by MSFT, should the need arise.
Step One: Travel times
The CPT has used detailed travel time analysis10 to assess its recommendations, including by ambulance, private car and public transport (see Section 7.2 for details on this analysis). However, for the initial determination of which hospitals could belong in the LHE, the CPT used private car travel times from Stafford and Cannock hospitals.
The rationale for this was that the majority of the population served by MSFT live in Stafford or Cannock and those other providers within a reasonable driving distance of these towns are likely to be impacted by any changes to services in Stafford and Cannock.
9 UHNS, Stoke-on-Trent; New Cross, Wolverhampton; Manor Hospital, Walsall; Queens Hospital, Burton; The Royal Derby Hospital; Heart of England, Birmingham; Princess Royal, Telford. 10 Based upon post code blocks (the first four/five characters of a postcode) Ernst & Young 20
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There are three other hospitals within 30 minutes11 of either Stafford or Cannock Hospitals (the travel time between Stafford and Cannock Hospitals being 20 minutes). These were UHNS, Stoke-on-Trent; New Cross Hospital, Wolverhampton; and Manor Hospital, Walsall.
Step Two: GP referring behaviour
It was previously noted that the majority of referrals from the catchment areas of Stafford and Surrounds CCG and Cannock Chase CCG were to MSFT, but that these referrals were reducing as a consequence of patient choice. The CPT therefore analysed these referral patterns to determine which alternative hospitals patients had chosen to attend. It would be reasonable to assume that any changes to the services at MSFT could see a similar drift of patients to other hospitals which would directly affect these providers.
On the basis of this analysis the CPT noted that four hospitals had received a significant increase in referrals from GPs in the Stafford and Surrounds CCG and Cannock Chase CCG catchment areas. These were the three hospitals noted in Step One, plus Queen’s Hospital, Burton. This is likely to be the patients in the eastern region of the catchment area where Burton is the closest hospital after MSFT.
Step Three: Initial engagement with the providers
The CPT spoke with the senior leaders for each of the seven hospitals it considered. The purpose of these conversations was to ascertain whether they considered changes in services at MSFT would have a significant impact on their hospital. Bearing in mind the overnight closure of the A&E unit at Stafford Hospital, these hospitals had a recent and credible experience that could be drawn upon to determine whether they would be affected.
On the basis of these conversations, Heart of England, Birmingham and The Royal Derby Hospital concluded that they would not be significantly affected.
UHNS (Stoke-on-Trent), New Cross Hospital (Wolverhampton), Manor Hospital, (Walsall), and, Queen’s Hospital (Burton) stated they believed they would be affected by any changes to services at MSFT – the latter also noting that it ran the Community Hospitals in Lichfield and Tamworth which could be affected.
Shrewsbury and Telford Hospitals NHS Trust, stated that the Princess Royal in Telford may be affected by certain changes to MSFT, especially as it is planning to consolidate a number of services, notably all maternity services, into Telford.
Therefore, the CPT has worked on the basis that the LHE comprises the following NHS Trusts:
11 There is no set standard for what is a ‘reasonable travel time’. However, 30 minutes has been used by other reconfiguration programmes (for example, the London Stroke and Trauma service reconfiguration) as a reasonable travel time for Ambulance transfers between hospitals. The CPT therefore worked on the basis that a 30 minute travel time limit for private car journeys – which take longer than ambulance transfers - was reasonable. Ernst & Young 21
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► University Hospital of North Staffordshire NHS Trust (UHNS), Stoke-on-Trent;
► The Royal Wolverhampton NHS Trust (RWT);
► Walsall Healthcare NHS Trust (WHT), which runs Manor Hospital;
► Burton Hospital NHS Foundation Trust (BHFT), which runs Queen’s Hospital;
► Shrewsbury and Telford Hospitals NHS Trust (SaTH), which runs Princess Royal Hospital;
► Staffordshire and Stoke-on-Trent Partnership NHS Trust (SSoTP), which runs community and social care services across Staffordshire;
► West Midlands Ambulance Service NHS Foundation Trust (WMAS). The CPT notes that there is one private hospital – Rowley Hall, Stafford – within the catchment area of S&S CCG and CC CCG. The CCGs do commission some services from Rowley Hall, but at only 14 beds, the CPT concluded that for the purposes of its work it would not be a significant contributor to the potential solutions that the CPT would be evaluating.
3.1.3 Other commissioners across the LHE The CPT spoke with leaders of other commissioning groups across the LHE. This includes Stoke on Trent, North Staffordshire and Wolverhampton. The purpose of these discussions was to ensure that their perspective and concerns were taken into consideration regarding the impact of any changes to services.
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3.2 Delivery of healthcare within the MSFT’s local health economy The CPT has engaged with the healthcare providers and commissioners across the LHE throughout its work. This engagement has included:
► Multiple meetings with the senior executives in each Trust;
► Regular involvement of medical directors and strategy directors of each trust, as well as clinical chairs of the CCGs with their participation in the Clinical Advisory Group12;
► In addition, representatives from the local CCGs, and Staffordshire LINks, formed the Protected Services Definition Group;
► Finance and operating directors from trusts and CCGs in the Operations and Finance Group;
► Gathering data from each of the Trusts to support the analysis of the CPT. The general consensus from all of the Trusts is that there needs to be change across the LHE in order to improve the delivery of services not just for the population served by MSFT, but the broader population of Staffordshire. The remainder of this section provides an overview of each of the providers and some of the issues and ideas concerning better delivery of services that are recognised across the LHE.
3.2.1 An overview of the LHE’s providers The map of Staffordshire in Figure 2 shows the location of the providers and the CCGs within the local health economy. The map shows Stafford is centrally located within the county, but there are other providers to the north, south, east and west.
Figure 2: The local health economy for MSFT
12 See Section 5.1 for full details of the working groups established by the CPT. Ernst & Young 23
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Tables 2-8 present an overview of the other providers in terms of the size and type of services they provide:
Tables 2-8: A summary of the other NHS providers in MSFT’s local health economy
Mid Staffordshire NHS Foundation Trust (MSFT) 2012/13 2011/12 2011/12 Surplus/(Deficit) Number of Number of Turnover Surplus/(Deficit) forecast staff beds
£155m (-£19.9m) (-£15m) 3,000 350 Mid Staffordshire NHS Foundation Trust provides general acute Hospital services for the populations of Stafford, Cannock and the surrounding areas. It provides services from two main sites: Stafford and Cannock Hospital. Stafford hospital provides the full range of acute services whereas Cannock does not receive emergency inpatients but provides some elective surgery and rehab beds.
University Hospital of North Staffordshire NHS Trust (UHNS) 2012/13 2011/12 2011/12 Surplus/(Deficit) Number of Number of Turnover Surplus/(Deficit) forecast staff beds £426m £3m (-£23m) 7,000 1,000 University Hospital of North Staffordshire is a major acute trust providing services predominantly from the City General Hospital in Stoke-on-Trent. The City General Hospital was redeveloped under a PFI scheme and opened in 2012. It provides specialist treatment such as major trauma and neurosurgery to the local populations of Newcastle under Lyme and Stoke on Trent and to the wider population of Staffordshire and South Cheshire and Derbyshire.
Burton Hospital NHS Foundation Trust (BHT) 2012/13 2011/12 2011/12 Surplus/(Deficit) Number of Number of Turnover Surplus/(Deficit) forecast staff beds £171m (-£5.3m) (-3.5m) 2,500 420 Burton Hospital NHS Foundation Trust provides general acute hospital services to the population of Burton and its surrounding areas. As well as providing general hospital services, it operates two community Hospitals: The Samuel Johnson Community Hospital in Lichfield and the Robert Peel Hospital in Tamworth. As well as hosting services at these sites the Trust provides a range of outpatient and inpatient services from there.
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Walsall Healthcare NHS Trust (WHT) 2012/13 2011/12 2011/12 Surplus/(Deficit) Number of Number of Turnover Surplus/(Deficit) forecast staff beds £227m £3.6m £3.7m 5,000 500 Walsall Healthcare NHS Trust is a provider of general acute hospital and community services to Walsall and its surrounding areas. The main acute based services are provided from the Manor Hospital in Walsall which was redeveloped under a PFI scheme in 2010. In addition to its general acute services it provides specialist bariatric surgery to areas of the West Midlands. As well as providing acute services it also provides community based services within Walsall which includes the provision of some intermediate care beds.
The Royal Wolverhampton NHS Trust (RWT) 2012/13 2011/12 2011/12 Surplus/(Deficit) Number of Number of Turnover Surplus/(Deficit) forecast staff beds £374m £8.7m £4.5m 6,500 800 The Royal Wolverhampton NHS Trust is a major acute trust providing services largely from New Cross Hospital in Wolverhampton. It provides a comprehensive range of services, including specialist services such as trauma and cancer, for the people of Wolverhampton, the wider Black Country, South Staffordshire, North Worcestershire and Shropshire. As well as providing major acute services, in April 2011 it took on the provision of Community services for the population of Wolverhampton.
Shrewsbury and Telford Hospitals NHS Trust (SaTH) 2012/13 2011/12 2011/12 Surplus/(Deficit) Number Number of Turnover Surplus/(Deficit) forecast of staff inpatient beds £300m £0.05m £1.9m 5,000 720 Shrewsbury and Telford Hospitals NHS Trust is a general acute trust providing services from two main sites: The Royal Shrewsbury Hospital and the Princess Royal Hospital, Telford. Services are predominantly provided to the population of Shropshire, Telford & Wrekin and West Wales. The Trust is currently reviewing the services provided at both sites and developing plans to reconfigure services across these sites ensuring clinically sustainable services in the future.
Staffordshire and Stoke-on-Trent Partnership NHS Trust (SSoTP) 2012/13 2011/12 2011/12 Surplus/(Deficit) Number Number of Turnover Surplus/(Deficit) forecast of staff inpatient beds 300 £204m £1.5m £2m 6,000 (community) The Staffordshire and Stoke-on-Trent Partnership NHS Trust provides community health care and adult social care services in Staffordshire and community health services in Stoke-on-Trent. The Trust was formed in September 2011. In April 2012 the Trust took on responsibility for Adult Social care in South and North Staffordshire. As well as providing community care across the whole borough, it also operates five community hospitals in the north of the county with approximately 300 community beds.
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3.3 Commissioning within the local health economy Health commissioning is the function which exists to ensure that high quality healthcare services are provided for the local population. To undertake this function, commissioners act as advocates for patients and communities to secure a range of high-quality healthcare services for the local population. In securing these services, commissioners are also the custodian of tax-payers money, placing on them a requirement to secure the best value healthcare services that they can find within their budget, which is based on the size and characteristics of the population they serve.
Commissioning across the NHS is being significantly restructured, with Primary Care Trusts (PCTs) and Specialised Commissioning Groups (SCGs) being replaced by local Clinical Commissioning Groups (CCGs) and regional ‘Local Area Teams’ (LATs) who will work under the strategic direction of the NHS Commissioning Board (NHS CB). This report does not dwell on the details of the changing commissioning bodies, other than to note that the CPT has been actively engaged with the individuals and organisations who will commission the significant majority of services at MSFT from April 2013.
The CPT has been working closely with the Stafford and Surrounds CCG and Cannock Chase CCG to develop the options presented in this report. Both CCGs are represented on the Clinical Advisory Group and Protected Services Definition Group (see Section 5.2 for further details on these groups). The CPT has also had regular meetings with both the CCGs and the PCT cluster (and the future Local Area Team) during the development of options presented in this report.
This section presents a high level outline of current commissioning intentions and sets out the process and conclusions of the process to define protected services.
3.3.1 Local commissioning intentions Stafford and Surrounds CCG and Cannock Chase CCG are committed to ensuring that services are delivered as locally as possible and centralised where necessary in order to ensure that the local population receives the highest possible standards of care. They accept that the scope, style and scale of these services may be significantly different in the future. They also understand and support the need for local health services to be both clinically and financially sustainable. On this basis, the CCGs have acknowledged that the services currently delivered by MSFT will need to change and this means that some services may need to shift away from Stafford and/or Cannock.
Specifically, Stafford and Surrounds CCG intentions are to:
► Commission a 24/7 Emergency and Urgent Care Service in Stafford;
► Ensure that services are provided as locally as possible but centralised where necessary in order to deliver highest quality of care;
► Ensure that services are clinically and financially sustainable in the future; Ernst & Young 26
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► Commission services which shift the pattern of care away from hospitals into community and home based services;
► Redesign several pathways to deliver better care, including long term condition, elderly care, Ear Nose and Throat (ENT), musculoskeletal services, colorectal surgery, general surgery, oral surgery, plastics, urology, gynaecology, cardiology and gastroenterology.
Specifically, Cannock Chase CCG intentions are to:
► Ensure that services are provided as locally as possible but centralised where necessary in order to deliver highest quality of care
► Continue commissioning a Minor Injuries Unit (MIU) in Cannock. (Note: The current MIU is operated out of Cannock Hospital by the Staffordshire and Stoke-on-Trent Partnership NHS Trust and as such is not part of the CPT review)
► Redesign several pathways to deliver better care, including long term conditions, elderly care, Ear Nose and Throat (ENT), ophthalmology, musculoskeletal services and end of life care. The CPT’s recommendations have sought, where possible, to reflect these intentions.
3.4 Stakeholder views on what change could look like During the course of its work, the CPT has engaged with a wide range of stakeholders in addition to the commissioners and providers in the local health economy.
The CPT has attended multiple stakeholder forums to brief on the CPT process and to give stakeholders an opportunity to ask questions and discuss their views. These forums have included:
► Briefings with the Board of Governors of MSFT;
► MSFT staff briefings;
► Public meetings organised by the Trust;
► The Staffordshire Health Scrutiny Committee;
► The Staffordshire Health Wellbeing Board;
► Local MP working groups;
► CCG patient forums.
The CPT has also received formal submissions on the views from the:
► Working group set up by the MP for Stafford;
► Board of MSFT;
► Governors of MSFT.
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This section summarises the most commonly expressed views and addresses two proposed solutions that have been consistently raised with the CPT as a means of managing the sustainability challenges faced by the Trust. 3.4.1 Common stakeholder views Whilst there is a wide range of stakeholder views, there is also a lot of commonality in some of the views expressed. The following views have been stated by multiple stakeholders; however, this not an exhaustive list of opinions, nor indeed does every opinion have universal support.
► Change is needed at MSFT, and the driver for change should be to secure clinically viable services and consistently good patient outcomes.
► As many services as possible currently delivered by MSFT should be retained locally, especially emergency care provision, maternity services and care of the elderly.
► If services are to be moved to another provider – and several stakeholders do not wish any services to move – it should only be those that are highly specialised, and then only to providers that deliver services to the same standard as currently delivered by MSFT.
► If services are to be moved, they should be the right size, sustainable in the long term and must not destabilise the operations or finances of another trust.
► Stafford needs a 24/7 ‘Accident and Emergency’ department, rather than a department that shuts overnight as the current service does – although some stakeholders do accept that it may not be possible to treat patients with highly complex needs.
► Some services must be retained in Cannock, although the majority of stakeholders accept that these services do not need to be provided by MSFT.
► The use of clinical networks with other providers should be used to enable as many services to be retained in Stafford and/or Cannock, taking advantage of the clinical skills of staff employed by other providers, but using the local facilities.
► Any proposal to move services to another provider raises concerns for those individuals reliant on public transport. Some stakeholders cannot see a resolution to this issue, whilst others are calling for a modernisation to patient transport services and an increase in capacity within the West Midlands Ambulance Service.
► There should be an aspiration to move to a more integrated model of care across acute, primary, community and social care, either through co-location of services in the same site or through redesigned care pathways. This is qualified by the view of several stakeholders that local community and social care services need to be significantly redesigned and performance improved before this aspiration can be fulfilled.
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► There is a general unease/lack of confidence about the other providers in the local health economy, especially in light of recent news of mortality rates and the financial position in some of the local providers.
► Any change must be properly managed, but cannot be allowed to drag on for a lengthy period of time. There is widespread concern that delaying change will lead to a drop in standards due to staff leaving and patients choosing to be treated elsewhere.
► Many stakeholders are clear that they do not want these changes to be used as an excuse to introduce private sector providers, although when challenged, very few stakeholders can explain why they hold this view. Engagement with stakeholders has been a key part of the CPT process and due consideration has been given to their range of views and opinions in arriving at its conclusions. However, the CPT has had to balance a range of inputs to the process, not all of which will be reflected in the final recommendation.
3.4.2 Considering solutions with the existing service model Before presenting the work the CPT has conducted, it is important to address two solutions that have been consistently suggested to the CPT by a variety of stakeholders.
The CPT understands why these solutions may seem obvious, but it does not believe that either solution is feasible or likely to solve the challenge of MSFT’s sustainability.
1. If there is spare capacity/empty wards within Cannock Hospital why can’t MSFT bring in more activity and consequently more revenue? Would this not help solve the financial problems?
Hospitals within the NHS can only deliver the services that health commissioners choose to purchase from each health provider. Just because there may be capacity within any single given trust and a waiting list for some services, does not mean there is the demand from the commissioners or the money to pay for those services, or for that matter, demand from patients, who have the choice of where to be treated for non-urgent (elective) care. The commissioners across Staffordshire and neighbouring counties have a finite amount of money to spend on purchasing health services and choose to spend that money in the manner and at the location they consider most appropriate
It should also be noted that if MSFT were to operate more services at either site – assuming commissioners were able and willing to pay for those services - then it would need to bear the cost of providing those services. It is quite conceivable that, especially in light of the higher than average cost base, these services would cost more money to operate than the revenue the Trust would receive – which would worsen the Trust’s financial problems.
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2. Why can’t MSFT close and/or sell Cannock Hospital and consolidate services into Stafford Hospital?
During the sustainability review, the CPT considered this possibility, but concluded that consolidating sites alone will not create a clinically or financially sustainable solution, without significant service reconfiguration as well. Consolidating sites would not address the issue that both the catchment population and activity levels across both hospitals are lower than those recommended by the Royal College Standards for an acute general hospital providing the full range of facilities, including specialist staff and expertise for both elective and emergency medical and surgical care.
The commissioners have also made it clear that they wish to commission services in both Stafford and Cannock. The CPT has therefore worked on the basis that it will try to identify a service configuration that retains some services in both localities, and would only consider consolidating onto a single site if an alternative sustainable solution was not identified.
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4. Protecting services currently delivered by MSFT
Under the new Healthcare Act when a provider becomes, or is likely to become, unable to pay its debts as they fall due, Monitor will place the provider in special administration. In the event that MSFT is placed under trust special administration, commissioners have a responsibility for ensuring that the local population continues to have access to key NHS services in their local areas. Monitor has issued draft guidance for commissioners on the designation of ‘protected services’ (“Ensuring continuity of health services and designating Commissioner Requested Services and Protected Services”). Monitor is currently working on finalising the guidance for publication and based on stakeholder feedback and the terminology of ‘protected services’ is likely to change to ‘location specific services’. However, for the purposes of this report the CPT will use ‘protected services’ terminology and refer to the published draft guidance which was used by the commissioners throughout the process.
The guidance defines ‘protected services’ as services for which “there is no acceptable alternative provider and would need to be kept running if the provider were to fail”. If designated as protected, these services will have extra regulatory protection under a trust special administration. It is important to note that only services provided by the ‘failing’ provider can be protected and that only services that currently exist can be protected. In addition, if a particular local service is not designated for protection, this does not mean it is not required or that it will not be commissioned. When a service is not protected, this is either due to availability of attractive alternatives or because commissioners believe they can commission it without extra regulatory protection.
Based on the draft guidance, the two CCGs have prepared draft lists of protected services for their respective localities, which have been signed off by their respective CCG membership boards. Both Stafford and Surrounds CCG and Cannock Chase CCG have confirmed that they support each other's draft list. It is important to note that the CCGs currently operate in the ‘shadow’ form until April1. In the meantime the PCT cluster has been providing necessary assurance and support for the CCGs in their decision making.
It is the responsibility of the CCGs to define protected services, supported by the CPT. Therefore, this report sets out the process followed and the conclusions that the CCGs have made. This informs the basis of the options development and evaluation that is then covered in the rest of this report.
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In preparing the draft list of protected services there are four criteria to consider:
Table 9: The criteria used when evaluating whether a service should be protected Criteria Question being addressed Access to Do alternative providers of a similar service exist? alternative Is the distance (travel time) to alternative providers acceptable? providers Are these services of 'equivalent' quality? Available Would alternative providers have the capacity and capabilities to capacity at deliver the services? alternative Could new capacity be created – either by existing providers or by providers new entrants - over a reasonable time period? Would withdrawing a service have a disproportionate impact on Impact on disadvantaged groups, who have lower health outcomes? Health Are there any unique and hard to replicate relationships with patient Inequalities groups or other public services? Inter- dependencies Are there any services which need to be protected because they are between interdependent with services already selected for protection? services
The CPT has supported the local commissioners in preparing a draft list of protected services. This has been through the establishment of, and support to, a ‘Protected Services Definition Group’ (PSDG), chaired by the CPT’s independent clinical advisor (see Section 5.2 for further description). The CPT provided the analysis and information necessary to enable the PSDG to assess the options available to them, as follows:
Criterion One: Identifying acceptable alternative providers of services
In order to identify alternative providers that were acceptable to commissioners, the PSDG considered travel times and clinical quality. The CPT used detailed travel time analysis to assess which alternative providers are within a reasonable travel time. The CPT analysed blue light, private car and public transport times at both peak and off peak times.
Criterion Two: Determining capacity at alternative providers
The CPT gathered data from all the relevant providers on activity and capacity. Through the Operating and Finance Group (OFG) assumptions on demographic growth, demand management and operational improvements such as average length of stay were agreed, allowing the CPT to forecast capacity requirements. The CPT then modelled these changes over time to assess what relevant capacity would be available both immediately and in 2015/16. The CPT’s estimates, assumptions and outputs were tested with all relevant providers in the region though one-on-one discussions.
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Criterion Three: Impact on health inequalities
In order to assess the impact on disadvantaged groups and health inequalities the CPT considered the increase in public transport times to alternative providers and the existence of unique relationships with patient groups or public services that would be hard to replicate elsewhere. The PSDG were concerned with the increased public transport times due to the rural nature of the area. As a result some of the more frequently used services were designated protected.
Criterion Four: Service interdependencies
The CPT tested all services classified as protected to assess if there were interdependent services, for example, if general surgery was protected, anaesthetics would also need to be protected as the services are interdependent. In preparing the draft list of protected services there are two considerations that must be taken into account: 1. The CCGs have undertaken the process for drafting protected services using draft guidance that Monitor has been consulting on and has yet to be finalised. Any changes to the guidance could impact on the final list of protected services; 2. The draft list of protected services is only relevant in the context of an appointment of a Trust Special Administration (TSA) who will go through the final confirmation of the protected services.
Table 10 sets out the high level draft list of protected services.
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Table 10: The draft list of protected services Stafford & Surrounds CCG Cannock Chase CCG At Stafford: At Stafford: No services are protected On the basis of Health Inequalities: Outpatients At Cannock: Patient facing diagnostics On the basis of Health Inequalities: Day case chemotherapy Outpatients Pre-natal and post-natal care Step down beds
On the basis of capacity and protected only until alternate capacity is available: Current 14/7 A&E13 Routine Obstetrics Selected Emergency (Non Elective) admissions/inpatients14 Select elective admissions for a range of medical specialties
On the basis of service interdependency and only protected for as long as the interdependent service is protected: High dependency services commensurate with services on site Sufficient neonatal resuscitation to support services on site Adult Anaesthetics
At Cannock: No services are protected
► Commissioners wish to retain access to services in both Stafford CPT Conclusion and Cannock, particularly Three: In Stafford: Outpatients, diagnostics, pre and post natal care, Services will be step down beds retained in both In Cannock: Outpatients Stafford and Cannock ► Commissioners wish to commission 24/7 emergency and urgent care service in Stafford
13 Noting that the commissioning intentions (as per Section XX) are to redesign the services and commission 24/7 Emergency and Urgent Care service
14 There are certain categories of patients who are admitted to hospital on an emergency basis and do not require specialist care or interventions. These patients would be suitable for receipt of services in Stafford until capacity was provided elsewhere. Ernst & Young 34
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5. Developing options for change
Having determined that MSFT at present is neither clinically or financially sustainable, the CPT was required to develop a ‘contingency plan’ to develop, for Monitor, a series of recommendations about changes that could be made in order to ensure that the population of Stafford, Cannock and the surrounding areas have access to high quality healthcare services, including those services currently delivered by MSFT.
This contingency plan sets out where and how the population can expect to access services taking into account: commissioning intentions; the draft list of protected services, and an assessment of the impact on the local health economy.
This section sets out how the CPT developed a long list of options for the future of clinical services at Stafford and Cannock and surrounding hospitals and the process it went through to reduce the long list to a short list for detailed evaluation before selecting a preferred option for the contingency plan itself.
5.1 CPT advisory groups The CPT established three working groups to support the development of options. These working groups met on multiple occasions and were chaired by senior independent advisors to the CPT. An overview for each of the three groups is presented in Table 11.
Table 11: An overview of the three working groups that have been established to support the CPT
Protected Services Definition Group (PSDG) Chair Membership Purpose Accountable Officer for The PSDG met five times to: Stafford and Surrounds follow the process outlined in and Cannock Chase CCGs Monitor’s consultation on Guidance Chairs, clinical leads, for Commissioners. Exex board members agree ‘protected services’ - the from Cannock Chase services for which, should MSFT fail, CCG, Stafford and there is no acceptable alternative Surrounds CCG provider. Professor Hugo Clinical Governance review the availability of alternative Mascie-Taylor Director, CC CCG provider services for the local Clinical Advisor to populations served by Stafford and CPT and Medical Primary Care Director, Cannock hospital, understanding Director for NHS CC CCG alternative provider capacity, Confederation Director, CC CCG capability and willingness to deliver Medical Director, services Staffordshire Cluster advise on, or identify questions to General Manager, be raised, at the Clinical Advisory Stafford and Surrounds Group on the clinical viability of CCG services that are proposed as being Representatives from protected Staffordshire LINk
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Clinical Advisory Group (CAG) Chair Membership Purpose The CAG met four times to: provide clinical advice to the Chair, Stafford and Surrounds programme, ensuring the CCG programme develops robust Clinical Chair, Cannock Chase clinical proposals CCG make clinical recommendations Medical Directors or their to the CPT delegated representative and Professor Hugo set out quality standards for Strategy directors from: Mascie-Taylor clinical services Clinical Advisor to MSFT; University Hospital of review and agree the clinical CPT and former North Staffordshire; Burton evidence base supporting Medical Director Hospital; The Royal proposed models of care for NHS Wolverhampton NHS Trust; Confederation Walsall Healthcare NHS Trust; review future activity and Shrewsbury and Telford NHS capacity assumptions Trust; Staffordshire and provide clinical input into the Stoke-on-Trent Partnership development of potential Trust; Cluster of Staffordshire options for change PCTs; West Midlands Ambulance Trust. provide expert clinical advice on CPT outputs – as and when requested
Operating and Finance Group (OFG) Chair Membership Objectives Directors of Finance, and The OFG met four times to: Directors of Operations or their delegated provide financial leadership Bob Alexander representatives from: MSFT; advice to the programme, Director of University Hospital of North ensuring the programme Finance, NHS Staffordshire; Burton develops financially robust South. From April Hospital; The Royal proposals 2013, the Wolverhampton NHS Trust; agree future activity, finance, Director of Walsall Healthcare NHS Trust; productivity and capacity Finance for the Shrewsbury and Telford NHS assumptions to be used by the NHS Trust Trust; Staffordshire and CPT Development Stoke-on-Trent Partnership Authority provide financial input into the Trust; Cluster of Staffordshire development of potential PCTs; West Midlands configuration options Ambulance Trust.
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5.2 The process for developing a short list of options The CPT’s primary objective is to develop a set of options that are clinically sustainable in the long term. The CPT focused on how clinical services currently provided in Stafford and Cannock could be delivered in future to ensure high quality care, unconstrained by estates or organisational implications. This ensured that there was a full debate and evaluation of the type and nature of services that could be delivered in the Stafford and Cannock localities.
It is important to be aware of the fact that, throughout this section any reference to future services in Stafford or Cannock does not mean that these services are guaranteed to be delivered at the existing Stafford and Cannock Hospitals. Once the clinical model is finalised, a separate assessment should be undertaken on the effectiveness and value for money associated with retaining/redeveloping the existing sites or developing new facilities.
The development of the options was regularly tested by and developed with the Clinical Advisory Group, and analysed using information developed with the Operating and Finance Group.
The primary considerations that were taken into account when developing the range of options were: the commissioning intentions of the two CCGs; the views of local stakeholders; national guidance on clinical standards; access to services based on the emerging outputs from the Protected Services Definition Group; and the range of services that are currently delivered by other providers in the local health economy.
The CPT has not looked in detail at the delivery of primary, community, social care and mental health services for the population of Stafford, Cannock and their surrounding areas, as these are provided by organisations other than MSFT. The CPT has worked on the basis that effective provision of these services is essential to underpin the successful delivery of any revised model of hospital care.
The CPT has followed a process for generating potential options for change:
► Step One: Assess the potential service configuration models that could deliver services in Stafford and in Cannock;
► Step Two: Develop and validate a long list of options for clinical service models across Stafford and Cannock based upon the potential hospital types identified in Step One;
► Step Three: Conduct a high level evaluation of these options in order to establish a short list of options for detailed evaluation. In doing so, a long list of thirty-two options was developed, which was reduced to an initial shortlist of eight options for detailed evaluation and a final shortlist of three (see Section 6). The remainder of this section details how these shortlisted options were determined. Ernst & Young 37
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5.3 Step One: Potential service configuration models The CPT worked very closely with the CAG to consider what service configuration models are possible for Stafford and Cannock.
The CPT and CAG agreed that there were a range of options for Stafford and Cannock, based upon variations of the traditional acute hospital model or the local hospital model that are emerging within the NHS. The CPT looked first at the options for meeting local needs for local and non-elective care.
5.3.1 Acute hospitals The traditional hospital model is the general acute hospital providing a broad range of services. Acute hospitals can range in size from larger more specialist tertiary centres and teaching hospitals (e.g. UHNS), down to smaller district general hospitals (e.g. Stafford Hospital). It should be recognised that in describing different types of hospital models there is a spectrum from a “community hospital” to a “major acute”. For the purpose of the options development described in this report the CAG defined hospitals providing a full range of acute services (including emergency surgery, critical care and unselected medical admissions) as “major acute hospitals”.
Recent service reconfigurations in the NHS have led to some district general hospitals providing a reduced range of non-elective/emergency services. For example, this may include the decommissioning of their emergency surgery service while retaining some acute medical services. These hospitals are often referred to as ‘warm sites’. These hospitals are often part of an established clinical network with one or more major acute hospitals.
Stafford Hospital currently offers a range of core emergency services, i.e. A&E, emergency surgery and an unselected medical take. It has set up some networking with UHNS, but this is at a relatively early stage.
The CPT and CAG agreed that both a major acute hospital and a warm site should be considered on the long list of options for Stafford Hospital.
The CPT and CAG noted that the characteristics of Cannock are more similar to the local hospital model described in the next section than that of a full acute hospital. Given the close proximity of Cannock Hospital to Walsall and Wolverhampton, it was therefore agreed that the option of an acute hospital (either major acute or warm site) in Cannock should not be considered.
5.3.2 A ‘local hospital’ Other recent service reconfigurations in the NHS have seen the emergence of the concept of the ‘local hospital’ which is distinctly different to the traditional acute hospital model, and closer, although different, to what is often called a “community hospital”.
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The concept of a local hospital is consistent with the principles of “centralise where necessary” and “localise where possible” and the drive towards better integration of care across primary, secondary and community services.
There is a national trend towards greater centralisation of specialist services onto fewer sites to improve safety and quality of care by ensuring the availability of fully trained specialists and equipment on a seven day a week basis, up to 24 hours a day. This creates a greater need for local hospitals to maintain access to more commonly needed and less specialised services. This has been reflected in the recommendations for recent healthcare reconfigurations e.g. in NW, SW and SE London and in Hertfordshire.
In addition, there are clearly stated commissioning intentions for improving the integration of clinical pathways across primary, community and acute care. A local hospital creates the opportunity to drive this integration, for example, by co- locating some of these services.
While it is informative to look at other examples, it is critical that the range of services at a local hospital should be tailored to the needs of the local population it serves. The following are some desirable characteristics of the services delivered by a local hospital:
► A local hospital provides access for a local population to a range of services for common conditions that are, therefore, used frequently;
► A local hospital is part of a clinical network, i.e. there are close links with:
i) Acute providers in the local health economy. For example, the acute provider is commissioned to provide an acute service for patients in the catchment of the local hospital, but all of the outpatient appointments and basic diagnostics associated with the patient’s treatment are delivered at the local hospital;
ii) Local community providers, especially in care pathways associated with care of the elderly and patients suffering from long term conditions.
The services within a local hospital could include some of the following:
► Emergency and Urgent Care service. This is not a full Accident and Emergency department, but a non-admitting unit such as a Minor A&E, an Urgent Care Centre or a Minor Injuries Unit. It is often desirable to integrate GP out of hours services in order to provide a coherent 24/7 service;
► Some emergency and urgent care services can be supplemented by facilities allowing short stay admissions of low-risk patients requiring some inpatient support who are then discharged back into the community. These patients may require access to medical cover which can be provided through a clinical network with a neighbouring acute hospital;
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► Outpatient services for the local population including pre and post natal appointments;
► Diagnostic services, as part of the outpatient service, and for GP direct referrals;
► Intermediate care inpatient beds that can act as a step down facility for other providers in the Local Health Economy, particularly for patients from the local area. These are often frail elderly patients who need ongoing inpatient care and/or rehabilitation before returning to their normal place of residence;
► Provision of minor procedures such as diagnostic investigations, day case procedures or outpatient procedures.
In many ways, Cannock Hospital is currently very similar to a local hospital, so the CPT and CAG agreed that the local hospital model should be considered for both Stafford and Cannock Hospital.
5.4 Step Two: Developing the long list of options Having determined the potential service configuration models for local and non- elective care that should be considered in Stafford and Cannock, the CPT and CAG also considered elective care. This included whether there were clinical and/or financial benefits associated with consolidating elective inpatient services onto only one of the sites. In addition, the CPT and CAG looked at the case for delivering some elective work currently done by other providers at one of the MSFT sites (an “elective centre”).
Taking this into account, it was agreed that there were 32 possible options for meeting local needs for local, non-elective and elective care that could be considered on the basis of the various combinations of hospital type in Stafford and Cannock15. These options are shown in Figure 3.
Figure 3: The long list of 32 options
Options for services in Stafford
Acute hospital (‘warm site’) Local hospital As current state 1. Major Acute 8) No services 2) + IP 3) + IP 4) No IP 5) + IP 6) + IP 7) No IP hospital / site closure elective centre elective care elective elective centre elective care Elective
A) + IP 1A 2A 3A 4A 5A 6A 7A 8A elective centre
B) + IP Local hospital 1B 2B 3B 4B 5B 6B 7B 8B elective care
services services Cannock in C) No IP 1C 2C 3C 4C 5C 6C 7C 8C elective
D) No services / site closure 1D 2D 3D 4D 5D 6D 7D 8D Options Options for
15 This conclusion was reached during Phase One of the CPT, so at the time the range of 32 options included the possibility of closing one or both of the hospitals as this was being evaluated as part of the sustainability review. Ernst & Young 40
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Notes
1) An elective centre implies that the site would deliver additional elective activity, currently delivered at other trusts in the region; elective care refers only to the elective activity currently delivered by MSFT. 2) Options 4 and 7 for Stafford, and option C for Cannock, include the provision of day case elective procedures that would be appropriate to the range of on-site support services (Options 7 and C being restricted to simple day case procedures and no critical care provision).
5.5 Step Three: Establish a shortlist of options Having established a long list of 32 options, the next step was to reduce this list to a short list of options that could be taken forward for a detailed evaluation during Phase Two of the CPT. Based upon the information gathered and analysis undertaken during Phase One, the CPT excluded 25 options from the long list of options. The rationale for excluding options is as follows.
5.5.1 Excluding options on clinical and financial sustainability grounds The CPT concluded that MSFT as a trust is clinically unsustainable. As was discussed earlier, the standards set out by the Royal Colleges imply that small hospitals struggle to recruit and retain sufficient senior medical staff to provide care on 24/7 basis. Even if it were possible to afford and recruit such doctors they would not have sufficient on-going work to maintain their skills and capabilities.
The CPT also concluded that the current services, which are effectively those of a sub-scale major acute hospital, are unsustainable financially. On this basis, the CPT has concluded that a major acute hospital in Stafford (option 1) is not a realistic option (as per CPT Conclusions One and Two – Section 2.3). Accordingly, the alternatives under option 1 have been excluded. This further reduced the number of options from 32 to 28.
5.5.2 Excluding options on commissioning grounds The local commissioners, in developing their draft list of protected services, determined they wished to retain access to outpatient services in both Stafford and Cannock (as per CPT Conclusion Three – Section 4). Therefore, the alternatives for option 8 and option D were excluded. This reduced the long list of options from 28 to 21.
5.5.3 Excluding options on clinical grounds The collective opinion of the CAG was that a site with a reduced set of acute services or a “warm site” option for Stafford was not desirable, due to the close interdependencies between different non-elective and emergency services, and complex elective services – in particular the requirement for on-site critical care. Exclusion of all warm site options would have further reduced the number of remaining options from 18 to 9.
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However, at the request of the Chairs and Chief Executives of the providers across the Local Health Economy, the CPT agreed to re-assess the clinical rationale for two specific warm site options - 3C and 4C - in depth with the CAG.
It was agreed to split option 3C into two variants:
► Variant 1: An ‘unselected acute medical take with critical care but not emergency surgery’. This means that patients needing, or possibly needing, emergency surgery, are taken to an alternative site.
► Variant 2: A ‘selected acute medical take with no emergency surgery and no critical care’. This means that patients needing, or being at risk of needing, critical care are taken to an alternative site.
Adding these three warm site options (3Cv1, 3Cv2 and 4C) increased the number of options back to 12.
No definitive conclusions were drawn on warm site options until the detailed evaluation.
5.5.4 Excluding options on the basis of activity levels If a local hospital was established in Stafford this would be within 10 miles of the local hospital in Cannock. As previously mentioned, operating inpatient beds means that there needs to be consultant, anaesthetist and resuscitation cover overnight. The CPT and CAG has concluded that with the current levels of demand for low risk inpatient elective care it would not make clinical or financial sense for both sites to operate inpatient beds. Therefore options 5A, 6A, 5B and 6B were excluded. This reduced the number of options being evaluated from 12 to 8.
CPT Conclusion ► Clinically appropriate inpatient elective work could be run Four: from either Stafford or Cannock
Consolidate ► However, this work should be consolidated onto one site to inpatient elective activity benefit from economies of scale to support appropriate on one site overnight cover.
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5.5.5 Finalising the shortlist of service configuration models In summary, the initial shortlist therefore comprises eight options, as illustrated in Figure 4. Appendix A provides a high level overview of the services included for each of these options. Figure 4: The shortlist of service configuration models
Options for services in Stafford
Acute hospital (‘warm site’) Local hospital As current state 1. Major Acute 8) No services 2) + IP 3) + IP 4) No IP 5) + IP 6) + IP 7) No IP hospital / site closure elective centre elective care elective elective centre elective care Elective
A) + IP 7A elective centre
B) + IP Local hospital 7B elective care
services services Cannock in 3C 3C C) No IP 4C 5C 6C 7C elective v1 v2
D) No services / site closure Options Options for
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6. Clinically evaluating the shortlist of options
The eight shortlisted options were evaluated against four criteria starting with clinical sustainability and quality. Only options that passed this evaluation were then further assessed in terms of patient access and financial sustainability. Table 12 sets out the high level criteria used:
Table 12: The evaluation criteria used to evaluate the short list of options
Evaluation test Criteria
What would be needed for this to be a viable model of care? Does the option improve clinical sustainability, by moving 1: Clinical closer to national standards for provision of acute and sustainability, emergency services for the population of Stafford and quality of care and Cannock? patient safety Does the option improve clinical effectiveness of elective treatment services for the population of Stafford and Cannock?
2: Access for the How many potential patient trips will be affected by the population of changes? Stafford and What is the impact on patient travel times? Cannock
Is the option financially sustainable? 3: Financial What is the financial impact of the option on other sustainability providers?
The remainder of this section sets out the clinical evaluation before presenting the CPT’s recommended clinical model. Section 7.2 outlines the likely impact on patients and the financial evaluation is presented in Section 8.
6.1 Clinical evaluation The CPT’s primary objective has been to develop a set of options that are clinically sustainable, ensuring the local population can access clinically safe and high quality services, with as many of services delivered locally as possible. The CPT and CAG assessed each of the eight shortlisted options on the basis of clinical sustainability, quality of care and patient safety.
The primary conclusions of this assessment were:
► A ‘warm site’ in Stafford would be clinically undesirable.
► Therefore, the local hospital model provides the best opportunity for the local commissioners to fulfil their commissioning intentions and meet national standards for emergency care.
► Maintaining current elective work at MSFT is clinically sustainable, but current caseload should be reviewed for clinical appropriateness in a local hospital
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model and inpatient work should be consolidated on one of the two sites to capture economies of scale.
► There does not appear to be a compelling clinical case for the establishment of an elective centre in Stafford or Cannock. However this option should be explored further in the next stage of work (see Section 10.1).
6.1.1 The evaluation of a warm site The CAG deemed that the “warm site” option in Stafford, (i.e. keeping a reduced selection of current non-elective (emergency) services) was clinically undesirable on the grounds set out in Table 13.
Table 13: The rationale for ruling out the warm site options ► A 24/7 emergency surgery service should have 8-9 general surgeons on the general surgery take, with one CPT Conclusion Five: consultant (ideally capable of conducting laparoscopic surgery) available on site within 30 minutes, any day or Emergency Surgery is time and available immediately by telephone not viable ► MSFT has five general surgical posts, of which only two are covered by substantive consultants. Only one of the staff is laparoscopically trained
► 39% of critical care beds are used for non-elective surgery CPT Conclusion Six: today (55% for non-elective medicine, 6% for elective surgery) Critical care therefore ► If non-elective surgery is no longer delivered, only 4-6 becomes unviable beds would be required ► Staffing and maintaining clinical skills at a very small unit is extremely difficult and unviable in the long term CPT Conclusion Seven:
► An unselected medical take without critical care, or Without critical care, an emergency surgery on site introduces clinical risk and unselected medical take therefore is not desirable and a consultant-led ► Consultant-led obstetrics service cannot be supported in a obstetrics service unit without critical care becomes unsustainable
► A selected acute medical take adds complexity in the process for assessment of emergency patients,, which is high risk and undesirable CPT Conclusion Eight: ► The lack of an on-site critical care service would be unsafe even for a selected acute medical take, in the event that A selected medical take patients deteriorate rapidly is high risk and reduces ► A selective consultant-led A&E will see significantly viability of a consultant- reduced activity, compounding existing problems with led A&E service consultant cover
► A service that only manages a small medical take will struggle to attract staff, due to the lack of opportunities to train and maintain experience for serious emergency cases
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The CAG and CPT therefore excluded options 3Cv1, 3Cv2 and 4C from further evaluation, reducing the shortlist of options to five. Local commissioners have determined that they wish to protect a clinically appropriate 24/7 Emergency and urgent care service in Stafford. One consequence of the conclusions around critical care is that Stafford would not be a clinically appropriate setting to treat patients with major urgent care needs. This means that some patients currently treated at Stafford A&E would need to be taken to an alternative provider. The CPT’s initial assessment is that approximately 50% of the patients currently attending A&E in Stafford would still be appropriate to attend any proposed new service that is not supported by critical care. In January 2013, the NHS Commissioning Board commenced a review (being led by Sir Bruce Keogh, the Medical Director of the NHS) into the model of urgent and emergency services in England. The CPT believes this a very timely review, which should significantly inform the final proposals for the service that should be established in Stafford. 6.1.2 Is midwife-led unit feasible in Stafford? Standalone midwife-led units (MLUs) can provide a viable alternative to an obstetric unit for lower risk women/babies. The CAG considered the option of a standalone MLU. The conclusion of the CAG was that it would likely not be viable as a standalone unit in Stafford, which is already amongst the smallest obstetric units in England. The CAG were concerned about the viability of a very small midwifery-led unit and noted that it would need to be staffed with very senior and experienced community midwives, which could be challenging to recruit. The CAG therefore thought it unlikely that there would be sufficient demand at Stafford to ensure a clinically and financially viable unit. The CPT has gathered information to validate the view of the CAG and has concluded that a stand alone midwifery-led unit is unlikely to be viable (see conclusion below).
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16 ► Estimates from national studies suggest that between 50-60% of pregnancies are classed as low risk.
► However, experience from MLUs across the country shows that only 10-12% of women actually choose to give birth in a midwife-led unit (co-located or standalone)17 where previously there was an obstetric unit. This is likely because epidural anaesthesia is not available and due to the possibility of an estimated 22% CPT Conclusion of women needing to be transferred during labour due Nine: to a complication.
A stand alone ► The current number of births in Stafford is around midwifery-led unit is 1,900 and therefore in a standalone MLU births there unlikely to be viable could be as few as 200 births per year.
► Given that any standalone midwife-led unit requires at least two midwives to be present at all times, a complement of around 16 WTE midwives would be needed.
► This would mean each midwife could expect to deliver as few as 13 babies a year - a number which is too low to maintain skills and capabilities - and is also a very expensive service model.
6.1.3 Is an elective centre clinically desirable and is it feasible? The CAG reviewed the options for elective care including an elective centre, whereby some of the elective surgical activity that is currently delivered at other trusts in the region could be drawn into a dedicated unit at Stafford or Cannock. This assessment is split into three parts: elective day cases, elective inpatient work currently undertaken at MSFT, and elective inpatient work currently undertaken at other sites. The CAG identified the following considerations:
► The CAG and CCGs both concluded that clinically appropriate day cases currently undertaken at Stafford and Cannock should remain there. The exact percentage requires further clinical audit, but is estimated to be a large proportion of current MSFT day case work (~95%).
► The CAG and CCGs also concluded that clinically appropriate elective inpatient work currently undertaken at Stafford and Cannock was viable as part of a local hospital model for each site. However, this work should be consolidated onto
16 Hollowell J et al. The Birthplace national prospective cohort study: perinatal and maternal outcomes by planned place of birth. Birthplace in England research programme. Final report part. NIHR Service Delivery and Organisation programme; 2011 17 Hospital Episode Statistics maternity data 2011/12 report that 12% of all births occurred in both types of midwifery units, (alongside midwifery units and free standing midwifery units) Ernst & Young 47
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one site to benefit from economies of scale to support appropriate overnight cover.
► A centre dedicated to elective care across a broader area of the LHE could bring benefits, in terms of reduced hospital acquired infection rates and reduced cancellations. However:
Practically, an elective centre works best if located very close to critical care and other acute facilities. A “remote” elective centre model would require either a very low risk patient population, or at least level 2 critical care on site. The CPT has modelled the former based on CAG advice.
Transfers are smoothest if the acute site and elective centre are part of the same organisation, or have a joint ownership structure (e.g. a Joint Venture of participating trusts)
Working across multiple sites increases complexity, therefore it is desirable to have limited number of specialities that have a critical mass on site
Overnight surgical cover is needed for an elective inpatient service, which requires sufficient scale in the relevant services at the site
Orthopaedics would most likely be the single largest specialty at an elective centre, accounting for ~ 50% of activity. Orthopaedic surgery should preferably be performed in a theatre that uses a laminar flow ventilator, which reduce the chance of post-operative infection. The majority of laminar flow theatres within MSFT are located in Cannock Hospital.
In addition to these clinical considerations, there is a significant question of whether there is sufficient demand from patients, GPs or other providers to support an elective centre in either Stafford or Cannock. MSFT has lost elective market share in recent years. Whilst this could potentially be turned around using a new approach to service provision, it does not suggest a significant amount of currently unmet patient/GP demand.
If an elective centre was situated in Stafford or Cannock then it could provide a service for patients currently treated at other hospitals. This might be one approach to resolving bed capacity shortages across the local health economy, but clinical considerations rather than capacity management should drive this decision.
On the basis that the core specialities suitable for an elective centre include orthopaedics, urology, gynaecology and general surgery, Figure 5 illustrates the CPT’s assessment of potential activity in 2015/16 if an elective centre was located in either Stafford or Cannock (expressed in terms of the number of beds required). This assessment includes only those inpatient procedures that are deemed suitable to be conducted in a centre without critical care level 2 or higher.
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Figure 5: The forecasted levels of potential elective inpatient activity in 2015/16
Potential elective inpatient activity 2015/16 No. of beds1
45 Total : 31-50 40
35 13-25 30
25 Total: 17-28
20 7-14 15 12-23 10
5 11 5 0 Stafford Cannock
Baseline of current activity From UHNS From Walsall From Wolverhampton
The CPT has therefore concluded that there is not a compelling case for an elective centre in Stafford or Cannock, but this should be finalised during detailed design.
CPT Conclusion Ten: ► There is not a compelling clinical or demand based rationale at this stage to make an elective centre part of the core There is no rationale options. to include an elective ► Therefore, the CPT did not evaluate in further detail the centre in either of elective centre options 7A and 6C. the proposed local hospitals ► However, further work should be undertaken on this once the core service model has been finalised.
6.1.4 The conclusion of the clinical evaluation The three core options remaining are all variations of a local hospital in both Stafford and Cannock and are shown in Figure 6. Figure 6: The remaining three options that have been evaluated further.
Options for services in Stafford
Acute hospital (‘warm site’) Local hospital As current state 1. Major Acute 8) No services 2) + IP 3) + IP 4) No IP 5) + IP 6) + IP 7) No IP hospital / site closure elective centre elective care elective elective centre elective care Elective
A) + IP elective centre
B) + IP Local hospital 7B elective care
services services Cannock in C) No IP 6C 7C elective
D) No services / site closure Options Options for
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7. The CPT’s recommended clinical model
Having developed and evaluated a series of options for the clinical configuration of services in Stafford and Cannock. This section summarises:
► the recommended clinical model;
► the CPT’s assessment on the implications of this model for patients. 7.1 The recommended clinical service model for Stafford and Cannock The CPT is recommending the establishment of a local hospital in Stafford and a local hospital in Cannock. There are still a number of elements of the hospitals in each locality to be refined if these recommendations are taken forward.
The clinical service model has seven types of service in each locality. In Stafford, five of these are considered to be core elements with two further types of service to be considered during the detailed design of the reconfiguration. In Cannock, four of these service types are core with three to be considered further.
The elements are outlined in Figure 7, with the core elements shown in grey.
Figure 7: The elements of the proposed local hospitals in Stafford and Cannock
Patient
Clinically Elective IP GP direct referrals 24/7 Hub for Specialty OP appropriate2 Intermediate activity Emergency primary and including ante medical and care beds (50- (current or Stafford and urgent community and post-natal surgical day 100 beds)4 from other care services1 services3 cases providers) 5
Clinically Elective IP Hub for Nurse led Specialty OP appropriate2 GP-led activity primary and Minor Injuries including ante medical and intermediate (current or 6 community Unit and post-natal surgical day 3 care beds from other Cannock services cases providers) 5
Therapies including physio, OT
Diagnostics including ultrasound, plain film X-ray, etc. both Support
services at at services Other clinical support including pharmacy, phlebotomy, etc.
Core services Potential add-ons
Notes
1. Incorporates GP out of hours services. Staffed by a multidisciplinary team, likely to include advanced nurse practitioners with prescribing rights, GPs and emergency medicine specialists, with access to specialist input, 999 and non-emergency transport. MSFT A&E has ~800 attendances a week today. If 50% of activity is retained, this will be ~400 attendances a week, or 50-60 attendances a day;
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2. Current MSFT work that can be safely performed without critical care support; day cases requiring theatres/ dedicated suites to be kept as is, if financially feasible, else consolidated on a single site; 3. Potentially includes a wide range of health and social services, including ambulatory care for long term conditions; 4. These beds are to be led by elderly care physicians or GPs. CPT initial estimates are that there will be the need for 50-100 beds in Stafford. These beds are likely to be provided in conjunction with UHNS and will alleviate some of the capacity pressures at UHNS; 5. The financial evaluation has indicated that elective care beds in one locality will deliver a larger surplus than having no elective care at either locality. However, the case for whether elective activity is retained in Stafford and Cannock needs further exploration;
6. The MIU in Cannock is currently operated by SSoTP. The CPT has not recommended changing the current MIU, but has not assessed whether SSoTP is the best placed to continue to provide this service. As stated above, there are a number of elements that need more detailed design following Monitor’s decision on how the CPT’s recommendations are taken forward. Section 10.1 outlines the further work that is required.
7.2 What are the implications of this recommendation for patients? The CPT believes that local hospitals in both Stafford and Cannock will secure the sustainable delivery of high quality health services for the local population.
Effective clinical networks with local acute hospitals supported by enhanced ambulance services will ensure that patients can access higher quality, more highly specialised services whilst still maintaining the vast majority of hospital attendances at their local hospital.
The CPT also believes that this presents an opportunity to deliver a much more integrated approach across acute, primary, community and social care. This will be especially critical in treating an ageing population and patients with long term conditions who are typically treated in all four types of care provision.
The CPT conducted a series of assessments to understand the impact on patients, especially access to care. These analyses were aimed to address the following questions:
1) Why are the proposed changes better for patients? 2) How many potential patient trips will be affected by the changes? 3) For services that would be relocated, what is the impact on patient travel times, assuming they travel to the nearest alternative provider of the service?
4) What does this mean in practice for patients? This section outlines the outcomes of these assessments.
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7.2.1 Why are the proposed changes better for patients? The CPT has worked closely with the local clinicians and the CAG to develop solutions that improve care for the local population and deliver better outcomes not only today but also in the future. In doing so the CAG reviewed standards for high quality services as defined by the Royal Colleges.
While recognising that best practice guidelines may not be achievable in all cases, the CAG agreed that these guidelines should define the aspiration for healthcare services for the local population, and any proposed models should move services closer to these aspirations.
Clinical evidence demonstrates that early and consistent input by consultants for non-elective and emergency care enables rapid and appropriate decisions. This ensures that patients receive correct diagnoses and are quickly on the right pathway of care, leading to better patient outcomes including reduced mortality rates and improved physical functioning and quality of life18.
Larger more specialist centres are able to attract and retain a greater level of consultant cover and associated teams. Greater centralisation of specialist services in such centres allows the consultant cover to extend to seven days a week and up to 24 hours a day which meets the Royal College guidelines19. Studies and reports have shown that centres with a higher level of consultant presence achieve better outcomes for patients who are looked after by more experienced staff. At these larger more specialist centres consultants and their teams see a wider range of patients that provides them with the experience to maintain their skills and enables them to invest in the latest technology and treatments. In a broad range of services – from vascular surgery to cancer care to acute cardiac care as well as critical care and emergency surgery – larger centres with more consultants are able to deliver better quality care resulting in fewer adverse events (deaths or complications) and better functional abilities for patients.
At MSFT today, the relatively small number of patients20 being treated does not provide consultants with the range and frequency of experience they need to maintain their skills and the number of consultants available means that it is often not possible to have seven day a week or up to 24 hours a day specialist consultant presence in many specialities. A good example of this is in emergency surgery where a high quality service would have at least 8 – 9 consultant general surgeons on the general surgery take so that one of them can be available 24 hours a day seven days a week – and where the majority are trained in the latest surgical techniques such as laparascopic surgery. This is not feasible at MSFT where the
18 National Confidential Enquiry into patient Outcome and death, 2007. Emergency admissions: A step in the right direction, NCEPOD; London Health programmes, 2011. Adult emergency services: case for change, London Health programmes
19 Seven Day Consultant Present Care December 2012. Academy of Medical Royal Colleges 20 Mid Staffordshire NHS Foundation Trust sustainability report, Monitor Contingency Planning Team, January 2013 Ernst & Young 52
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numbers of patients being treated is too small to enable such numbers of surgeons to be trained and maintain their skills.
The consolidation of services in Staffordshire has already taken place for some services. Currently patients with stroke, heart attack or vascular surgery go to UHNS because the Trust is better placed to provide consultant delivered service on a 24/7 basis and has the necessary expertise and equipment that enable them to save patient lives. The CPT’s recommendations are an extension of this, to ensure the population of Stafford and Cannock can continue to get an excellent service at units which are closer to achieving the best practice guidelines.
While some of the proposed changes call for centralisation where it is necessary to deliver better care for the local population, the CPT recognises that where possible (i.e. where clinically and financially sustainable) services should be delivered locally. Over 80% of the current patient attendances to either Stafford or Cannock hospitals will remain within the same locality (Section 7.2.2 for further detail). In addition, given the needs of the local population, the CPT recognises the need to have access to intermediate care beds locally and to improve the provision of out of hospital care as well as care integration. This will provide more appropriate care to a growing elderly population, avoiding admission to an acute hospital bed where it is not necessary.
7.2.2 How many potential patient trips will be affected by the changes? In all of the remaining options, some acute services currently delivered by MSFT will need to move to an alternative provider. Bearing in mind commissioner intentions to provide as much care as possible close to home, outpatient clinics will remain in Stafford and Cannock, minimising patient journeys elsewhere. Currently, over 55% of all patient trips to Stafford and Cannock Hospitals are for outpatient appointments. These can be delivered safely through a local hospital model. Therefore, it is highly desirable to keep these in the current locality, as reflected in the draft list of protected services from the CCGs. Similar considerations apply to urgent care, pre and ante natal maternity services, and the majority of paediatric visits and elective day cases. Figure 8 presents movements of services by type of patient trip, concluding that the total number of trips moving as a result of the proposed changes is about 16%.
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Figure 8: The forecasted impact on patient access to services
6C Local hospital, 7B Local hospital, Current elective IP in elective IP in 7C Local hospital, Department Activity Stafford Cannock no elective IP
A&E/ PAU/ UCC2 43,971 49% 51% 49% 51% 49% 51% Activity remaining at site Activity moving off site1 Adult OP 200,170 91% 9% 91% 9% 91% 9%
Adult elective IP 3,981 39% 61% 26% 74% 0% 100%
Adult Daycase 28,373 93% 7% 93% 7% 93% 7%
Paediatrics4 27,963 85% 15% 85% 15% 85% 15% Maternity (inc. ante and 47,923 90% 10% 90% 10% 90% 10% post natal)
84% 15.9% 84% 16.0% 84% 16.3% Total 355,381
Notes 1) Activity moving from one MSFT site to the other is counted as a move to an alternative site 2) These figures do not include the impact of intermediate care beds, which would increase the amount of activity retained for ‘Adult elective inpatients’ in all scenarios. These numbers have not been assessed as the intermediate care beds are a service not currently provided. 3) Non-elective inpatients are included in the A&E numbers as this is the point of access 4) Paediatrics includes elective, day cases and out patients. Non-elective is included within the A&E figure
► For maternity services ~ 90% of patient visits will stay at MSFT CPT Conclusion under a local hospital model, as all non-complex ante- and Eleven: post-natal outpatients would still be delivered in the current locality. The majority of ► For paediatrics ~ 85% of patient visits (outpatients, day cases) patient attendances will stay in the same locality under the local hospital model. (>83%) will stay within the same ► For A&E, it is estimated that at least 50% of attendances locality in all of the (those that are currently discharged with no/ GP follow up) options considered. could stay locally, but this will depend on the nature of the Emergency and Urgent Care service that is delivered in Stafford.
Section 7.2.4 presents some examples of the impact on patients of these recommendations
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In addition, two further areas are not reflected in the numbers above:
► “Step up” intermediate care beds could accommodate some of the current attendances. This requires further clinical audit of caseload in the next phase of work. But as a broad indication, this might involve 10-15 beds with an average stay of 2 days accounting for potentially 20% of current A&E admissions, particularly for the frail elderly.
► “Step down” intermediate care beds at Staffford would accommodate the post- acute rehabilitation part of the hospital stay of acute medical admissions moving to another trust. This would comprise 50-100 beds (ideally at the lower end of this range) accounting some of the current acute medical bed days at Stafford.
7.2.3 What is the impact on patient travel times? The CPT’s analysis of the three local hospital models concluded that approximately 16% of current patient visits will no longer be delivered in the same locality if a local hospital is established in both Stafford and Cannock. The analysis also showed that approximately half of the attendances that are relocated are emergency cases and the other half are planned elective attendances. The CPT assessed the impact on patient travel times for those attendances that are likely to be relocated. The assessment of travel times is based upon the average time to travel during peak traffic periods from each postal code area within the catchment areas of Stafford and Surrounds CCG and Cannock Chase CCG to the nearest alternate provider. In making these assessments, the following assumptions were made:
► Patients attending a hospital in an emergency case are likely to travel either by ambulance or in a private car.
► Patients attending a hospital for a planned elective attendance are likely to travel in either private car or by using public transport.
In either situation, patients travel to the nearest alternative provider. This is likely to be true in emergency cases, although for elective care, patients may choose to travel to providers that are further away.
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The results of this analysis are shown in Table 13.
Table 13: The estimated impact on average travel times Stafford and Surrounds CCG Cannock Chase CCG Proportion population population Type of of current Mode of Travel time Travel time Travel attendance attendance travel Travel time with local with local time today affected today (mins) hospital hospital model (mins) model (mins) (mins) No change in 84% No change access Ambulance/ Emergency / 8 15 13 14 non-elective Blue light 8% with change in access Private car 13 23 20 21
Elective Private car 13 23 9 21 planned care 8% with change Public 40 66 29 62 in access transport
For travel for non-elective (emergency) care at peak times, on the assumption that these journeys are conducted by ambulance or private car:
► For Stafford and Surrounds CCG, the average blue light travel time increases from 8 minutes to 15 minutes, and private car travel time increases from 13 minutes to 23 minutes;
► For Cannock Chase CCG, the average blue light travel CPT Conclusion time increases from 13 minutes to 14 minutes, and Twelve: private car travel time increases from 20 minutes to 21 minutes. Travel for non- ► The CPT analysis also indicates that the maximum blue elective (emergency) care will increase, light ambulance travel time would be less than 25 but it is within minutes. acceptable standards ► Therefore, overall travel times for Cannock residents would not change significantly while for Stafford they would increase, but remain relatively low compared to many if not most parts of the NHS. For example, the London Health Programme determined that 30 minutes should be the maximum ambulance travel time to the nearest hospital for patients who have suffered a major trauma or are showing symptoms of having suffered a stroke21.
21 http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/Travel-Times-Ambulance-Coverage-Analysis.pdf Ernst & Young 56
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For travel for elective care at peak times, on the assumption that these journeys are conducted by private car or public transport:
► For Stafford and Surrounds CCG, the average private car CPT Conclusion travel time increases from 13minutes to 23 minutes, Thirteen: and public transport travel time increases from 40 Travel for elective minutes to 66 minutes care, especially by ► For Cannock Chase CCG, the average private car travel public transport, is time increases from 9 minutes to 21 minutes, and public higher than commissioner transport travel time increases from 29 minutes to 62 aspirations, has led minutes to the protection of ► 17% of the Stafford population (9,742 households) and some local regularly 20% of Cannock population (8,213 households) do not accessed services, have access to private cars. While the number of and may require patients potentially affected is a small part of MSFT’s revised commissioning of total patient population, the analysis has shown there is patient transport a significant rise in travel times for this group. services ► The local commissioners recognise the impact that this could have on health inequalities and expect that any move to a local hospital model will need to be supported by an appropriate change to patient transport services to address the needs of this segment.
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7.2.4 What does this mean in practice for patients? The proposed options will improve the quality of care by ensuring increased compliance with national standards for emergency care while delivering the majority of services locally. The CPT has not assessed the impact on every care pathway, but for illustrative purposes, the following diagrams indicate how the recommended changes will impact three common patient pathways.
Illustrative case study 1: A paediatric case with a minor injury. The 24/7 emergency and urgent care centre, in the local hospital model, would replace the 14/7 A&E which may previously have been used:
Figure 9: A minor paediatric case study
Pathway for urgent paediatric: An 8 year old girl hurts her finger playing football. She has some discomfort and suspects it may be dislocated. She attends the A&E at Stafford to get it checked out.
Attends A&E Attends EUCC Has x-ray and Sent home Attends follow for assessment for assessment other checks with dressings up clinic
Element of As Is Stafford N/A Stafford Stafford Stafford pathway remains as now Element of pathway moves Local N/A Stafford Hospital Stafford Stafford Stafford
Illustrative case study 2: A non complex maternity case. Patients will receive their ante and post natal care (check-ups and scans etc.) in Stafford or Cannock but will have their birth at another hospital of their choice:
Figure 10: A non complex maternity case study
Pathway for maternity care: A 27 year old woman who is receiving regular ante natal care at Stafford and plans to have her baby at Stafford Hospital. She has had some minor complications during her pregnancy and is under the care of the Consultant Obstetrician.
See GP for Consultant-led Short stay on Visits midwife Attend ante- Attend post- confirmation birth in maternity & health natal clinic natal clinic of pregnancy delivery suite ward visitor
Element of Local GP As Is Stafford Stafford Stafford Stafford Home pathway remains surgery as now Element of pathway moves Local Local GP Stafford Other hospital Other hospital Stafford Home Hospital surgery
Illustrative case study 3: An elderly patient who needs a hospital admission. The patient will initially go to another hospital in the area but will be transferred back to Stafford for rehabilitation and monitoring:
Figure 11: A care of the elderly case study Pathway for care of the elderly: A 82 year old women has been off her feet for a few days. She has had a fall and was found by a neighbour who called an ambulance. On arrival at A&E she was confused and unstable. She was admitted for 14 days under the care of the geriatricians.
Ambulance Admitted for Further Monitoring in Post discharge assessment at Attend A&E diagnosis & monitoring on step down follow up by home assessment ward beds Geriatrician
As Is Home Stafford Stafford Stafford N/A Stafford Element of pathway remains as now Element of Local Other acute Other acute Home N/A Stafford Stafford pathway moves Hospital hospital hospital
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8. The financial evaluation of the CPT’s recommended clinical model
The financial evaluation has assessed the potential implications for the three options, in terms of the income and expenditure associated with delivering the options. The CPT used the same data and information provided by MSFT for the sustainability report. The following steps were taken:
1. Establish a financial and activity baseline for 2015/16 based upon MSFT delivering the same range of services as today, making assumptions about efficiency benefits that could feasibly be delivered; 2. Assess the impact on the baseline income and expenditure directly associated with the changes in the clinical service model for each of the three options; 3. For each of the three options, assess the impact on the baseline costs following a reduction in indirect costs and an estimation of the potential savings through collaboration and/or outsourcing; 4. For each of the three options, assess the further impact on costs following an estimation of the potential savings that could be achieved through a change to the organisational form. The financial evaluation does not include the cost of implementing the solution or any capital requirements associated with the proposed reconfiguration. 8.1.1 Setting the 2015/16 baseline To forecast the 2015/16 financial and activity baseline (see Table 14) the CPT used the same information and activity dataset that was used to assess MSFT’s sustainability in Phase One of the CPT.
The CPT used forecasts based on the financial and activity datasets provided by MSFT which were then projected forward to determine a full year financial position for 2012/13. The 2015/16 financial baseline was calculated using income, cost and activity growth assumptions agreed by the Operating and Financial Group.
Efficiency benefits were capped at 4% and were applied equally to all areas of spend at a cost centre and account code level. This enabled the CPT to estimate costs associated with each service and point of delivery.
Current income associated with rental of premises and high cost drugs was removed from the baseline so that the CPT could evaluate the sustainability of the core service model.
The same dataset was used to forecast the activity and income values. The financial and activity evaluation has been based on known activity but sensitivities must be considered during the detailed design.
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Table 14 shows the movement from 2012/13 baseline to the 2015/16 baseline for core services.
Table 14: The forecasted financial baseline for 2015/16 Base Case £m
Income 12/13 158 Tariff deflator -2 Non-tariff deflator -1 Non-recurrent -3 Non Core income -2 Pass through -16 Income 15/16 135 Expenditure 12/13 173 CIP Efficiencies -23 QIPP -5 Pay and Non-pay Inflation 13 Activity moves 3 Depreciation 8 PDC 1 Non-recurrent -1 Pass through -16 Non-core cost -1 Expenditure 15/16 152 Surplus/(Deficit) -17
8.1.2 Assessing the impact of changes to the clinical service model The CPT assessed the financial impact of changes to the clinical service model. For the purposes of this assessment the CPT looked at the income associated with clinical activities, and the costs directly associated with delivering those services e.g. doctors, wards, theatre sessions, diagnostics.
It is important to note that despite the areas of good performance demonstrated in the sustainability report e.g. high utilisation of beds driven in part by a low mean length of stay (3.7 days) compared to its peers, the Trust maintains a high reference cost index. This means that there are some inherent inefficiencies throughout the organisation leading to a high cost base for the amount and type of activity. The method used to evaluate the options includes the cost impact of some of these inefficiencies e.g. theatre and out-patient productivity. However, it is anticipated that once the final clinical model is fully determined and the new pathways of clinical care are understood, greater efficiencies in both productivity and cost could be realised. At this point a detailed, bottom-up costing and
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workforce plan would need to be undertaken with additional efficiencies explicitly identified.
The movement of the income associated with the changes in activity followed the principle laid out in the 2012/13 Payment by Results rules that payment will follow the activity.
Costs were assumed to fall into one of three categories and were treated as follows:
► Variable – an increase or decrease in income/cost occurs for every increase or decrease in activity, e.g. the trust is paid for each person that is treated. This value can go up or down depending on how many patients are treated;
► Stepped – the cost incurred increases or decreases in increments, e.g. the cost of a 28 bedded ward will be the same up to the point when 29 beds are needed at which point another ward is needed; and
► Fixed – these costs are not linked directly to movements in activity and remain the same until a decision is made that directly increases or decreases the cost.
The CPT assessed every cost centre and account code and allocated direct costs to each service and, by using a standard apportionment methodology consistent with that of the NHS reference cost submissions, split out the direct costs to the appropriate point of delivery, i.e. outpatients or inpatients.
The CPT assessed the impact of changes in activity levels to understand where there were step cost implications. Step costs are typically applied where surgical activity is linked to the number of theatre sessions and where the number of bed days required dictates the number of wards needed to meet demand.
All assumptions were applied consistently to all options and Table 15 outlines this assessment.
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Table 15: The assessment of the impact of changes to the clinical service model £ 000 Base case Option 6c Option 7b Option 7c Income 122,942 69,758 70,425 63,901 Other Income 11,798 6,270 6,255 5,058 Total Income 134,740 76,029 76,679 68,959
Clinical Services 84,635 39,968 41,476 37,680 Expenditure Support Services 15,365 11,268 11,264 11,281 Expenditure Total Exp 100,000 51,237 52,740 48,961
Margin (£) 34,740 24,792 23,939 19,998 Margin (%) 26% 33% 31% 29%
CPT Conclusion ► Each option was found to improve the financial position of Fourteen: MSFT by up to 7% from the base case forecast, achieving a margin of up to 33% before overheads and capital charges. The local hospital models will deliver a ► In particular, the figures indicated that the financial impact better financial margin of the service changes was improved when elective than the forecasted inpatient care was maintained in addition to medical and margin for the base surgical day case activity (options 6c and 7b). case scenario
8.1.3 Assessing the potential for savings on overheads, cost of capital and benefits due to collaboration, outsourcing and changes to the organisational form The CPT reviewed the remaining overhead costs not directly associated with service delivery to determine which costs could be reduced. This included:
► Examining the overheads in the same way as the direct costs to determine those costs that could be reduced as a consequence of reducing activity, e.g. linen or patient meals; and
► Determining which costs could be reduced further through financial efficiencies associated with outsourcing or collaboration; and
► Whether or not the cost would be reduced further should there be a change in organisational form.
It should be noted that if the collaborating parties are not part of the same organisation then potentially only a share of these savings could be claimed.
Even taking the cost efficiencies into account, the retained overheads are significantly higher than would be expected if the organisation was designed from scratch. This is due to the legacy of having a cost base linked to the estate, infrastructure, operating structure and cost of capital associated with an acute Ernst & Young 62
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general hospital that has been running at a deficit for over four years. The CPT’s sustainability report demonstrated that the cost base was comparatively higher than national averages as a percentage of turnover in areas such as HR&T, Quality and Risk, IM&T and Estates. Further work would be required to go through these legacy costs in detail to understand which would need to be retained and which could be reduced to reflect the revised clinical model.
With these legacy costs retained, the CPT view is that delivering the services in Stafford and Cannock through a standalone organisation would not be possible as the current cost base could not be reduced to a level sufficient to break even. The CPT therefore also looked at the potential benefits of changes to organisational form.
At this stage the CPT assumed that part of the overhead cost base would no longer be required if the services were run by another organisation as there would be duplication of effort that could be removed and organisational synergies that could be realised. The analysis focused on removing functions such as the Trust Board and the removal/reduction of some management roles and administrative functions, e.g. Finance, Human Resources and Procurement.
Again, the impact of collaboration with other providers and restructuring would need to be determined once the clinical model is finalised through a detailed, bottom-up costing of the infrastructure and estate footprint to confirm the removal of the legacy inefficiencies and reduce the high cost base.
This assessment is outlined in Table 16.
Table 16: The assessment of the potential for savings associated with changes to the organisational form £ 000 Base case Option 6c Option 7b Option 7c Income 122,942 69,758 70,425 63,901 Other Income 11,798 6,270 6,255 5,058 Total Income 134,740 76,029 76,679 68,959
Clinical Services Expenditure 84,635 39,968 41,476 37,680 Support Services 15,365 11,268 11,264 11,281 Expenditure Total Exp 100,000 51,237 52,740 48,961
Margin (£) 34,740 24,792 23,939 19,998 Margin (%) 26% 33% 31% 29%
Overheads 41,072 25,203 25,368 21,722 Cost of Capital 10,775 7,162 7,138 7,046 Potential benefits through collaboration and changes (5,958) (9,089) (9,129) (8,949) to organisational form Total Surplus/(deficit) (11,148) 1,516 563 179
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CPT Conclusion Fifteen: The CPT estimated potential savings that would improve The local hospital models have the financial position to such an extent that, for each of been assessed to be the options, there is the possibility that a small surplus financially sustainable could be delivered.
8.1.4 Key assumptions It is important to note that in any forecasting there is an element of inherent risk and uncertainty and that a number of assumptions must be made. The key assumptions used within this evaluation are:
► Assumptions around demand management (reducing the number of patients needing hospital care through prevention and primary/community care interventions) are achieved and that both demographic and non-demographic growth will materialise;
► All projections and forecasts are based on the actual activity levels for months 1-6 of 2012/13;
► The baseline cost assumes that the target 4% cost efficiencies are achieved in FY14,15, and 16 and that these savings are delivered equally across all areas of spend;
► Commissioners will only pay for activity at the tariff rate;
► The costs and income do not include some of the elements of the model of care which are significantly different to the current services. This includes the intermediate care beds, the Urgent Care Centre, MIU, or the associated cost impact of future capital investment. Further refinement of these costs and models is required following the detailed design of the solution. The inherent risks and uncertainty associated with forecasting have been mitigated as best as possible through detailed analysis of the individual cost centres and through the validation of data and assumptions with the OFG, and the information and finance team at MSFT during Phase One of the CPT programme.
The methodology for modelling the activity and finance data used a top-down approach for most of the costing scenarios with the exception of where stepped costs were assumed to occur. This method was used in order present a realistic picture of the challenge faced and the scale of the changes required to deliver financial sustainability. However, the CPT was concerned that the detailed analysis could be misleading and would inherently include some current cost inefficiencies that were not identified. To validate the conclusions reached, the CPT produced a bottom-up model which estimated the cost of delivering and then managing the proposed options as an entirely new entity operating out of a purpose-built facility. When compared, the results of the bottom-up and top-down assessments were found to be not materially different and therefore the CPT is confident that the conclusions reached through the financial evaluation are credible.
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9. How should the preferred solution be implemented?
The CPT has considered the restructuring alternatives capable of delivering our recommendation, ensuring the continuity of high quality patient care during the transition and into the future. Of the three options available, our recommendation to Monitor is to appoint a Trust Special Administrator. This section explains each option and our reasons for choosing the recommended option.
9.1 Options for restructuring There are three options for how the restructuring could be taken forward: Trust-led, commissioner-led, and TSA-led. It should be noted that regardless of who is given the mandate, there will be a requirement to develop a detailed implementation and consultation plan. Each of these three options is described below with the following section outlining the CPT’s recommendation.
9.1.1 Trust-led restructuring In a Trust-led restructuring, the current Trust board is the accountable body and decision maker on any changes carried out. The CPT’s preferred option has a substantial impact on the local health economy.
Therefore to govern decisions on changes needed outside of Trust, a local area decision-making body would need to be established. In addition to this local area decision-making body, additional support would be required from regional and national bodies, e.g. the NHS Trust Development Authority, NHS Commissioning Board (NCB) or its Local Area Teams (LATs)22 to arbitrate where there is no consensus on change.
In this capacity, the Board would appoint the programme delivery team, which would probably require external support/resources to deliver the transition. As the CPT’s preferred solution requires the reconfiguration of local services, the Board would also require local commissioners to run the 90 day public consultation.
9.1.2 Commissioner-led restructuring In a commissioner-led restructuring, local commissioners would be the accountable body and ultimate decision makers. CCGs have been set up across England primarily to commission healthcare to the extent they consider necessary to meet the reasonable requirements of: (i) patients registered with the GP practices who are members of the CCG; and (ii) people who usually live within the CCG’s defined
22 The main aim of the NHS CB is to improve the health outcomes for people in England by empowering and supporting clinical leaders at every level of the NHS through clinical commissioning groups (CCGs), networks and senates, in the NHS CB itself and in providers, and helping them to make genuinely informed decisions, spend taxpayers’ money wisely and provide high quality services (adapted from http://www.commissioningboard.nhs.uk/about/#info). LATs aim to achieve a sustainable solution that establishes the definitive local presence of the NHS CB (adapted from NHS Commissioning Board: Local area teams, Department of Health, June 2012, p. 3). Ernst & Young 65
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geographic area who are not registered with any GP practice (except where regulations prescribe otherwise)23.
In this option, the current Trust board would be retained and would have responsibility to deliver changes under the direction of the commissioners. As noted above, the CPT’s recommended option has a substantial impact on the local health economy. Therefore to ensure that change is delivered across providers in multiple CCGs, the LAT would need to arbitrate.
Local commissioners would appoint a programme delivery team; again this would probably need external support/resources. In this option, the commissioners themselves would run the 90 day public consultation.
9.1.3 TSA-led restructuring In a TSA-led restructuring, the TSA assumes the role of chief executive and accounting office holder for the Trust. This means that the Trust’s Board is suspended, and the TSA would be the ultimate decision maker, with Monitor and the Secretary of State for Health retaining accountability for the final decision.
Monitor would manage the process of identifying and appointing the TSA and the TSA would draw upon Monitor-appointed external support/resources to deliver the programme - which could be jointly procured alongside the TSA.
The TSA would operate to a strict timetable and after 45 working days would present its plan for restructuring to the Secretary of State for Health. The TSA would then run a 30 day public consultation before taking a further 15 working days to refine the recommendations to Monitor and the Secretary of State.
23 The Functions of Clinical Commissioning Groups, Department of Health, June 2012, p. 8. Ernst & Young 66
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9.2 Recommendation on restructuring approach Although a Trust-led restructuring is one potential option for Monitor, the likelihood that the recommended solution could involve the de-authorisation and dissolution of MSFT the CPT has concluded that a Trust-led restructuring is not feasible.
9.2.1 Assessment of a preferred option The CPT has proposed a series of criteria to assess whether a commissioner-led or TSA-led option is the most applicable. Table 17 outlines the assessment against these criteria.
Table 17: The advantages and disadvantages of commissioner vs. TSA led restructuring
Commissioner-led restructuring TSA led-restructuring Criteria Advantages Disadvantages Advantages Disadvantages
Capability to As budget holders, CCGs are newly TSA will be appointed TSA may not have the deliver change CCGs will have the established and have not solely to deliver the remit for delivering the in the Trust ability to influence the done this before, raising change required for solution, which would Trust significant questions on patients, and could do separate decision- ability to lead change in so without compromise making from the LHE implementation Likely to need agreement by committee (if multiple CCGs are the lead commissioners)
Capability to CCGs have an in-built Will need support from TSA will have the TSA will not have the deliver change incentive to other CCGs to influence ability to quickly elicit remit to deliver change across LHE demonstrate value for the LHE, which may lead support from NTDA / across the LHE money achieved with to compromise on a NCB in order to deliver the overall budget solution the change CCGs can construct May need considerable contracts which provide oversight if consensus is “levers for change” not achieved on key decisions
Likely to Provides opportunity to CCGs may seek to avoid TSA will take decisions TSA will not have remit deliver radical deliver commissioning radical change in their in support of the best to deliver change change intentions (the shift early days as they outcome for patients, across LHE from acute to establish themselves regardless of how community care) radical the changes are
Ability to None CCGs have competing TSA able to make an None source demands for funding objective assessment centrally held of funding needed funds for transition
Maintains Changes will not take May lead to disputes TSA will have remit to Appointment of TSA performance up as much capacity in between commissioners ensure performance is may see staff leave in the Trust Trust management, and Trust about the root maintained, but will be which could undermine allowing them to focus cause of poor able to create a service delivery on Trust performance performance (with the separation between (although this risk is Trust blaming the TSA and the day to day equally associated with commissioners change delivery of care CPT) programme)
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Other relevant factors have been identified: ► The local CCGs are newly authorised and going through a period of significant change as the PCT is dissolved. It is highly unlikely that the CCGs will have the capacity at this stage to deliver the scale of change that is likely to be required;
► Multiple stakeholders across the LHE have indicated their preference for the appointment of a TSA;
► The changes required will require the support and cooperation from providers outside the direct influence of the two primary CCGs in Stafford, Cannock and the surrounding areas.
CPT Conclusion Sixteen:
The appointment of a TSA represents the strongest chance of delivering a successful restructuring
Whilst a TSA appointment represents the strongest chance of delivering a successful restructuring it should be noted that there are multiple challenges the TSA will need to overcome if it is to succeed:
► The TSA does not have the remit to enforce change across the other providers within the local health economy. Any solution will require the TSA to work with other providers and central bodies (such as Monitor, NTDA, NCB) to arrive at a consensus decision for the best way forward;
► The providers in the local health economy are neither individually nor collectively in positions of strength. Should the appropriate incentives be in place, there is no guarantee that the providers will be able to effectively implement the recommended changes;
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10. Delivering the recommended solution
Delivering transformational change across health economies whilst maintaining standards of care is always challenging and it is anticipated that delivering the CPT’s recommended solution would be no different.
As has been previously described, the recommended solution will involve significant change at Stafford and Cannock Hospitals as well as an increase in flow of patients to other providers within the health economy. It will also involve the development and implementation of new models of care (e.g. in the form of intermediate care) which will require significant input from clinicians across the health economy to ensure that patients can be cared for in the most appropriate way in the most appropriate setting. This will require much closer working between the various components of the health economy, which could be challenging given some of the current issues across the local health economy.
10.1 Elements of the recommended solution requiring further development Given the scale of the changes proposed for the delivery of services for the population of Stafford and Cannock, there are inevitably some key areas where additional engagement with stakeholders is required to further develop elements of the recommended option. In particular, there are three areas that need further development, of which the first two are discussed in more detail below:
(i) the detailed specification of the clinical services to be delivered at Stafford and Cannock;
(ii) the organisational form and non-clinical support that will be required to ensure that these services are delivered in a clinically effective manner;
(iii) the timetable for implementation.
10.1.1 Detailed specification of clinical services The CPT has undertaken a significant amount of work to define the recommended clinical solution, however, further work is required to fully develop certain elements that will be continue to be delivered at Stafford and Cannock. In particular, the following areas need further consideration:
1) Core emergency and urgent care services at Stafford; 2) Intermediate care beds; 3) Alignment with the finalised list of protected services; 4) Clinically appropriate day cases; 5) The presence of an elective centre; 6) Clinical support services.
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The first two elements are especially critical as they have not been included in the CPT’s financial evaluation. This is because they are both new services, without precedent in the local health economy and will require the commissioners to establish an appropriate tariff for the delivery of these services. These elements and their associated tariffs will need to be designed in such a way as to ensure they do not compromise the financial sustainability of the local hospitals.
Each of these is discussed below.
1) Core emergency and urgent care services at Stafford
The working assumption for the CPT’s recommended solution for the provision of urgent care services at Stafford is that c 50% of current A&E attendances (60-80 attendances per day) are clinically appropriate to be retained at Stafford. In addition, audits of patient throughput have found that c 40-50% of A&E activity could be handled by primary care. Further work is required to understand exactly what type of patients could be seen by primary care, which require an urgent care service and what is the most appropriate setting for the different patient groups to be seen.
It is proposed that the retained emergency and urgent care services at Stafford will form part of a suite of services which will enable access to treatment, advice and support from the most appropriate clinicians, including access to specialist opinion where required. Further work is required to understand how this core service fits in with other emergency and urgent care services to deliver a coherent “24/7” service. Other services that could form part of the broader suite of services include: A&E departments at other providers, GP urgent care, GP out of hours, and existing intermediate care teams.
Based on current A&E attendance activity levels, between one and four clinicians would need to be available from multidisciplinary teams at any given time and at least one of these clinicians should have prescribing rights. However further work is required to understand what staffing skills mix is required, at what location(s), and with what supporting infrastructure.
2) Intermediate care beds
The CPT is proposing that intermediate care beds should be available at Stafford and/or Cannock as described earlier in this document. However, the precise groups of patients who will use these beds and the type of services to be offered are as yet to be agreed. It is likely that the ‘step down beds’ would be used by patients from the locality who have had acute treatment at other providers and could rehabilitate / recover at Stafford. Further work is required with local clinicians and commissioners to understand how many of these ‘step down beds’ would be required.
The step up beds will be used for low risk admissions, or for patients who can be conclusively diagnosed, or for those needing to be kept in for observation. Again, Ernst & Young 70
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further work is needed to understand the number of beds required for this patient group.
Part of the process of deciding which patient groups could be admitted to an intermediate care facility will be an assessment of the types of staff (in particular clinical staff), facilities and services that are available on site. There will also be a very strong dependency on linkages with primary, community and social care services that could support a seamless transfer of patients from acute care to intermediate care and then home.
3) Alignment with the finalised list of protected services
If a TSA is appointed, the CCGs will be required to finalise their list of protected services. If the finalised list differs from the current draft list, further work will be required to assess the impact on the clinical model and revisions may be necessary.
4) Clinically appropriate day cases
For day cases, a specialty-by-specialty review will be needed to ensure that there is a sufficient volume of activity to deliver financially viable rotas, theatres and other associated infrastructure across both local hospitals and to ensure that they are clinically appropriate given the other services that will be retained on site. It is noted that the commissioner preference would be to retain day cases on both sites, but it may not be feasible to do so.
5) Elective centre
Section 6 set out the arguments for an elective centre in either Stafford or Cannock. The CPT has not made a recommendation on whether or not an elective centre should be part of its preferred solution and there is more work to be done with the other providers in the local health economy to determine whether this is a feasible option.
6) Clinical support services
Further work is required to understand what clinical support services are required. It is likely that access to specialist consultation by phone, 999 and non-emergency transport; basic on-site radiology; a “24/7” pharmacy; and sufficient blood tests to support the services offered will all be required.
10.1.2 Specification of the organisational form and non-clinical support Once the final clinical service model has been determined, the organisational form and associated non-clinical support services will need to be finalised. The CPT’s recommendations have been developed to be neutral of organisational form, although the financial evaluation has indicated that reductions in management overheads will need to be achieved in order to ensure financial sustainability.
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In addition to organisational form, there should be consideration for non-clinical support that will include:
► the level of administrative support necessary to support operations;
► the “back office” capacity needed to support operations (e.g. functions such as estates, HR and IT). The financial evaluation of the proposed options has demonstrated that consideration should also be given to collaboration or outsourcing of clinical and non-clinical support services.
10.1.3 Alignment of estate and infrastructure Once the final clinical model is determined, it will be necessary to consider whether the current estate and infrastructure is clinically and financially appropriate. Redeveloping the current estate is likely to cost less in the short term than building new facilities in Stafford and/or Cannock, but consideration should be given as to whether this allows for a facility that is fit for purpose and presents value for money in the mid to long term.
10.2 Transition costs The transition to the new models of care described in this report will require investment to ensure that patient care continues to be safely delivered during the period of the transition. Investment is also required to upgrade facilities so that they are fit for purpose; this means investment not only at both Stafford and Cannock, but potentially at other providers in the local health economy.
The three final options that were evaluated are derivations of a local hospital model, so it has been assumed that the cost of transition does not significantly differ between the three options – which is why the transition costs were not used as a differentiating factor on the options evaluation.
The transition costs have been split into four broad categories, as follows.
1) Staff costs The changes proposed in this document will have a substantial impact on the staff currently working at MSFT. The staff transition costs relate to the need to ensure that staff are treated fairly, and in compliance with HR policies.
It is likely that an outcome of this reconfiguration will be that some staff and staff groups could be either relocated to work elsewhere in the local health economy or put into a redundancy situation. This could affect all staff groups, but at this stage it is not possible to determine who could be affected and how many could be affected.
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2) Double-running costs To ensure that the quality of patient care is maintained during the transition requires a period when services continue to be provided, but ramped down, at MSFT whilst being introduced/ramped up at another provider”. This requires double running costs to cover the provision of staff, facilities and equipment across the two sites.
3) Implementation costs The cost of implementing organisational change during the transition includes allowances for the complexities of a TSA (if one is appointed), an implementation team to oversee the transition programme, and infrastructure redesign (e.g. IT, electronic patient records) to merge/migrate systems where necessary. The implementation costs have been calculated based on assessment of previous NHS mergers and reconfigurations and adjusted for the size and complexity of the current proposal.
4) Capital costs It is likely that the local hospitals proposed for Stafford and Cannock will not need to occupy the full footprint of the current hospitals in each town. It will be necessary to consider whether the best option for the long term is to redevelop the existing hospitals or to commission a new – fit for purpose – facility. In either case there will be a requirement for capital funding.
Once the service model is finalised in detail, it may be necessary for there to be some capital investment in other providers in the local health economy to accommodate the changes in activity.
10.2.1 Total transition costs The CPT has made an initial assessment of indicative total transition costs and has estimated them to be in the range of £60-70m24. These costs will need to be fully developed as part of the detailed design.
10.3 Managing the transition to the new clinical model Transitioning to any new models of care needs to be clearly planned and communicated, and requires significant clinical and managerial leadership and time.
The transition also needs an approach that is integrated across the local health economy and which manages interdependencies between the various local implementation plans of the providers involved – including alignment with those providers’ own change programmes.
24 This estimate excludes the cost of funding the MSFT deficit during the transition period. Ernst & Young 73
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Some of the considerations that will be required include:
► The establishment of organisational development plans will be required to integrate services into their new host organisation(s), including but not limited to:
Operational changes such as job and rota planning; changes to clinical teams’ ways of working; establishing new and revised outpatient clinic templates and theatre sessions;
HR frameworks to provide a transparent approach, in line with relevant policies, for transitioning staff;
IT frameworks to ensure that systems support the revised clinical requirements.
► The changes to the service models will need to be agreed and contracted with the local CCGs, which could potentially include revisions to payment tariffs where new or revised services are being introduced;
► A strong Programme Management Office (PMO) will be needed throughout the complex transition process to report progress to local and national stakeholders. The PMO will need to be supported by a clear governance structure and escalation processes.
10.4 Management of the risks and challenges The implementation of the CPT’s recommendations will not be straightforward and the CPT has identified several risks and challenges, not least the fact that MSFT is operating in a local health economy that itself is facing several challenges. The new clinical models of care (including care provided in non-acute settings) need to be clearly defined and mapped with the close involvement of key local, regional and national stakeholders. This definition and mapping must be done with a clear understanding of where potential adverse impacts are likely and how to mitigate these, as well as identifying key metrics and governance to allow safe transition to new models of care.
Particularly critical is the involvement of GPs and CCGs in creating the care models for the UCCs and clarity on paediatric care and ensuring continuity of care during the transition, especially for vulnerable groups.
Ensuring that the displacement of activity does not destabilise the LHE will be essential. This is a time when there are issues across the entire LHE.
Table 18 outlines the main risks and challenges associated with the CPT’s recommendations, with some additional moderate level risks outlined in Appendix B.
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Table 18: The main risks and challenges associated with the CPT’s recommendations
Challenge/Risk Impact Key mitigations Risk rating
The impact on ► Any poorly planned or unplanned ► Establish a local oversight group that High the stability of movements of activity to other monitors any changes to activity flows the LHE providers in the LHE could further into each provider in the LHE to assess if destabilise the operational and the programme of changes centred on financial position of one or more MSFT is impacting the operational and providers. financial stability of the LHE. ► This should be supported by escalation protocols to commissioners, Monitor and potentially the NCB and NTDA
Primary and ► Length of stay goes up from delayed ► Develop and agreed model of care for the High community care discharges LHE responding to ► Bed capacity reduces ► Develop a new focus on admissions for the new models ► The cost to the system is increased as specific interventions and not because it is of care patients are treated in more in acute the only option settings ► Provision of step down beds and ► The model for care of the elderly will community geriatricians not be delivered ► Close working between secondary and community providers and CCGs
Capacity at ► The development of suitable capacity ► A detailed plan will be developed with High other providers at other providers is critical to deliver other providers which identifies the and leadership the programme to ensure the capacity needed and the actions needed to deliver the performance at these providers will not to develop the capacity. Capital change be adversely affected expenditure will be needed in some areas ► Patient experience will worsen from ► A focus on creating capacity through deteriorating performance efficiencies will be needed to ensure the projections on LOS are delivered
Intermediate ► Beds are inappropriately used ► Develop access criteria for the beds High beds are ► Length of stay is increased ► Clear management protocols inappropriately ► Risk to patients sitting in step down used beds as an outlier
Staff will find ► Services will not have critical mass of ► Rapidly understand the skills mix required High alternative staff to run safe service and the ability of the current workforce to employment ► Patient care may suffer deliver them during the ► Transition costs will increase from the ► Rapidly implementing HR frameworks to transition use of additional temporary staff provide a transparent approach
Patients ‘switch’ ► Other providers do not have the ► Current board and TSA must continue to High to other capacity to cope with unplanned message it is business as usual in Stafford providers before increase in activity and Cannock the transition is ► Other providers receive higher than ► Ensure patients are kept abreast of the completed expected activity which may trigger the changes marginal rate ► Rebase A&E activity with providers if ► Increase transition costs needed
Patients ► Patient will require blue light transfer ► Develop transfer protocols with High inappropriately to appropriate department leading to ambulance trust attend a local potential delay in emergency treatment ► Ensure clinical protocols are developed hospital ► Increase pressure and cost to the ► A clear engagement plan will be ambulance service developed for patients so they understand ► Potential risk to patient outcomes when to use the EUCC and when to go to a neighbouring A&E
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11. Conclusion and next steps
The people of Stafford, Cannock and the surrounding areas, rightly expect their local health services to be the very best; with the best standards of care, delivered with compassion by appropriately qualified staff. The CPT’s primary objective has been to develop a set of options that are clinically sustainable, ensuring the local population can access clinically safe and high quality services. Critically, the CPT has looked at long term solutions rather than a short term fix to the clinical sustainability issues have been identified.
The CPT believes that the clinical and financial sustainability of the services currently delivered by MSFT is dependent on a reconfiguration of services in the local health economy. The CPT is therefore recommending that some services currently provided by MSFT should move to other providers and that local hospitals should be established in Stafford and Cannock. 11.1 What happens now The CPT presented their recommendations to Monitor on 27th February 2013. Monitor has agreed to consult with stakeholders on the appointment of a TSA to deliver the recommendations of the CPT. If a TSA is appointed, it will be passed the CPT’s report for consideration. The TSA should consider the CPT’s recommendations, but will have the licence to explore alternative options for change. Any decision that is taken in future to propose any changes to the current pattern of services would be subject to a statutory public consultation. In the meantime it is therefore essential that the leaders and staff of the Trust and the local commissioners focus on ‘business as usual’ activities at MSFT.
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Appendix A: Outline of the services included in the shortlisted options.
Option Stafford services Cannock services Acute/Emergency services Consultant led MAU and A&E with unselected Option 3C v1 Acute/Emergency services medical take + ward support; ITU level 2+;
PAU + ward support; Obstetrics and NICU Stafford: Warm site (As Primary care led Minor level 2+; now but with no Injuries Unit
emergency surgery) (No emergency surgery; No PICU) Elective services
Cannock: Local Outpatients; diagnostics; Elective services hospital Elective day cases Outpatients, Elective inpatients, day cases, diagnostics Acute/Emergency services Option 3C v2 MAU and clinically appropriate EUCC with Acute/Emergency services selected medical take + ward support; Stafford: Warm site (As outpatients, PAU; now but with no Primary care led Minor ’ in Stafford options Stafford in ’ emergency surgery, Injuries Unit (No emergency surgery; No critical care; No ITU, obstetrics, PAU ward support; No Obstetrics) paediatrics) Elective services
Outpatients; diagnostics; Elective services ‘Warm site ‘Warm Cannock: Local Elective day cases Outpatients, Elective inpatients, day cases, hospital diagnostics. Acute/Emergency services Option 4C MAU and clinically appropriate EUCC with
selected medical take + ward support; Acute/Emergency services Stafford: Warm site (As outpatients, PAU; elective day cases now but with no
Acute Hospital / Hospital Acute Primary care led Minor emergency surgery, (No emergency surgery; No critical care; No Injuries Unit ITU, obstetrics, PAU ward support; No Obstetrics, No paediatrics, elective inpatient elective) Elective services inpatients) Outpatients; diagnostics;
Elective services Elective day cases Cannock: Local Outpatients, Elective inpatients, day cases, hospital diagnostics. Option 5C Acute/Emergency services Acute/Emergency services Clinically appropriate EUCC; intermediate Stafford: Local hospital care beds Primary care led Minor
plus elective centre Injuries Unit Elective services Cannock: Local hospital Outpatients; diagnostics; Elective day cases Elective services
options with no elective and inpatients (including referrals from Outpatients; diagnostics;
inpatients outside of catchment area) Elective day cases Option 6C Acute/Emergency services Acute/Emergency services
Clinically appropriate EUCC; intermediate Stafford: Local hospital care beds Primary care led Minor retaining current MSFT Injuries Unit elective inpatients Local Hospital Local Hospital Elective services
Outpatients; diagnostics; Elective day cases Elective services Cannock: Local hospital and inpatients (referrals from catchment Outpatients; diagnostics; with no elective area) Elective day cases inpatients Ernst & Young 77
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Option Stafford services Cannock services
Acute/Emergency services Option 7A
Acute/Emergency services Primary care led Minor Stafford: Local hospital Clinically appropriate EUCC; intermediate Injuries Unit with no elective care beds
inpatients Elective services Elective services Outpatients; diagnostics; Cannock: Local hospital Outpatients; diagnostics; Elective day cases Elective day cases and plus elective centre inpatients
Acute/Emergency services Option 7B
Acute/Emergency services Primary care led Minor
options Stafford: Local hospital Clinically appropriate EUCC; intermediate Injuries Unit with no elective care beds inpatients Elective services
Elective services Outpatients; diagnostics; Cannock: Local hospital Outpatients; diagnostics; Elective day cases Elective day cases and plus current MSFT inpatients (referrals from elective inpatients catchment area) Local Hospital Local Hospital Acute/Emergency services Option 7C Primary care led Minor Acute/Emergency services Stafford: Local hospital Injuries Unit Clinically appropriate EUCC; intermediate with no elective care beds inpatients Elective services
Outpatients; diagnostics; Elective services Cannock: Local hospital Elective day cases and Outpatients; diagnostics; Elective day cases with no elective inpatients (including referrals inpatients from outside of catchment area)
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Appendix B: Additional risks associated with the CPT’s recommendations.
Challenge/Risk Impact Key mitigations Risk rating Insufficient ► Patients will choose not to ► The biggest demand for PTS is for Medium patient transport access services if insufficient outpatients. These will be remaining transport arrangements are in therefore the current provision services (PTS) place remains ► Delayed transfers for patients ► Cost of the additional PTS will be ► Restricted access for families scoped ► Alternatives will be actively sought and developed through the other sectors Under utilisation ► Spare capacity will exist in the ► A clear engagement plan will be Medium of the UCC from UCC developed for patients so they ► The UCC may not be understand when to use the UCC patient choice financially sustainable and when to go to a neighbouring ► Increase activity at other A&E providers Length of stay ► Additional capacity is not ► Assumptions have been tested with Medium reductions are delivered providers and commissioners ► Current performance will not realised both deteriorate at providers from providers ► Additional capital expenditure and required to create capacity commissioners Actual patient ► Attendances at other providers ► Assumptions have been tested with Medium flows to other is more than expected providers and commissioners ► Adverse impact on ► Assumptions based on current flows providers are performance in areas different to the ► Additional costs of seeing this assumed activity numbers Establishing an ► There could be an increased ► An early options appraisal on the Medium appropriate cost to commissioners potential payment mechanisms will ► Providers may not be be undertaken payment adequately funded ► The options appraisal will look at mechanism for ways to potentially split the tariff or the step down propose locally agreed tariffs for the spells as they stand beds
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APPENDIX C: Glossary of terms
A&E / EUCC Accident and Emergency / Emergency and Urgent Care Centre, the latter to be fully defined as part of the Sir Bruce Keogh review into urgent care services. Acute care / acute A pattern of health care in which a patient is treated for a brief hospital but severe episode of illness, an urgent medical condition, or during recovery from surgery - in an acute hospital. Attendances Each discrete patient visit to a hospital. Could be 1 hour in (patient) duration for an outpatient appointment, or several days/weeks for an inpatient stay. BHFT Burton Hospital NHS Foundation Trust CAG Clinical Advisory Group – formed by CPT and defined in detail in Section 5.1. Catchment area Catchment area is the defined area covered by an organisation vs catchment – in this instance MSFT. Population of a catchment area is the population number of people living in the catchment area. Catchment population is the number of people who choose to use that organisation. CCG Clinical Commissioning Group - a group of local clinicians responsible for commissioning and monitoring effectiveness of health services. From April 2013, CCGs will be responsible for commissioning healthcare services in the NHS. Clinical networks Organisations used to deliver locally integrated services across a number of providers, usually where there is benefit in sharing specific expertise or resources to improve outcomes for patients. Clinical pathways A pre-determined course of care for patients with a specific condition or disease process. The care pathway can often cross organisational boundaries (i.e. some of the pathway delivered by an acute hospital and the rest delivered by community care. Clinical service An overarching design for the provision of health care services model that is shaped by a theoretical basis, evidence based practice and defined standards which broadly define the way health services are delivered. ‘Clinically Care that is provided in an appropriate clinical location by appropriate’ care appropriately trained clinical staff that does not compromise the quality of care provided to the recipient of the care. For example, it would be clinically appropriate to treat a major trauma in a location supported by critical care. It would be clinically inappropriate if there was no access to critical care. Community Typically, small hospitals that provide a range of clinical and hospital / rehab services. Normally do not have resident or 24/7 community care consultant cover and are mainly staffed by nurses, physiotherapists, OTs and care assistants (may have some GP or community physician led services). Community care is provided by the NHS and social services to assist people in Ernst & Young 80
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their day to day living at home. Many community staff are attached to GP practices and to health centres. CPT Contingency Planning Team CQC The independent regulator of health and social care. From April 2009, the CQC brought together the work of the Commission for Social Care Inspection (CSCI), the Healthcare Commission and the Mental Health Act Commission. Critical care Encompasses a range of units (including High Dependency Units (HDUs), Intensive Care Units (ICUs)), which concentrate special equipment and specially trained personnel for the care of seriously ill patients requiring immediate and continuous attention. Day case A patient admitted for planned treatment, generally a surgical procedure, who is expected to return home the same day. Elective vs non- Elective care is that which is planned to take place in an agreed elective care location at an agreed time, almost exclusively following a GP referral for that episode of care, Non-elective care is care which is unplanned FT Foundation Trust - NHS hospitals that are run as independent, public benefit corporations, which are both controlled and run locally. Inpatient A patient who stays in hospital for more than 24 hours; may have been a planned or emergency admission. Intermediate care The range of services which are designed to help patients to avoid admission to an acute hospital (‘step up’), or to rehabilitate after discharge from an acute hospital (‘step down’). KPI Key performance indicators - Financial and non-financial metrics used to quantify objectives to reflect strategic performance of an organization. Local hospital The CPT is proposing local hospitals for Stafford and Cannock (see Section 7 for more detail on the CPT’s recommendations). Locality vs Locality is a term meaning a general region whereas location a location specific place within a locality. For the context of this report, locality refers to the towns of Stafford and Cannock. LTC Long term condition - conditions, such as diabetes, asthma and arthritis that cannot currently be cured, but whose progress can be managed and influenced by medication and other therapies. Medical vs Medical treatment is the diagnosis and management of patients surgical care using medicine and minimally invasive interventions (e.g. endoscopy). Surgical treatment is the diagnosis and/or management of patients using invasive surgery. MIU Minor Injuries Unit - A self-referral unit for injuries such as cuts, eye injuries, simple fractures, sprains, minor head injuries, minor burns and scalds. Monitor The independent regulator of foundation trusts and responsible body for the CPT. MSFT or the Trust Mid Staffordshire NHS Foundation Trust
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NHS CB NHS Commissioning Board - The NHS CB’s overarching role is to ensure that the NHS delivers better outcomes for patients within its available resources. The NHS CB would play a vital role in providing national leadership for improving outcomes and driving up the quality of care.
NHS TDA NHS Trust Development Authority - From April 2013, the role of the NHS TDA will be to provide governance and accountability for NHS trusts in England and delivery of the foundation trust pipeline.
OFG Operating and Finance Group – formed by CPT and defined in detail in Section 5.1. Outpatient A patient who attends a hospital for a scheduled appointment but does not require admission. PCT Primary Care Trust - NHS body with responsibility for commissioning health care services and delivering health improvements to their local areas. Will cease to exist in April 13 and their function will be largely taken over by CCGs. PDC Public Dividend Capital Primary care The collective term for all services which are people’s first point of contact with the NHS, e.g. GPs, dentists. Protected Protected services are defined by local commissioners as those services services provided by a healthcare provider that is likely to fail, where there is no alternative acceptable provider of those services. Providers A hospital, clinic, health care professional, or group of health care professionals who provide a service to patients. PSDG The Protected Services Definition Group – formed by CPT and defined in detail in Section 5.1. Royal colleges The professional bodies working to improve the quality of healthcare by ensuring the highest standards of care for the population. Includes colleges for GPs, Obstetricians and Gynaecologists, Paediatrics and Child Health, Physicians, Radiologists, Surgeons and Medicine. RWT The Royal Wolverhampton NHS Trust SaTH Shrewsbury and Telford Hospitals NHS Trust SSoTP Staffordshire and Stoke-on-Trent Partnership NHS Trust Sustainability In the context of the CPT’s work, sustainability is as follows: ‘The Trusts can be said to deliver services in a sustainable manner if those services meet the needs of the present and there is assurance that these services can be appropriately maintained to meet the needs of the future’. Sustainability The CPT’s interim report, published in January 2013, that report concluded that MSFT is neither clinically or financially sustainable. Tertiary care / Highly specialised treatment, that takes place in specialist tertiary hospital tertiary hospitals, typically for patients drawn from a wider catchment area than those that attend the hospital for acute
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care. TSA Trust Special Administration UHNS University Hospital North Staffordshire NHS Trust Warm site Recent reconfigurations in the NHS have seen the establishment of ‘warm site’ hospitals that are acute hospitals offering a reduced range of non-elective/emergency services, often typified by the decommissioning of emergency surgery. WHT Walsall Healthcare NHS Trust. WTE Whole time equivalent – the equivalent one full time post.
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REPORT TO THE CLINICAL COMMISSIONING GROUP Governing Body Meeting TO BE HELD ON: Monday 15th April 2013
Subject: Quality and Safety Report
Board Lead: Val Jones
Recommendation: For Approval For Discussion For Information PURPOSE OF THE REPORT:
To update the Governing Body Board members on the current quality and safety issues
KEY POINTS: Please see attached report which describes the key quality issue for local providers.
1. There is a high level for MSHFT relating to the potential risk of destabilisation due to the Monitor report and the uncertainty for this provider until the Trust Special Administrator (TSA) is appointed.
2. BHFT continues to be a high level of concern although is being closely monitored by the commissioners and the Local Area Team (LAT). This Trust has been identified as one of the 14 following the Francis report that will come under scrutiny by the DoH for a high mortality rate and the quality paper includes a briefing on the action taken to address high rates for non-elective COPD.
Relevance to Key Goals
A 10% reduction the levels of obesity against the expected prevalence
A reduction in the proportion of people with undiagnosed disease from 30 – 10 %. A “levelling up” of health outcomes so Commissioning for quality will enable the CCG to put in that all residents experience the same place exemplary systems for commissioning intentions health care outcomes and provider performance management that will deliver A reduction in excess winter deaths of its Key Goals 50%
A reduction in unplanned admissions to
1 | P a g e hospital for people with Long Term Conditions of 50%
Implications
Legal and/or Risk Enable the CCG to meet its statutory responsibilities for commissioning quality; reduce and mitigate risks to the organisation d t ti t CQC Enable the CCG to meet commissioner responsibilities for CQC Essential Standards for Health including that providers have up to date registration with the CQC. Patient Safety Integral element of the Quality Strategy which describes the systems that will be deployed to “keep patients safe.” Patient Engagement Integral element of the Quality Strategy which describes how the CCG will use patient engagement and experience to form the intelligence essential for effective and safe commissioning Financial Following the baseline assessment of the CCG structure, systems and processes there maybe implications for additional f di Sustainability A three year plan which will be refreshed on an annual basis through the annual Quality Improvement Plan PBC/ CCG Workforce / Training Organisational Development Plan for the CCG is in place to develop members, staff and leadership.
Equality Delivery N/A Strategy
RECOMMENDATIONS / ACTION REQUIRED: The CCG GOVERNING BODY is asked to note :
1. The reasons for the high level of concern for MSHFT. 2. The key quality and safety issues reported to the Clinical Quality Review Groups (CQRM).
KEY REQUIREMENTS Yes No Not Applicable
Has a quality impact assessment been undertaken?
Has an equality impact assessment been undertaken?
Have partners / public been involved in design?
Are partners / public involved in implementation?
Are partners / public involved in evaluation?
2 | P a g e CCG Quality Meeting March 2013 Infection Prevention and Control Report Allison Heseltine - Head of Infection Prevention & Control
MRSA Bacteraemia I have enclosed the attachment, ‘Guidance on the reporting and monitoring arrangements and post infection review process for MRSA bloodstream infections from April 2013’ which is now finalised.
The purpose of this guidance is to support commissioners and providers of care to deliver zero tolerance on MRSA bloodstream infections, as set out in the planning guidance Everyone counts: Planning for Patients 2013/14.
The planning guidance sets out a requirement to institute a Post Infection Review in all cases of MRSA bloodstream infection and the purpose of the review is to identify how a case occurred and to identify actions that will prevent it reoccurring.
The outcome of the Post Infection Review will be to attribute responsibility for MRSA bloodstream infections. It relies on strong partnership working by all organisations involved in the patient’s care pathway, to jointly identify and agree the possible causes of, or factors that contributed to, the patient’s MRSA bloodstream infection.
The guidance also supports the identification, data exchange and reporting of cases of MRSA bloodstream infection to help Clinical Commissioning Groups (CCGs) and healthcare providers conduct the Post Infection Review.
Burton Hospital NHS Foundation Trust BHFT have demonstrated their commitment to reducing Clostridium difficile with a reducing in the numbers in the recent months and are looking like they will come in under trajectory for 2012-13.
The target for BHFT MRSA bacteraemia was set locally which is 1 not 0 as stated on the SHA documentation.
Norovirus has hit BHFT during February and early March, prompt actions put in place to control the outbreak with minimal disruption.
In the Intensive Care Unit there have been a number of patients have been colonised with Vancomycin Resistant Enterococci (VRE), no infections due to this organism have been identified. All cleaning and precautions have been put into place.
The Norovirus Strategy is being updated by the Health Economy Infection Prevention and Control Group.
1 Mid Staffs Foundation Trust MSFT have breached their annual trajectory for Clostridium difficile. The trajectory for 2013-2014 of 12 has been challenged at Department of Health, National Commissioning Board and NHS Midlands & East but with no result.
They have appointed a Locum Consultant Microbiologist until March 2013 who has an interest in Infection Control; there is no information of the permanent position being advertised. The permanent Lead Nurse 8a post has been advertised and interviews taking place mid-April.
During February they have had a cross Trust outbreak of Norovirus/D&V, all appropriate precautions have been put in place and outbreak meetings held. Amongst others MSFT has seen a different type of Norovirus this season; lasting longer than usual (72 hours) with increased numbers of patients have relapses.
The Norovirus Strategy is being updated by the Health Economy Infection Prevention and Control Group.
University Hospitals of North Staffs A Clostridium difficile reduction strategy has been developed and is being worked through and the Trust is now within trajectory.
They have been continued wards affected by Norovirus from mid-February to current time; HIPC has been informed that precautions have been put in place. There have not been any formal outbreak meetings and this has raised this with the Trust who are using daily bed management meeting for this purpose. There continues to be delays in the reporting Serious Incidents.
They have an outbreak of 2 patients with Health Care Acquired Influenza A, one patient has died but not yet aware of contents of death Cert. Outbreak meeting called but delayed by a day as Microbiologist not available.
An additional decontamination has been reported (late) regarding the same scope being used on two patients without being decontaminated, investigation is underway.
A decontamination incident relating to the new scopes being introduced continues to be investigated following further development. The risks to individual patients continue to be very low. The Norovirus Strategy is being updated by the Health Economy Infection Prevention and Control Group.
A meeting is being arranged with the Head of Infection Control and Prevention to discuss the infection control concerns.
Staffordshire and Stoke on Trent Partnership NHS Trust Clostridium difficile action plan is in place and they have now reached the trajectory for the end of year.
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The Norovirus Strategy is being updated by the Health Economy Infection Prevention and Control Group.
South Staffs and Shropshire NHS Foundation trust Have had wards affected by Norovirus all precautions have been put in place.
The mother and baby unit has had cases of Rotavirus, precautions put in place.
The Norovirus Strategy is being updated by the Health Economy Infection Prevention and Control Group.
Combined Healthcare Have had wards affected by Norovirus all precautions have been put in place.
HIPC has attended the ICC and has suggested their Infection Control Nurse attends an ICC at SSSNHSFT.
The Norovirus Strategy is being updated by the Health Economy Infection Prevention and Control Group.
Heart of England Foundation Trust HEFT have had a number of wards affected by Norovirus across all sites.
The Norovirus Strategy is being updated by the Health Economy Infection Prevention and Control Group.
Independent Contractors and Independent Social Care Home Sector A numbers of Care Homes have had Norovirus/ D&V outbreaks.
The Norovirus Strategy is being updated by the Health Economy Infection Prevention and Control Group.
3 Item: 7 Enc: 05
SAS CCG Governing Body Quality and Safety Report – Public Meeting Date of Report: 15th April 2013
CSU Quality Lead: Lynn Tolley CCG Lead Director: Val Jones GP Clinical Lead: Anne Marie Houlder
Developing CCG Capacity and Capability for Quality Improvement
• The Governing Bodies of the Stafford and Surrounds CCG and the Cannock Chase CCG will be holding a joint meeting on the 11th April to discuss the findings, implications and actions to be taken following the publication of the second Francis report on the Mid Staffordshire Enquiry. • Additional resource have been agreed to develop the capacity of the CCGs to be able to fully implement the recommendations from the Francis report and deliver their responsibilities for quality and safety functions within the context of the continuing issues from the legacy of Mid Staffordshire. • Lay members are to be invited to attend one of the provider CQRMs to observe the crucial role undertaken by CQRMs in enabling Commissioners to hold providers to account for the delivery of high quality safe services. Main Issues/Top Themes For Providers
1. Mid Staffordshire Hospital Foundation Trust (MSHFT) a. Destabilisation risk b. Breast Cancer Services 2. Staffordshire Stole On Trent Partnership Trust (SSOTPT) a. Pressure Ulcers b. Diabetic backlog c. Podiatric Service 3. South Staffordshire Shropshire Healthcare Foundation Trust (SSSHFT) a. Suicide Strategy update b. Serious incidents 4. Walsall Healthcare NHS Trust a. No significant Issues reported 5. Wolverhampton Foundation Hospital Trust a. Access to CQRM reports for associate commissioners - update 6. Burton Foundation Hospital Trust (BHFT) a. Mortality Review b. COPD 7. University Hospital North Staffordshire (UHNS) a. Outpatient waiting time Backlog - update b. A&E performance - update c. Radiology 8. Rowley Hall Hospital a. No significant issues 9. Hospices a. No CQRM 10. British Pregnancy Association (BPAS) a. No CQRM
Regulators involvement and issues MSHFT - CQC visits The CQC report of the responsive visit made on the 1st February is now available and reports that MSHFT is 1compliant | Page with the following Essential Standards of care: 1. Respecting and involving people who use the services Item: 7 Enc: 05
2. Care and welfare of people whom use the services 3. Safeguarding 4. Supporting workers 5. Complaints A follow up review is to take place in six months’ time against outcomes of the visit
Other Main Issues for Providers
MSHFT – Potential Destabilisation risk The potential risk of stabilisation at MSHFT from staff migration as a result of the outcome of the Monitor review is being taken seriously by commissioners and regulators and a Risk Summit is to be organised to agree actions to mitigate this risk. Any impact on quality and safety is being closely monitored through Clinical Quality Review Meeting (CQRM), CCG Quality Committee and the newly established Quality Surveillance Group.
It was noted that sickness levels and vacancies had increased with managers believing this is due to the impact from the Francis report. Commissioners have requested a workforce assurance report for the April CQRM. Medical staffing at A&E is a potential workforce risk issue with the recent resignation of one of the consultants. Commissioners have requested from the Trust a risk mitigation plan for addressing this.
MSHFT – Breast Cancer Services Review The Royal College of Surgeons (RCS) completed their review as scheduled on the 15th February and found no immediate safety issues or concerns. The report is not yet available and is scheduled for the June CQRM. The review by the West Midlands Cancer Peer Group has been undertaken and the verbal feedback has been very positive.
SSOTPT – Pressure Ulcers (PUs) Pressure Ulcers contain to be the major reported issue for Serious Issues (SIs) and avoidable PUs have remained fairly static throughout the year despite a number of initiatives and a zero tolerance action plan in place. This has been comprehensively reported to members previously with regard to the Commissioning for Quality and Innovation (CQUIN) performance where they are meeting the targets set for this. All PUs are subject to an RCA with the results scrutinised at the Tissue Viability Board which is attended by both the Director of Nursing Services (DNS) and the Commissioning Support Unit (CSU) quality lead. There are issues around the completion of documentation and validation which the Trust have a zero tolerance approach to. The development and roll out of the PU Tracking Tool will facilitate better targeting of resources and a reduction in PUs.
SSOTPT –Suspension of the Podiatric Service – update This matter has previously been reported to members. The Trust provided a report to the March CQRM on how they are managing the rescheduling of patients following the suspension of the service. Patients are now able to access an alternative number of service options through the “Choose and Book” system. A verbal update will be provided by the CCG service director leading on this.
SSOTPT – Diabetic Backlog Issues with the community diabetic service in the North in Dec 2011 as a result of an internal audit which identified significant team and clinic capacity and efficiency issues which were reported to commissioners. A number of remedial actions were taken to address this however these were not entirely successful and a repeat audit in Dec 2012 demonstrated that the situation had not improved. A waiting list audit conducted in February concluded that urgent appointments appear to be managed but that the follow up appointment backlog is excessive. A number of recommendations have been made which include the redesign of the diabetic team to develop more capacity and improvements in appointment scheduling.
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Item: 7 Enc: 05
SSOTPT- Heart failure Service – Update An update was presented to CQRM on the actions the Trust has taken to address the capacity issue in the Stafford team due to sickness and maternity leave. Interim action has been taken to prioritise urgent cases with some support from the Cannock team with a new fully trained Heart Failure CNS recruited to start work on 15th April
SSSHFT – Suicide reduction - update A representative from Public Health attended the CCG Joint Quality Committee to present the strategy for preventing and reducing the number of suicides in Staffordshire and to respond to the concerns reported previously by clinical commissioners regarding the number of suicides. It was reported that there is an increase locally in suicides but this is in line with increases reported nationally and Staffordshire is not thought to be an outlier in this regard. However the rep did report that there is no way of benchmarking suicides due to differences in the way in which providers categorise and report them.
UNHNS – Outpatient waiting list Backlog - Update The backlog numbers have decreased very slightly and North Staffordshire CCG as the lead commissioner for this Trust have requested weekly reporting. Ophthalmology has the largest backlog and is now closed to new referrals and a new provider has been commissioned there are also plans to reallocate those who have been waiting the longest to the new provider. There are no reported safety issues relating to the backlog however additional protocols have been agreed to ensure the safe management of patients in the backlog.
UHNS – A&E Performance update This has previously been reported to members. A contract query was raised and the Remedial Action plan forms part of the process. It is anticipated that if all the actions from the Local Health Economy Action Plan are delivered then performance will be at 95% from late February.
UHNS – Radiology As a result of SHA regional review of reported SIs the Trust have conducted a local review and developed a new referral and imaging policy. During their local review the Trust identified that whilst they were using the World Health Organisation (WHO) surgical safety check list there is also a Radiological checklist which has now been added to the consent form.
BHFT – Mortality Following the Francis report the Trust was identified as one of the 14 Trust with higher than average mortality. The Trust is to undergo a review of their mortality data by a member of Sir Bruce Keogh’s (National Medical Director) team. The terms of reference (TORs) for this review are to be discussed at the Local Area Team Quality Surveillance Group. The ToRs have been made available to members of the CCG Governing Board.
BHFT – Chronic Obstructive Pulmonary Disease(COPD) Mortality Following identification of a higher than expected mortality in non-elective COPD patients managed by the Trust, the COPD service was peer reviewed on 7th March 2012. In response, an action plan has been devised to address the peer review recommendations, and focuses on: • A review of Structures and process in place for patients admitted with COPD • A Review of the Non Invasive Ventilation Service and recommendations concerning further development. • Consideration of concerns with specific reference to mortality in patients with COPD and the assessment of the service provided against NICE Quality Standards.
The Action plan is monitored through the CQRM
Infection Control WALSALL Data in the Walsall Quality and Safety report relates to December when there were 3 cases of hospital
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Item: 7 Enc: 05 attributable C.DIFF and no cases of community attributable C.DIFF. and 1 case attributable to the wider community. Of the 3 positive results, the RCA highlighted inappropriately prescribed antibiotics on ward 16. There was one case of MRSA within the acute during December 2012 and the Trust has reached its agreed trajectory of no more than two cases with quarter 4 outstanding. There were no cases reported within the community.
UHNS, SSOTP, MSHFT Please see attached economy wide infection control report from Alison Heseltine Head of Infection Prevention and Control Patient Experience
MSHFT - Net Promoter Although the Net promoter score had risen in January to 60 there were two wards which achieved a lower than expected score, which were the acute stoke unit and ward 11. Ward 11 is the winter pressures ward and the Trust has found it difficult to engage the staff in ensuring the net promoter needs to be completed. The lead on patient experience has been to see the ward managers in both areas and has educated them on the need to increase these responses for next month. In addition there were low numbers of patients which affected the response rate.
SSOTPT – Net Promoter Net promoter score is improving month by month and 77.7 is the highest score yet.
BHFT – Net Promoter In January the Trust achieved a score of 75.28 for the Friends and Family test which is 2 points lower than the previous month in December. This however the remains above the SHA average of 70.
WASALL The net promoter score for November was 60 a decrease from October’s score of 72.
UNHS – Net Promoter. Latest score is 73.08 February score is not yet available. Eliminating Mixed Sex Accommodation
No breaches reported for any provider. Patient Safety
MSHFT - Serious Incident (SIs) There have been 13 SIs reported in January. There was one never event involving a retained guide wire which has resulted in a referral to the GMC for further investigation. There has been one avoidable event which occurred in A & E (retained Venflon cannula ). The Trust have been challenged on the use of Venflon cannulas in A & E and a request has been made informally for a review. A formal request will be made at Incident Review Group (IRG) if update not received prior to meeting. There were 11 pressure ulcers reported in January, of which 8 were grade 2 (avoidable), 3 were grade 3 (1 avoidable, 1 unavoidable and 1 awaiting review completion)
SSOTPT- Serious Incident (SIs) 37 SIs reported in December the majority (29) of which were pressure ulcers which are reported on in the first section of this report. They SIs included 1 confidential information leak, an unexpected death of a patient and an allegation against HC non professional.
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Item: 7 Enc: 05
UHNS- Serious Incidents (SIs) There have been 4 SIs reported for January. These have included 2 Clostridium Difficile, 1 retained Venflon cannula and I retrospective drug error as a result of a Coroner’s letter to the Trust.
BHFT – Serious Incidents (SIs) There were 15 Sis reported in January. 6 were pressures ulcers, 3 unexpected deaths and two retained Venflon cannulas that bring the total of retained cannulas to 11 for this year so far. One SI relating to a retrieved body part of a male who had part of his ear bitten off was withdrawn as The body part was in saline by the side of the patient, when his friend took it and threw it away outside the emergency department. This was withdrawn as an SI as the actions of other people cannot be accounted for.
WALSALL – Serious Incidents (SIs) There have been 7 SIs in January. I was due to a surgical error , 1 was a grade 3 PU, 1 was an allegation of assault which resulted in a fractured humorous, I was a Clostridium Difficile 2 were unexpected admissions to the neonatal unit and 1 patient fall resulting in a fractured neck of femur. All are subject to a Root Cause Analysis (RCA) investigation and the results, actions and recommendations will be reported through the Trust internal governance process and through to the Walsall Clinical Quality Review Committee.
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Item 9 Enc 06
REPORT TO THE STAFFORD & SURROUNDS CLINICAL COMMISSIONING GROUP GOVERNING BODY TO BE HELD ON: Monday 15th April 2013
Subject: Finance Report as at Month 11 Board Lead: Andy Chandler Officer Lead: Anne Perry Recommendation: For Approval For Discussion For Information
PURPOSE OF THE REPORT:
To present the finance position for the CCG as at Month 11 (28th February 2013) and forecast for 2012/13.
KEY POINTS:
1. This report sets out the in-year financial position at month 11, based on 10 months of Secondary Care data. The CCG is currently showing an overspend of £0.4m against plan. The CCG planned position was break-even at the end of period 11. A number of significant pressures have been identified, details of which are contained within the body of the report.
2. The CCG is still forecasting a balanced position at year end. This is, however, after factoring in the receipt of £2.5m of SHA support and delivering £1.5m of mitigating actions. 3. The CCG holds a £3.5m contingency reserve of which 11/12ths (£3.2m) has been phased into the year to date position.
4. Based on the information from Providers the main significant areas of overspend at Month 11 are with University Hospitals North Staffs (£1.6m), Rowley Hall (£0.8m), Royal Wolverhampton (£0.5m), Mid Staffs Hospitals (£0.2m) and Continuing Health Care (£0.9m).
Relevance to Key Goals A 10% reduction the levels of obesity Financial Plan supports delivery against the expected prevalence
A reduction in the proportion of people Financial Plan supports delivery with undiagnosed disease from 30 – 10 %. A “levelling up” of health outcomes so Financial Plan supports delivery that all residents experience the same health care outcomes
A reduction in excess winter deaths of Financial Plan supports delivery 50% Page | 1
Item 9 Enc 06 A reduction in unplanned admissions to Financial Plan supports delivery hospital for people with Long Term Conditions of 50%
Implications Legal and/or Risk Note the risks identified relating to delivery of Quality, Improvement, Productivity and Prevention (QIPP), Acute Trust Activity and Continuing Health Care. CQC None. Patient Safety None. Patient Engagement None. Financial Note the year to date and year end forecast. Sustainability None. Workforce / Training None.
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Have partners / public been involved in design? Are partners / public involved in implementation? Are partners / public involved in evaluation?
RECOMMENDATIONS / ACTION REQUIRED:
The CCG Governing Body Board is asked to: • Note the year to date position of £0.4m deficit, and the value of contingency factored into the month 11 position. • Note the over spend to date on a number of provider contracts and continuing health care. • Note the forecast year end position, associated risks and mitigating actions.
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Item 9 Enc 06
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Item 9 Enc 06
1. Stafford and Surrounds CCG Financial Position
1.1. The overall position for the CCG is included in table 1 below. There is a year to date deficit of £0.4m. The detailed position is shown at Appendix 1.
Table 1 - Stafford CCG Current Performance Forecast YTD Budget YTD Actual Variance Annual Budget Forecast Variance £000 £000 £000 £000 £000 £000
Acute Contracts 91,856 95,044 3,188 97,982 102,701 4,718 Mental Health 13,782 13,950 168 15,026 15,200 174 Community Services 9,315 9,298 (17) 10,230 10,180 (50) Other Commissioned Services 16,690 17,620 930 18,213 19,307 1,094 Total HCHS 131,644 135,912 4,269 141,452 147,387 5,935
Prescribing 21,255 21,541 285 23,114 23,252 139
Locality Management 1,397 1,434 38 1,648 1,697 49
Contingency Reserve 3,204 0 (3,204) 3,498 0 (3,498) QIPP/Other (1,239) 58 1,297 (1,352) 63 1,415
StHA 2,292 0 (2,292) 2,500 0 (2,500)
Mitigating Actions 0 0 0 0 (1,540) (1,540)
CCG Total 158,553 158,945 392 170,860 170,860 0
1.2. The CCG is still forecasting a balanced position at the year end, based on 10 months contract information. This position, however, assumes delivering £1.5m of mitigating actions and containing the current known risks as outlined at section 4.2.
1.3. The main areas of risk remain around the Acute Contracts which show an overspend of £3.2m as at Month 11, which is forecast at c£4.7m at the year end. There is also an over performance on Continuing Health Care at Month 11 of £0.9m with a forecast overspend of £1.0m. QIPP achievement also remains a key area of risk. QIPP achievement has not been good and the current finance forecast position has factored in the non-delivery of £1.8m.
2. Contract Performance
2.1 University Hospitals North Staffs - year to date overspend of £1.6m (forecast overspend £1.7m). The main areas of pressure identified are Non Electives (mainly General Surgery, General Medicine & Stroke) and A&E.
2.2 Rowley Hall – year to date overspend of £0.8m (forecast overspend £0.9m) mainly on Trauma & Orthopaedics and Gastroenterology.
2.3 Royal Wolverhampton Hospitals – year to date overspend of £0.5m (forecast overspend £0.6m) with the main areas of pressure identified as Emergency Short Stay Non-Electives (Cardiology & Paediatrics), Outpatient First Attendances (Cardiology, T&O and Ophthalmology), Outpatient Follow- ups (Ophthalmology) and A&E.
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Item 9 Enc 06 2.4 Mid Staffs Hospitals – year to date overspend of £0.2m (forecast overspend £1.4m) with the main areas of pressure identified as Day-cases (T&O, Rheumatology and Colorectal Surgery). Non Elective (specifically General Medicine and Obstetrics), Outpatient Procedures First Attendances (Gynae and Diagnostic Imaging)
2.5 Continuing Health Care – year to date overspend of £0.9m (forecast overspend £1.0m).
2.6 The breakdown by practice is shown at Appendix 2 (Year to date – February) and Appendix 3 (Forecast year end)
3. Quality, Improvement, Productivity and Prevention (QIPP)
3.1 The CCG Finance Plan, as previously presented to the Board, has a targeted delivery of £3.9m of QIPP savings. The required savings for each individual scheme have been added to the relevant budget line.
3.2 The current finance forecast position has factored in the non-delivery of £1.8m of QIPP.
4. Contingency/Risks
4.1 The CCG currently holds a contingency reserve budget of £3.5m, £3.2m of which has been released into month 11.
4.2 There are still a number of risks that need to be managed to ensure the CCG achieves a break even position at the end of the financial year namely containing current acute and continuing care over performance at current forecast levels and delivering the remainder of the QIPP programme.
4.3 The above position also includes an additional payment to UHNS of £1m due to an adjustment to the Emergency Threshold in recognition of the increase in admissions from Stafford & Surrounds patients. This has now been agreed by the Trust as a full and final settlement of all outstanding 2012/13 issues.
4.4 In order to support the year financial position of the overall PCT, a number of actions have been agreed with the Cluster Finance Team in the form of an agreed action plan. In addition a formal financial recovery approach has been taken between now and the year end to ensure that the surplus position is achieved.
5. Mitigating Actions
5.1 As described above, in order for the CCG to break even at the year end, it needs to achieve £1.5m of mitigating actions. The table below shows the current plan as to how this will be delivered together with a RAG risk rating to assess likelihood of delivery.
Action £m RAG Contract Negotiations (SSSHFT) 0.5 Reduction in Prescribing Year End Forecast 0.3 Continuing Healthcare Provision 0.6 NHS 111 Service Delayed Implementation 0.1
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Item 9 Enc 06
Appendix 1 Finance Position as at 28th February 2013
Current Performance Forecast Stafford CCG YTD Budget YTD Actual Variance Annual Budget Forecast Variance £000 £000 £000 £000 £000 £000 Hospital and Community Health Services Acute Mid Staffordshire Foundation Trust 60,671 60,903 232 63,913 65,341 1,428 Burton Hospitals Foundation Trust 825 657 (168) 896 717 (179) Heart of England Founation Trust (HEFT) 192 149 (43) 209 163 (46) Royal Wolverhampton Hospital Trust 6,038 6,549 511 6,574 7,214 639 Dudley Group of Hospitals 126 77 (50) 138 84 (54) University Hospitals of Birmingham 1,071 821 (250) 1,168 912 (256) University Hospital North Staffordshire NHS Trust 14,059 15,632 1,572 15,377 17,050 1,673 Derby Foundation Trust 208 227 19 227 240 13 Walsall Manor Hospital Trust 330 494 164 353 540 187 Birmingham Childrens Hospital 534 533 (1) 582 587 5 Row ley Hall 2,237 3,011 773 2,441 3,353 912 Other acute 5,565 5,992 427 6,103 6,500 397 Sub-Total Acute 91,856 95,044 3,188 97,982 102,701 4,718 Mental Health Sth Staffordshire & Shropshire Healthcare FT 11,956 11,969 13 13,036 13,040 4 Other Mental Health & Learning Disability Agreements 1,827 1,982 155 1,990 2,159 169 Sub-Total Mental Health 13,782 13,950 168 15,026 15,200 174 Community Staffordshire & Stoke on Trent Partnership Trust 8,281 8,260 (21) 9,075 9,043 (32) Other Community Agreements 1,035 1,039 4 1,155 1,137 (18) Sub-Total Community 9,315 9,298 (17) 10,230 10,180 (50) Other West Midlands Ambulance 3,491 3,734 243 3,797 4,128 331 Continuing Care & Funded Nursing Care 9,673 10,553 880 10,552 11,537 985 Other Service Agreements 3,526 3,334 (193) 3,864 3,642 (222) Sub-Total Other 16,690 17,620 930 18,213 19,307 1,094 QIPP/Other Reserves - Locality 0 0 0 0 0 0 Reserve - Cancer Semen Storage 0 0 0 0 0 0 Reserve - Healthw atch 27 27 0 30 30 0 Reserve - M&E NTL Safety Therm 12 12 0 13 13 0 Reserve - WM Perinatal Safety Therm 19 19 (0) 21 21 (0) QIPP Savings (1,297) 0 1,297 (1,415) 0 1,415 Contingency Reserve 3,204 0 (3,204) 3,498 0 (3,498) Planned Surplus 0 0 0 0 0 0 Primary care Workers 0 0 0 0 0 0 StHA 2,292 0 (2,292) 2,500 0 (2,500) Mitigating Actions 0 0 0 0 (1,540) (1,540) Sub-Total QIPP/Other 4,257 58 (4,199) 4,646 (1,477) (6,123) Total HCHS 135,901 135,970 69 146,098 145,910 (188) Prescribing GP Prescribing - normal 20,170 20,565 395 21,912 22,161 249 GP Prescribing - High Cost 72 66 (6) 78 82 4 Home Oxygen 448 354 (94) 489 373 (116) Central Topslice 505 468 (37) 551 519 (32) Essential Shared Care 61 88 27 84 118 33 Sub-Total Prescribing 21,255 21,541 285 23,114 23,252 139 Locality Management Locality Management 1,397 1,434 38 1,648 1,697 49 Sub-TotalCCG Management 1,397 1,434 38 1,648 1,697 49 Total Locality 158,553 158,945 392 170,860 170,860 0
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Item No: 9 Enc: 07
REPORT TO THE Clinical Commissioning Group Governing Body Meeting TO BE HELD ON: Monday 15th April 2013
Subject: Finance Plan 2013/14 Board Lead: Andy Chandler Officer Lead: Anne Perry Recommendation: For Approval For Discussion For Information
PURPOSE OF THE REPORT:
To present the Finance Plan including QIPP 2013/14 for approval.
KEY POINTS:
1. This paper presents the process, underlying principles and assumptions used in generating the financial plan for NHS Stafford & Surrounds Clinical Commissioning Group (SSCCG) in 2013/14.
2. The plan includes the plans to spend within our running cost allocation of £3.6m in 2013/14 which equates to £25 per head of patient population.
3. The paper outlines the plan to deliver a £1.5m (1%) surplus in 2013/14 against our programme costs allocation and notes key risks to the delivery of that plan as follows: a. Specialised Services allocation adjustment (£10.9m budget removed from CCG baseline which needs to be offset by equal cost reduction). b. Operational risks regarding continuing healthcare and emergency admissions growth. Risk of delivery against significant QIPP savings (c£7.5m) planned for 2013/14.
4. Mitigation is in place against these risks individually but also the CCG financial plan includes provision of the following funding in order to mitigate these and further risks: a. 0.5% (£0.8m) Contingency. b. 2.0% (£3.1m) of the transformation fund will not be committed initially.
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Item No: 9 Enc: 07 Relevance to Key Goals A 10% reduction the levels of obesity Financial Plan supports delivery against the expected prevalence
A reduction in the proportion of people Financial Plan supports delivery with undiagnosed disease from 30 – 10 %. A “levelling up” of health outcomes so Financial Plan supports delivery that all residents experience the same health care outcomes
A reduction in excess winter deaths of Financial Plan supports delivery 50% A reduction in unplanned admissions to Financial Plan supports delivery hospital for people with Long Term Conditions of 50%
Implications
Legal and/or Risk Note the risks identified relating to delivery of Specialised Services, Quality, Improvement, Productivity and Prevention (QIPP), Acute Trust Activity and Continuing Health Care. CQC None. Patient Safety None. Patient Engagement None. Financial Note the 2013/14 Financial Position. Sustainability None. Workforce / Training None.
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Have partners / public been involved in design? Are partners / public involved in implementation? Are partners / public involved in evaluation?
RECOMMENDATIONS / ACTION REQUIRED:
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Item No: 9 Enc: 07 The CCG Governing Body is asked to: • Note the contents of this report. • Approve the Finance Plan and budget for 2013/14 noting the risk contained within the report.
1. Background and Context
The NHS Commissioning Board advised Clinical Commissioning Groups in December of their 2013/14 allocations and in the document “Everyone Counts: Planning for Patients 2013/14” also published in December, the planning principles to be applied when commissioning services including levers and incentives.
The plan incorporates wherever possible local knowledge of developments and cost pressures and current negotiations with providers.
The NHS National Commissioning Board has advised CCGs of their growth uplifts for 2013/14 and specified over-arching financial requirements:
• Growth – CCG Growth uplifts and allocations have been announced with allocations increasing for all CCGs by 2.3% - this equates to £3.5m for the CCG.
• Tariff Inflation – Tariff inflation has been calculated at 2.7% and has been applied equally to services covered by both national PbR tariff and non-tariff services. This means that the unit cost of commissioned services will increase by 2.7%.
• Tariff Cost Improvement – a 4% cost improvement has been set for 2013/14 and will apply equally to services covered by both national PbR tariff and non-tariff services. This means that the unit cost of commissioned services will decrease by 4% (a net reduction of 1.3% in total when aggregated with tariff inflation).
• Planned Surplus – CCGs are required to plan for a recurrent surplus of 1% which will be carried forward at the end of 2013/14. This figure for the CCG is £1.5m.
• Transformation Fund - CCGs are required to hold a non-recurrent 2% Transformation Fund (headroom); this reserve may only be committed non-recurrently following business case approval by the Area Team. This equates to £3.1m for the CCG.
• Contingency Reserves – CCGs are also required to hold a minimum of a 0.5% Contingency Reserve to facilitate management of risks within the Health Economy. This figure for the CCG is £0.8m.
2. Financial Principles
The following principles have been applied in constructing the financial plan 2013/14:
• Population Growth – this is the growth in services necessary to reflect the change in size and demographics of the population within Stafford & Surrounds.
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Item No: 9 Enc: 07
In absolute terms, the population is forecast to grow by 0.64% in 2013/14.
• Cost Pressures 2012/13 – In Year, the CCG has had to deal with levels of service demand greater than anticipated and contracted for, such as activity shifts to providers outside of South Staffordshire, increased emergency admissions and the knock on effect on emergency thresholds and additional ambulance costs as a result of the overnight A&E closure at Stafford Hospital. Some of these additional service demands are recurrent in nature and therefore have had to be funded to set contract levels at 2012/13 outturn levels. The cost of such pressures is calculated to be £4.2m and represents a call upon CCG resources.
These pressures have previously been reported to both the Membership Board and Governing Body meetings in the forecast financial outturn element of the monthly Finance report.
• Cost Pressures/Investments 2013/14 – drawing upon the knowledge of Finance and Contract Management Teams across Staffordshire, a number of cost pressures and investments for 2013/14 have been identified, shared and agreed. Using this approach means that when negotiating with a single provider on behalf of all associate commissioners, a common approach has already been agreed.
• Continuing Health Care (CHC) – in previous years the CHC budget has only been uplifted by about 3% each year to meet rising demand, however, indications have emerged that the actual forecast overspend has increased and that a higher uplift would be required. Accordingly, it was agreed, in conjunction with the CHC lead, that the budget uplift 2013/14 would be based on a review of actual requirements rather than applying a historic rate of increase. The review indicated that a minimum budget uplift of 7% was more reflective of current demand growth.
• Specialised Services – the list of services to be commissioned as specialised by the National Commissioning Board has now been finalised and the corresponding financial adjustments advised. The CCG’s allocation has therefore been reduced by a further £10.9m compared to the original assessment when the dis-aggregation returns were first submitted in early 2012/13.
• QIPP – The QIPP programme which is a large scale transformational programme is essential in ensuring the NHS makes the best use of available resources and thereby ensuring financial balance is maintained. The QIPP for 2013/14 is circa £7.5m and the detailed schemes are:
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Item No: 9 Enc: 07 QIPP Challenge £7,552,871 Value £7,552,871 Gap £0
Programme QIPP Target £ RAG Transactional Various 504,500 G
Transactional 504,500 G Planned Reduction in 1st OPA SAS 5% reduction in 1ST OPA 878,912 A Total 878,912 A
Planned reduction in elective admissions SAS 5% reduction in elective admissions 1,256,630 A Total 1,256,630 A
Planned 2,135,542 A Unplanned A&E attendances SAS 6% reduction in A&E attnednaces 290,548 R Total 290,548 R
Unplanned NEL admissions SAS 6% reduction in NEL admissions 2,728,722 R Total 2,728,722 R
Unplanned 3,019,270 R
Med Mgt Medicines Mgt 750,000 A
Med Mgt 750,000 A
Other Finance Strategy (TBC) 1,143,559 A
Other 1,143,559 A
Total 7,552,871 A
Details of the QIPP schemes have been outlined and are provided in Appendix 1.
• CQUIN – Nationally, the percentage of turnover which can be paid under the CQUIN arrangements remains at 2.5%. As this is based, however, on turnover and contract values have increased due to cost pressures etc., the CCG has had to commit additional resources to meet the increase in CQUIN payments.
• Transformational Funds – The Commissioning Board requires CCGs to set aside 2% of their recurrent baseline on a non-recurrent basis. This equates to £3.1m for Stafford & Surrounds CCG. Although precise arrangements have yet to be notified, it is understood that funding will be released back to CCGs upon approval of business cases by their Area Team.
3. Summary Resource and Expenditure Plan
The Summary Resource and Expenditure Plan has been constructed using the growth uplift, Everyone Counts requirements and overarching principles and applying them to the 2012/13 rollover budgets.
The net result is a financial plan which is in balance and includes known cost pressures and developments.
The Plan is summarised below:
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Item No: 9 Enc: 07 Stafford & Surrounds CCG: Summary Resource and Expenditure Plan
Sources £'000 Applications £'000
Recurrent Allocation 150,804 Outturn 2012/13 162,827 Cost Pressures 4,189 Contingency Reserve (0.5%) 771 Specialised Services (10,900)
Growth 3,469
Sub Total 154,273 2012/13 Rollover Budgets 156,887
Running Costs 3,590 Net Provider Inflation / Efficiency (316) Demographic / Non Demographic Growth 1,574 2013/14 Cost Pressures & Developments 511 Running Costs 3,590 Non Recurrent Allocations - Return of PCT Surplus 2012/13 171 QIPP Schemes (7,553) - Social Care Funding 1,242 Transformational Reserve (2%) 3,085
Total Sources 159,276 Total Applications 157,778
Surplus (to meet NCB Requirement) 1,498
In regard to the summary, the following points should be noted:
a) The surplus of £1.5m represents the requirement for the CCG to deliver a 1% surplus. b) The plan is in financial balance. c) The CCG is required to hold a non-recurrent 2% Transformational Fund.
A more detailed plan is shown at Appendix 2.
4. Risks and Mitigation
The financial plan involves a degree of financial risk which has been assessed and included in the returns submitted to the Area Team over the last month.
The following areas of significant risk have been identified:
Specialised Services – The most significant risk to the CCG is the top slice of allocation (£10.9m) in relation to the Specialised Services algorithm and whether or not the apparent reduction in CCG expenditure will take place as a result. Initial analysis suggests it will be very difficult to transact the changes proposed to the specialised algorithm and as such a large proportion of specialised expenditure may continue to be charged to the CCG by Providers. The risk is further compounded for CCGs by the fact that the final specialised algorithm is different to that which was expected at the time that specialised commissioning colleagues completed their returns to the DoH in the summer. So far only £6.9m has been extracted from Provider contracts leaving £4.0m still unaccounted for.
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Item No: 9 Enc: 07 QIPP Delivery – Given the scale of the QIPP challenge there is clearly a risk of deliverability of the full scale of the savings planned. The current QIPP plans have been RAG rated and an assessment made as to level of confidence of delivery.
Contracting – Key operational risks for the CCG involve containing growth in Emergency Admissions and Continuing Health Care expenditure. Many parts of the CCG’s planned activities for the year revolve around actions to mitigate these risks including growth assumptions and delivery of QIPP schemes in these areas.
In mitigation of the financial risks within the plan, the CCG has the following reserves:
• Contingency Reserve £0.8m
• Transformational Fund (2%) £3.1m
• Planned Surplus £1.5m
5. Conclusion
The CCG has prepared and submitted a balanced financial plan to the Area Team.
In constructing the plan, the notified allocations have been incorporated, where allocations are anticipated these have been clearly described and the corresponding expenditure included in the plan.
Expenditure plans meet DoH requirements for reserves and includes all known forecast cost pressures, adjustments for efficiencies and Pay & Prices etc.
Inevitably, the plan includes an element of financial risk, though mitigation is in place, work will continue throughout the financial year to clarify further the degree and level of risks and ensuring additional mitigations are put in place as required.
6. Recommendations
The Stafford & Surrounds Clinical Commissioning Group Governing Body is requested to:
• Note the contents of this report. • Approve the Finance Plan and budget for 2013/14 noting the risk contained within the report.
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Item No: 9 Enc: 07
Appendix 1
QIPP PLAN 2013/14
£ Impact Expected Impact Lead Clinical Lead PID Best Investment Q1 Q2 Q3 Q4 RAG Transactional Trigger point Ashleigh Gibbs NA NA 198,000 No G Wheelchair Rebecca Johnson NA NA 60,000 No G Nursing home Tammy Lott NA NA 146,500 No G Integrated Equipment Rebecca Johnson NA NA 100,000 No R 504,500 Planned Vasectomies Alex Bennett Yes 10,000 No A MSK Phase 1 Mel Savage Gary Free Yes 808,412 Net A MSK Phase 2 Mel Savage Gary Free Yes 0 Unknown A PLCV Alex Bennett Gary Free No 315,243 No A Planned Care Pathways Alex Bennett Gary Free No 150,000 No A Demand Management Alex Bennett Gary Free 851,887 A 2,135,542 Unplanned EUCS Alex Bennett Sue Knight No 265,767 No R AEC Alex Bennett Sue Knight No 0 Unknown R Respiratory Alex Bennett Sue Knight Yes 0 No R Diabetes Paediatric Alex Bennett Sue Knight No 0 Unknown R UTI Jonathon Bletcher Tim Berriman Yes 0 No R Falls Jane Chapman Anna Onabalou Yes 0 Net A 1,244,703 R 1,510,470 Coordinated Care LTCs programme Ashleigh Gibbs Adel Adelfy Yes 159,000 Yes A Nursing Homes Tammy Lott Anne Marie Houlder Yes 79,500 Yes A Continence Rebecca Johnson Yes 5,300 No A Dementia Jonathon Bletcher No 265,000 Outcome A 508,800 Prescribing HOS-AR Ashleigh Gibbs Dr Cooke Yes 12,223 Net G Med Mgt Jane Chapman No 681,868 A BGTS standardisation Ashleigh Gibbs Dr Cooke Yes 45,909 Net G Diabetes Procurement Ashleigh Gibbs Dr Cooke Yes 10,000 A 750,000 Primary Care Primary Care Incentive Scheme Jonathon Bletcher Mo Huda No 1,000,000 Outcome A 1,000,000 Other Finance Strategy (TBC) 1,143,559 A 1,143,559
Total 7,552,871
*Supported by: Clinical leadership programme Practice support packs Self Management programme GP peer networks
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Item No: 9 Enc: 07
Appendix 2
FINANCE PLAN 2013/14
Annual Budget Stafford & Surrounds CCG £000 Hospital and Community Health Services Acute Mid Staffordshire Foundation Trust 60,948 Burton Hospitals Foundation Trust 421 Heart of England Founation Trust (HEFT) 168 Royal Wolverhampton Hospital Trust 6,985 Dudley Group of Hospitals 68 University Hospitals of Birmingham 815 University Hospital North Staffordshire NHS Trust 13,948 Derby Foundation Trust 245 Walsall Manor Hospital Trust 331 Birmingham Childrens Hospital 555 Row ley Hall 3,797 West Midlands Ambulance 4,704 Other acute 3,055 Adjustment (Specialised Services) (4,008) Sub-Total Acute 92,032 Mental Health Sth Staffordshire & Shropshire Healthcare FT 13,174 Other Mental Health & Learning Disability Agreements 1,283 Sub-Total Mental Health 14,457 Community Staffordshire & Stoke on Trent Partnership Trust 9,529 Other Community Agreements 1,017 Sub-Total Community 10,546 Other Continuing Care & Funded Nursing Care 10,353 Other Service Agreements 6,030 Sub-Total Other 16,383 QIPP/Other QIPP Savings (7,552) Contingency Reserve 771 Other Reserves 0 Planned Surplus 1,498 2% Non Recurrent 3,110 Sub-Total QIPP/Other (2,173) Total HCHS 131,245 Prescribing GP Prescribing - normal 22,917 Other 1,524 Sub-Total Prescribing 24,441 Locality Management Running Costs 3,590 Sub-TotalCCG Management 3,590 Total Locality 159,276
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Item No: 9 Enc:08
REPORT TO THE Clinical Commissioning Group Governing Body meeting TO BE HELD ON: Monday 15th APRIL 2013
Subject: Performance Report –January 2013 Board Lead: Andy Chandler Officer Lead: Chris Wood
Recommendation: For Approval For Discussion √ For Information
PURPOSE OF THE REPORT:
- To provide a high level summary of the key performance issues for the CCG’s main providers for 2012/13 (January 2013). Performance is based on RAG dashboards and exception reporting. - To provide assurance and details of remedial action being taken to improve performance and mitigate risk and, where applicable, contract queries that have been issued and financial penalties applied.
Full Provider performance dashboards are available via the member’s area of the CCG website.
KEY POINTS:
1. Performance measures not achieved in January 2013:
Mid Staffordshire FT – Daily Discharges & Weekend Discharges; Diagnostic Waiting times >6 weeks; Cancer two week wait from GP referral (symptomatic breast); Cancer 62 day wait from urgent GP referral to patients receiving first definitive treatment; Quality Stroke Services: 80% of people spend at least 90% of their time on a stroke unit; Choose & Book – users able to book appointments with named consultant-led teams; GUM seen within 48 hour; A&E 4 hour wait.
SSOTP - Complaints – % responded to in timescale agreed with complainant; Podiatry Waiting times; Time from referral to Implementation of all services;
SSSHFT - 18 weeks non-admitted waiting time for Paediatrics and Delayed transfers of care.
Royal Wolverhampton Hospitals NHS Trust – A&E 4 hour wait and Delayed transfers of care.
Relevance to Key Goals A 10% reduction the levels of obesity against the Performance metric to be developed to show expected prevalence improvement. A reduction in the proportion of people with undiagnosed Performance metric to be developed to show disease from 30 – 10 %. improvement. A “levelling up” of health outcomes so that all residents Performance metric to be developed to show experience the same health care outcomes improvement. A reduction in excess winter deaths of 50% Performance metric to be developed to show improvement. Item No: 9 Enc:08 A reduction in unplanned admissions to hospital for Performance metric to be developed to show people with Long Term Conditions of 50% improvement.
Implications Legal and/or Risk Note the risks identified relating to delivery of Quality, Improvement, Productivity and Prevention (QIPP), Acute Trust Activity and Continuing Care. Reputation risks if any of the elements of the national operating framework are not delivered. CQC None Patient Safety Patients and their safety are at the centre of everything the CCG commission. Poor performance in services where patients are waiting longer than required to access services may be a patient safety risk. Patient Engagement The inclusion of patient feedback in performance reporting is essential for Board assurance. Work is ongoing with colleagues in the Quality and Governance team to establish lines of reporting. Financial Financial risks associated with delivering key performance targets and delivering contracts in line with contract values. Sustainability Workforce / Training Work to develop understanding of performance management
RECOMMENDATIONS / ACTION REQUIRED: The CCG Governing Body is asked to: . Note those areas where the current performance rating is red and the remedial actions being taken to improve performance and mitigate risk.
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? X Has an equality impact assessment been undertaken? X Have partners / public been involved in design? X Are partners / public involved in implementation? X Are partners / public involved in evaluation? X
Item No: 9 Enc:08
1. Performance Report – January 2013
1.1 Staffordshire Cluster Performance Report – Integrated Measures (see Appendix 1) This is the latest validated key performance indicators at South Staffordshire PCT and Provider level. From April 2013 this will be available at a CCG level.
1.2 Mid Staffs
Mid Staffs has submitted the following exception comments to the PCT for each of the following indicators that are under performing.
Diagnostic Waiting Times Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date There were 52 breaches: For areas where capacity has been 0 52 1040 February identified as an issue, this is being ↑ 2013 The adverse weather led to a reviewed within the teams in capacity (98.08%) (96.29%) number of sessions being and demand modelling. cancelled and patients also DNA’d appointments. Due to Where patient choice is key factor, these unforeseeable issues the patients are offered several Trust have been given to the end appointments to facilitate meeting the of February to achieve the target target and explanation of requirements otherwise contractual fines will be of pathway made as appropriate. imposed. 13 patients also declined dates given in favour of a Meeting of target trajectory planned for later date. Without these issues end of February. the Trust would have achieved the 99% target. Only a small number of patients are now waiting due to capacity issues.
Cancer two week wait from GP referral (symptomatic breast) Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date There were 4 patient breaches of To reinforce message to GPs and 93% 91.1% 93.6% February the waiting time standard out of 45 patients that referrals for urgent ↓ 2013 referrals. Breast symptoms are classed as All were due to patient choice and urgent, and that there is an were offered 2 appointments within expectation that the GP will check with the timescale. the patient, at the point of referral, that the patient is available to attend.
Cancer 62 day wait from GP referral to first definitive treatment. The Trust originally reported non achievement of this standard. However, the figure provided to Trust Board was in advance of validation by the Cancer Quality Manager. Following validation there were 47 treatments and 7 breaches resulting in a performance of 85.1%.
Quality Stroke Services: at least 80% of patients spend at least 90% of their time on a stroke unit Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date There were 5 patient breaches of This standard has been met for 80% 76.19% 85.8% February the standard out of 21 patients. consistently for the last 6 months, until ↓ 2013 Breaches due to this month. Regular monitoring of 1 patient not stable for stroke stroke patients across the organisation rehab/not for transfer to ASU. is undertaken by the site team and the 3 patients on other wards due to stroke nurse. capacity issues on stroke ward. It is anticipated that due to Norovirus, 1 patient unable to be transferred to the target may not be met until Royal Wolverhampton Hospital due March 2013, however all actions to to capacity issues. ensure that stroke patients are in the clinically most suitable place are being Capacity issues have been taken on a daily basis. significant affected by Norovirus Further discussion with New cross will across several wards and therefore be required, to review patient pathway movement of patients has been in times of capacity issues within their Item No: 9 Enc:08 closely monitored and on occasions Trust. restricted to manage the IPC situation.
A&E waiting time- Total Time in the A&E Department Current Issues Actions for resolution Target w/e YTD Current Expected 10/03/13 Trend Improvement Date A widespread outbreak of A Recovery Plan was initiated during 95% 85.29% 93.75% Ongoing norovirus has seen numerous week beginning 07/01/12 and is ↓ wards closed to admissions ongoing. This involved the release of throughout the month. The Trust all senior operational staff from other has regularly had over 20 empty duties to solely focus on maintaining beds that have been inaccessible safe, timely care. for emergency admissions, in addition to many more being Deep cleaning of affected wards has occupied by patients who cannot be also been undertaken. discharged to nursing /residential homes until the ward is re-opened. Introduction of feeder list of patients to The outbreak has affected the vast transfer out of AMU to medical wards. majority of adult medical and Cancellation (where absolutely surgical wards at some point. necessary) of routine electives to free Furthermore, this lead to over- capacity to emergency admissions. crowding in ED with cubicle Use of additional bed capacity (ED capacity full, delays in examination Flex, GPAU, Surgical Day Ward, Ward and clinical decisions. 2 additional beds, T&O additional bed) to try to compensate for closed beds The Trust has now failed to achieve throughout the Trust. both the Q4 target and the year end 4-hour target.
GUM % seen within 48 hours of first contact with the Provider's GUM services Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date Patient choice is the main reason A patient survey is now carried out each 95% 85.01% 89.9% Ongoing for not achieving this target. month. 296 calls were made to ↓ patients to determine the reason why they could not attend within 48hours. Reasons were stated as, work commitments, annual leave or child care. An action plan has been developed which has been discussed and agreed with representatives from the CCG.
Choose & Book Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date Building on the Exception Report The Team have committed to improving 95% 74.24% 62.31% Ongoing produced last month, and the % further by end of February. There ↑ improvement in the % by the end does remain a risk if consultants are not of January has been delivered registered on C&B and the Trust with an increase from 58.33% to remains unable to register them and 74.24%. produce smartcards then the 95% will not be achieved.
It is expected that the gap between 74.24% and 95% will be closed further by 28/2/13.
Ambulance Turnaround Times within 30 minutes Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date During the first and last two To continue to work in conjunction with 85% 83.15% 82.85% Ongoing weeks in January winter WMAS and HALO to manage patients ↓ pressures relating to norovirus conveyed by ambulance. To ensure that and delay in opening additional the nurse in charge in ED and PAU capacity resulted in patient flow capture the release of the ambulances becoming compromised, therefore using the CAD on-line. Recovery plan is Item No: 9 Enc:08 the Emergency Department has underway. not be able to turn the ambulances around in a timely fashion as would have liked.
Daily Discharges Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date Lack of identification of patients Commencement of the Patient Flow 30% 7.87% 9.34% Ongoing for discharge on the following day; Wheel which will have a dedicated team ↑ Confirmation of care packages to focus on the blockages; Identification not always identified until the day of potential discharges the day before at of discharge; Not all patients go to daily Bed Meeting; Utilisation of real time the discharge lounge as they bed management which incorporates require a stretcher ambulance. EDDs.
Weekend Discharges Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date Issues causing under New weekend handover session 50% 46.28% 44.05% Ongoing performance against Trajectory established each Friday since ↓ include: 11/01/13.The Weekend Handover - Reduced Consultant presence at session involves a Consultant from each weekends ward presenting their patients for clinical - Formerly no structured weekend or discharge review to the Weekend handover process embedded Team (Weekend On-Call Consultant, - Reduced access to Diagnostics SAP, Therapy Lead, Sunday Acute at weekends Physician). This allows a discussion to - Reduced access to Therapy take place regarding management plans services at weekends for sick patients, and regarding - Reduced access to Social Care discharge parameters for potential services at weekends discharges. It also ensures that the weekend team know who each other Norovirus in January 2013 has are, and are prepared for Saturday meant a reduced number of morning. medical wards can discharge patients. Further actions include: - Embedding handover session on Friday with all clinical teams - Trialling new Saturday to Sunday handover session - Auditing all medical inpatients for reasons for being in hospital on a Sunday
1.3 The following indicators improved at Mid Staffs since last month and targets were achieved for January:- . Choose & Book slot issue rate.
1.4 Staffordshire & Stoke on Trent Partnership Trust
17 of the 54 indicators have been rated as red. The most significant are as follows:-
% of complaints acknowledges within agreed timescales Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date Performance issues relate to the 100% 80% N/A handling of social care complaints In December the Executive Management Health, ↓ within agreed timescales. Team (EMT) stated that no further 43% The Health compliance rate for extensions to any complaint timescales Social closures fell to 80% and social should be granted unless it is deemed Care care rate has fallen to 43% in as an exceptional circumstance. January. Weekly performance reports have been submitted to EMT in January along with Social Care: 14 formal complaints weekly escalations to the Chief were closed in January, only 6 of Operating Officers. which were within timescale. Of the 8 breaches, 5 were completed by the Investigating Officers (IO) Item No: 9 Enc:08 but were delayed due to concerns relating to the quality of the investigations, and the remaining 3 were not concluded within timescale by the appointed IO.
Podiatry Waiting Times Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date 95% of patients referred into the An action plan is in place to reduce the 100% 71.6% 56.2% podiatry service should be offered wait times for biomechanics. The service within ↑ an appointment within 3 weeks. In has identified the additional capacity 3 order to clear the backlog of long- required and is in the process of weeks waiters within community clinics, increasing staffing levels in order that performance against target has additional sessions can take place. remained fairly static for biomechanics during 2012/13 as staff prioritised the community clinic waiting lists. New staffing
rotas commenced in September, this saw the percentage offered appointments within community clinics increase but waiting times for biomechanics remain short of the target.
Time from referral to implementation of Social Care Services Current Issues Actions for resolution Target Jan-13 YTD Current Expected Trend Improvement Date East Staffs and Lichfield remain the only 80% 68.1% N/A The SSOTP component parts of districts meeting the target for this ↔ this indicator are now rated green, indicator. Part one relates to and discussions are ongoing with assessments being carried out in a Staffordshire County Council to timely manner, while the second part of improve the timelines of care the indicator relates to the packages being put in place implementation of services and is shared with Staffordshire County Council (SCC) as the authority is responsible for commissioning contracts.
An action plan is in place with a particular focus on the South West where separate meetings have been convened in order to review issues and set a trajectory for recovery. It should be noted that all teams are currently showing an improvement from the actual outturns from 2011/12.
1.5 Other Notable Performance:
1.5.1 Shropshire and South Staffordshire Foundation Trust - 2 areas have been rated red:-
. 18 weeks non admitted waiting time for Paediatrics – Actual 91.9% for January, however under achieving for year to date 92.7% (Target 95%) . Delayed Transfers – Actual 9.42% for January, year to date 7.63% (Target 7.5%)
1.5.2 Royal Wolverhampton Hospital NHS Trust – 2 main areas rated red:-
. A&E 4 hour wait – Actual 93.99% for January, however achieving for year to date 96.1% (Target 95%). The Trust continues to see significant increases in A&E attendances and ambulance numbers. . Delayed Transfers – Actual 5.52% for January (Target 5%).
Item No: 9 Enc:08 1.5.3 Primary care services current waiting times:-
• ENT (Wolverhampton Rd Surgery) - 6 weeks (+2 change on last month) • Dermatology (Brewood Surgery) - 3 weeks (no change from last month) • Carpal Tunnel (Brewood Surgery) - 3 weeks (no change from last month) • Vasectomy – (Brewood Surgery) - 3 weeks (no change from last month)
1.5.4 Integrated Care Team - Patients Refused by Team – There was 1 patient refusal since 17th February. This was for IV Gentamycin- patient had had a previous adverse reaction to the drug in hospital, therefore felt unsafe for administration in community.
1.5.5 EWISS –The waiting time is currently 4 weeks.
1.6 Additional provider dashboards Available on the member’s area of the CCG website:
• Mid Staffordshire NHS FT (Performance dashboard) • Staffordshire and Stoke on Trent Partnership Trust (Detailed exception report and dashboard) • EWISS (Referral, activity and waiting times report) • Shropshire & South Staffs Healthcare Trust (Performance dashboard) • Integrated Care Team (monthly activity summary) • Ramsay Healthcare Trust (Rowley) (Performance dashboard)
2.0 Recommendations
The Board notes the report and the actions taken to improve underperforming areas. Enc: Item No :
8 Enc: Item No : APPENDIX 1 - Staffordshire Cluster Report – Integrated Measures – as at 13th March 2013
9 Enc: Item No :
10
Item 10 Enc 09
REPORT TO THE Clinical Commissioning Group Governing Body Meeting TO BE HELD ON: Monday 15th April 2013
Subject: Everyone counts – planning 2013/14 Board Lead: Andy Donald Officer Lead: Alex Bennett
Recommendation: For Approval For Discussion For Information
PURPOSE OF THE REPORT: The purpose of this report is to outline the Everyone Counts planning for 2013/14 and proposed local targets.
In December 2012 the NHS Commissioning Board published its planning guidance for 2013/14, called “Everyone Counts – Planning for Patients”; this document outlines the targets for the national and locally determined priorities. From 2014/15 the quality premium will be used to reward CCG’s for measurably improving the quality of services commissioned, associated improvements in health outcomes and a reduction in health equalities. Furthermore the guidance set out five offers from the Board to support commissioners to produce better health outcomes:
• Seven day working • More transparency and choice • Listening to patients and increasing their participation • Better and more consistent data • Safer care KEY POINTS:
Supporting the Commissioning Process: The Quality Premium will be available to CCG in 2014/15 if the CCG can demonstrate that it has improved or achieved a high standard of quality. The four national targets applied to NHS Stafford & Surrounds are based on measures within the NHS Outcome Framework which are:
1. To reduce or stabilise avoidable emergency hospital admissions based on a composite of four indicators. 2. Reduction in years of life lost form avoidable death. 3. Reduce health care associated infection. 4. Improve patient experience of hospital through the roll out of the friends and family test.
In addition to the national priorities and in accordance with Everyone Counts Planning Guidance NHS Stafford & Surrounds CCG has submitted three local targets. These have 1
been identified and prioritised from the CCG’s Integrated Plan and have been presented to the NHS Commissioning Board Area Team.
Local Targets - Proposed local priority Target 2013/14
• Reduction in excess winter deaths - Increase number uptake of flu vaccinations in the >65’s and carers
• Increase diagnosis rates and numbers of people on practice registers with Hypertension
• Increase diagnosis rates and numbers of people on practice registers with COPD
This approach enables the CCG to respond to local needs and health challenges identified within our local plan.
In order to respond to the requirements of Everyone Counts and the NHS Outcome Framework the CCG has prepared a ‘strategic’ plan on a single page. A copy of the NHS Stafford & Surrounds CCG plan is presented in Appendix 1.
Relevance to Key Goals A 10% reduction the levels of obesity against the expected prevalence
A reduction in the proportion of people with undiagnosed disease from 30 – 10 %. A “levelling up” of health outcomes so that all residents experience the same health care outcomes
A reduction in excess winter deaths of 50%
A reduction in unplanned admissions to hospital for people with Long Term Conditions of 50%
Implications Legal and/or Risk N/A CQC N/A Patient Safety N/A Patient Engagement N/A Financial Opportunity and assists in Quality premium Sustainability N/A Workforce / Training N/A
2
RECOMMENDATIONS / ACTION REQUIRED:
The CCG Governing Body is asked to: The SAS governing body are asked to approve the everyone counts planning for 2013/14
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Have partners / public been involved in design? Are partners / public involved in implementation? Are partners / public involved in evaluation?
3
Everyone Counts Planning – 2013/14
The proposed targets set for Everyone Counts planning for 2013/14, have been informed by the analysis of the data from the Atlas of Variation (Right Care), the need to reduce the variation across practices and to move towards National or Office of National Statistics (Peer Group) averages. Actual activity and finance figures are based on 2012/13 forecast outturn.
Whilst the targets are ambitious the majority of the schemes needed to deliver these targets are either worked up or being developed to make the changes required to deliver the proposed targets. Clinical engagement and cross agency working will also be essential in the delivery of these plans. It is recognised that support from primary care clinicians will be needed to support the use of referral pathways etc. An overview of the National activity targets can be seen in the table below.
Table 1: National target activity reductions for 2013/14 for NHS Stafford & Surrounds CCG Activity Stafford & Surrounds 1st Outpatient appointments 5% Reduction Elective admissions 2% Reduction A & E Attendances 6% Reduction Non-elective admissions (emergencies) 6% Reduction
First outpatient and elective admissions has been set at a 5% & 2% reduction respectively to ensure the CCG is moving towards its national and ONS peer group averages. The A & E attendances and the NEL’s have remained at 6% which is in line with the CCG’s 5 year target within the commissioning intentions and on achieving the National or ONS (CCG Peer Group) average.
Local Targets - Proposed local priority target 2013/14 • Reducing the number of Excess winter deaths (EWD) which includes increasing the uptake of flu vaccinations for the >65 and carers
• Increase the number of patients diagnosed and on practice registers with Hypertension
• Increase the number of patients diagnosed and on practice registers with COPD
National guidance has meant that a number of the more obvious local targets that the CCG would have wished to be included could not be used. The proposed local targets have been identified as they support the CCG’s integrated plan, overall goals, management of unexplained variation and prevention agenda.
Responsibility of the Membership Board and Governing Body: The CCG Membership and Governing Body will need to drive the implementation of Everyone Counts. In particular the Governing Body will be annually assessed on how its plans have:
• Improved the quality of services
• Reduced inequalities
• Sought and used professional/clinical advice
• Involved the public
• Met its financial duties and take account of local health and wellbeing strategies
Next Steps
• Development of an operational delivery plan which is aligned to the CCG’s strategic plan and goals
4
Item No: Enc: Stafford & Surrounds CCG Everyone counts Planning 2013/14 Needs, Context & Challenges
Higher than national average Excess winter Ageing population in both the over 65 and 75 age Financially challenged acute Trust which is clinically Unwarranted variation across Problems with access and patient flow through urgent care CCG significant QIPP mortality rates groups and financially unviable practices syste m Challenge
Goals Programmes Transformation Change Scheme 2013/14 Target 2013/14 Outcomes Risk (to be delivered by March 15) The vision for Stafford & Surrounds CCG Planned Care ● Better care pathways and GP to consultant communication 5% reduction 1st OPA = 1,454 ● Reduction in first outpatient attendance (CI) Difficulties in changing is for people in the Borough to receive The CCG is an outlier in relation to the National and ONS reducing growth in hospital referrals and subsequent 1st OPA ( target of 27,634) ● Reduction in elective admissions reducing unnecessary steps in the embedded NHS culture median for elective admissions and above ONS median for treatments pathway and improving patient satisfaction (CI, EC, OF) first class healthcare leading to high 1st OPA 2% reduction on EL Delays in redesign work quality patient experience and excellent A strategy for the reconfiguration of planned care pathways admissions = 439 (target outcomes has been agreed with local providers. 21,511) Instability of patient flow ● Reduction in outpatient follow ups and face to face ● Improved New : Follow Up ratio's avoiding unnecessary appointments This will undergo review following the outcomes of the across the LHE due to the consultations by redesign for patients (CI) Our values are: monitor report at MSFT Francis report and monitor Optimisation of treatment at the appropriate time avoiding PLCV reduction 209 cases ● Reduction in procedures of low clinical value ensuring patients not review of MSFT ● unnecessary intervention treated inappropriately(CI) Quality first
Prevention of ill health Unplanned Care ● EUCS - modernising services which are sustainable and of 6% reduction ● Reduction in A&E Attendance / Emergency Difficulties in changing The CCG is an outlier in relation to the National and ONS high quality across the local health economy. Efficient A & E attendances = 2,239 admissions (adults and children) (EC, OF, CI) embedded NHS culture Patient views and involvement median for non-elective admissions access and rapid assessment as alternatives to hospital (target 35,080) Delivery of care close to home, easy access and improved patient admissions. Implementation of NHS 111, AEC model, review ● satisfaction Delays in redesign work Integration with a wide range of partners There is a local agreement to transform the emergency and of MIU's and ICT/social care model NEL admissions = 861 (target urgent care system. This will include the development of an 13,496) Instability of patient flow Contribution of all our members and staff ambulatory care unit, review of MIU's, GP OOH's and a ● Nursing Homes - targeted support to nursing homes to avoid Included in numbers above Reduction in A&E and emergency admissions through case across the LHE due to the model for integrated and social care unnecessary hospital admissions management of patients to ensure optimal care in the home setting Francis report and monitor Openness and honesty in all that we do (CI,OF,EC) review of MSFT The CCG is also exploring the introduction of a GP Our CCGs goal are to: enhanced LES to reduce unnecessary hospital admissions Inability to effect change in ● Winter Deaths - to work with Stafford Heath & Well Being 17% EWD (England rate) ● Excess winter deaths within national average (CI,OF,EC) nursing home practice Reduce obesity levels by 10% against expected Board to support warmer homes policy = 7 deaths prevalence 75% (National) currently at ● Increase uptake of flu vaccinations >65's (local priority) & 68% equates to additional ● Increased uptake of vaccinations and reduction in flu and pneumonia cases Increase uptake of flu vaccinations in carers (local priority) uptake of 2,123 (target Reduce the proportion of people with undiagnosed 22,961) disease from 30% to 10% 70% (National) currently at 44% equates to additional uptake of 124 (target 335) Levelling up of health outcomes so that all Co-ordinated Care - ● LTC - Provision of high quality integrated care through roll out 6% reduction ● Reduction in A&E Attendances / Emergency admissions. Delivery of Difficulties in changing residents experience the same health care To develop a holistic integrated care model which of risk stratification and case management. Care pathway A & E attendances & NEL care closer to home, easy access and improve patient self embedded NHS culture. outcomes encompasses a preventative, anticipatory and whole reviews and patient self management admissions( included in management and satisfaction (CI,OF,EC) person approach to ensure that patients with LTC, unplanned care figures) Delays in redesign work. dementia and mental health problems feel supported to Reduction in excess winter deaths by 50% manage their condition, have improved functional ability and Instability of patient flow can access care closer to home. A seamless integration Dementia - Increased diagnosis rates and improve access to 60% = increase by 444 across the LHE due to the of care across all sectors ● treatment. Ensuring there is sufficient capacity for step down patients ● Increased number of diagnosed patients on the register, accessing Francis report and monitor Reduction in unplanned admissions to hospital with and on-going management services and support (OF,CI,C) review of MSFT long term conditions by 50%
● Mental Health - Improve access to services 13% - increase by 206 ● Increased patients accessing treatment Insufficient IAPT compliant NHS Outcomes Framework patients (1,652 pts. receiving (M, EC, CI, C) capacity to meet demand 1st treatment ) Domain 1: Preventing people from dying ● Sustainability of number of patients in recovery within 2 years (M, EC, Ability to capture robust data prematurely ● Pts in recovery within 2 years National target 50% - CI, C) SAS currently achieving 67% Domain 2: Enhancing quality of life for people with in 12/13 long term conditions Primary Care - ● Increase number of diagnosed patients with hypertension 5% increase = 1718 patients ● Increased number of patients diagnosed with hypertension improving health Difficulties in identifying Domain 3: Helping people to recover from Clinically appropriate evidence based performance of care reducing long term complications associated with (23,190 pts.) and well being and reducing health related comorbidities (OF, CI, M, C) patients. Accurate coding in episodes of ill health or following injury linked to local quality premium under development undiagnosed (local priority) General Practice.
Domain 4: Ensuring that people have a positive Improve patients health and well being and increase number Increase to 1.5% prevalence Increase number of patients on GP registers and ensuring equity across the experience of care ● of patients on disease registers and ensure access to rate = 286 (target 2,169) ● local health economy. Reduce unwarranted variation, premature mortality Difficulties in identifying appropriate treatment for COPD (local priority) and health inequalities patients. Accurate coding in Domain 5: Treating and caring for people in a safe General Practice. environment and protecting them from avoidable harm ● Management of unwarranted variation across practices to To achieve peer group ● Reduction in referrals and activity on secondary care (OF, CI, M) Unable to change include practice level peer review in relation to referral and/or national average in trust/clinicians behaviour. management across planned and unplanned care and line with the 5% & 6% Delays in redesign optimisation of community services planned and unplanned care activity above Key Principles Page | 5 Choice Quality & Equality Evidence based - need lead Information & Performance management Partnership working Patients Voice Risk Management Strategy Key: OF = outcomes framework M = mandate CI = commissioning intentions C = NHS constitution EC = everyone counts 2013/14 Item: 10 Enc: 09
Stafford & Surrounds CCG Everyone counts Planning 2013/14 Needs, Context & Challenges
Higher than national average Excess winter Financially challenged acute Trust which is clinically Unwarranted variation across CCG significant QIPP Ageing population in both the over 65 and 75 age groups Problems with access and patient flow through urgent care system mortality rates and financially unviable practices Challenge
Goals Programmes Transformation Change Scheme 2013/14 Target 2013/14 Outcomes Risk (to be delivered by March 15) The vision for Stafford & Surrounds CCG is Planned Care ● Better care pathways and GP to consultant communication 5% reduction 1st OPA = 1,454 ● Reduction in first outpatient attendance (CI) Difficulties in changing for people in the Borough to receive first The CCG is an outlier in relation to the National and ONS reducing growth in hospital referrals and subsequent treatments 1st OPA ( target of 27,634) ● Reduction in elective admissions reducing unnecessary steps in the embedded NHS culture class healthcare leading to high quality median for elective admissions and above ONS median for pathway and improving patient satisfaction (CI, EC, OF) 1st OPA Delays in redesign work patient experience and excellent outcomes 2% reduction on EL A strategy for the reconfiguration of planned care pathways admissions = 439 (target has been agreed with local providers. Instability of patient flow across ● Reduction in outpatient follow ups and face to face 21,511) ● Improved New : Follow Up ratio's avoiding unnecessary appointments for Our values are: This will undergo review following the outcomes of the the LHE due to the Francis consultations by redesign patients (CI) monitor report at MSFT report and monitor review of Optimisation of treatment at the appropriate time avoiding ● Reduction in procedures of low clinical value ensuring patients not treated Quality first PLCV reduction 209 cases MSFT ● unnecessary intervention inappropriately(CI) Prevention of ill health Unplanned Care ● EUCS - modernising services which are sustainable and of high 6% reduction ● Reduction in A&E Attendance / Emergency Difficulties in changing Patient views and involvement The CCG is an outlier in relation to the National and ONS quality across the local health economy. Efficient access and A & E attendances = 2,239 admissions (adults and children) (EC, OF, CI) embedded NHS culture median for non-elective admissions rapid assessment as alternatives to hospital admissions. (target 35,080) Delivery of care close to home, easy access and improved patient ● Integration with a wide range of partners Implementation of NHS 111, AEC model, review of MIU's and satisfaction Delays in redesign work There is a local agreement to transform the emergency and ICT/social care model NEL admissions = 861 (target Contribution of all our members and staff urgent care system. This will include the development of an 13,496) Instability of patient flow across ambulatory care unit, review of MIU's, GP OOH's and a ● Nursing Homes - targeted support to nursing homes to avoid Included in numbers above Reduction in A&E and emergency admissions through case management the LHE due to the Francis Openness and honesty in all that we do model for integrated and social care unnecessary hospital admissions of patients to ensure optimal care in the home setting (CI,OF,EC) report and monitor review of MSFT The CCG is also exploring the introduction of a GP enhanced Our CCGs goal are to: LES to reduce unnecessary hospital admissions Inability to effect change in Reduce obesity levels by 10% against expected ● Winter Deaths - to work with Stafford Heath & Well Being Board 17% EWD (England rate) ● Excess winter deaths within national average (CI,OF,EC) nursing home practice prevalence to support warmer homes policy = 7 deaths 75% (National) currently at 68% ● Increase uptake of flu vaccinations >65's (local priority) & equates to additional uptake of ● Increased uptake of vaccinations and reduction in flu and pneumonia cases Reduce the proportion of people with undiagnosed Increase uptake of flu vaccinations in carers (local priority) 2,123 (target 22,961) disease from 30% to 10% 70% (National) currently at 44% equates to additional uptake of 124 (target 335) Levelling up of health outcomes so that all residents experience the same health care outcomes Co-ordinated Care - ● LTC - Provision of high quality integrated care through roll out of 6% reduction ● Reduction in A&E Attendances / Emergency admissions. Delivery of care Difficulties in changing To develop a holistic integrated care model which risk stratification and case management. Care pathway reviews A & E attendances & NEL closer to home, easy access and improve patient self management and embedded NHS culture. encompasses a preventative, anticipatory and whole person and patient self management admissions( included in satisfaction (CI,OF,EC) Reduction in excess winter deaths by 50% approach to ensure that patients with LTC, dementia and unplanned care figures) Delays in redesign work. mental health problems feel supported to manage their condition, have improved functional ability and can access Instability of patient flow across Reduction in unplanned admissions to hospital with care closer to home. A seamless integration of care across Dementia - Increased diagnosis rates and improve access to 60% = increase by 444 the LHE due to the Francis long term conditions by 50% all sectors ● treatment. Ensuring there is sufficient capacity for step down patients ● Increased number of diagnosed patients on the register, accessing report and monitor review of and on-going management services and support (OF,CI,C) MSFT
● Mental Health - Improve access to services 13% - increase by 206 patients ● Increased patients accessing treatment Insufficient IAPT compliant NHS Outcomes Framework (1,652 pts. receiving 1st (M, EC, CI, C) capacity to meet demand treatment ) Domain 1: Preventing people from dying ● Sustainability of number of patients in recovery within 2 years (M, EC, CI, Ability to capture robust data prematurely ● Pts in recovery within 2 years National target 50% - C) SAS currently achieving 67% Domain 2: Enhancing quality of life for people with in 12/13 long term conditions Primary Care - ● Increase number of diagnosed patients with hypertension 5% increase = 1718 patients ● Increased number of patients diagnosed with hypertension improving health Difficulties in identifying Domain 3: Helping people to recover from episodes Clinically appropriate evidence based performance of care reducing long term complications associated with undiagnosed (23,190 pts.) and well being and reducing health related comorbidities (OF, CI, M, C) patients. Accurate coding in of ill health or following injury linked to local quality premium under development (local priority) General Practice.
Domain 4: Ensuring that people have a positive Improve patients health and well being and increase number of Increase to 1.5% prevalence Increase number of patients on GP registers and ensuring equity across the experience of care ● patients on disease registers and ensure access to appropriate rate = 286 (target 2,169) ● local health economy. Reduce unwarranted variation, premature mortality and Difficulties in identifying treatment for COPD (local priority) health inequalities patients. Accurate coding in Domain 5: Treating and caring for people in a safe General Practice. environment and protecting them from avoidable harm ● Management of unwarranted variation across practices to To achieve peer group and/or ● Reduction in referrals and activity on secondary care (OF, CI, M) Unable to change include practice level peer review in relation to referral national average in line with trust/clinicians behaviour. management across planned and unplanned care and the 5% & 6% planned and Delays in redesign optimisation of community services unplanned care activity above
Key Principles Choice Quality & Equality Evidence based - need lead Information & Performance management Partnership working Patients Voice Risk Management Strategy
Key: OF = outcomes framework M = mandate CI = commissioning intentions C = NHS constitution EC = everyone counts 2013/14
Page | -1- Item: 10 Enc: 09
Stafford & Surrounds Clinical Commissioning Group
A new approach to clinically led commissioning from 1/4/2013
Listening to Patients – NHS constitution Customer convenience - 7 day week access Real time patient and carer experience feedback Friends & Family test Outcomes Publication of consultant level data NHS outcomes framework to inform planning
Rewarding excellence Quality premium for CCG’s to secure quality improvements CQUIN – quality improvements Review of incentives, rewards and sanctions available 13/14 Financial & related levers and enablers for better patient outcomes Improving Knowledge and Data Timely and accurate data to inform commissioning NHS providers to comply with information standards
Assurance of CCG plans:- Plan on a Page – sets out CCG plans for 2013/14
Self certification of commitment to delivery of the rights and pledges of the NHS Constitution, Mandate and Clostridium difficile objective
Self certification of assurance that provider cost improvement plans are deliverable without impacting on quality and safety of patient care
Dementia – trajectory for diagnosis rates and Improving Access to Psychological Therapies Trajectories for locally selected priorities
Mental Health Increase patients accessing treatment and sustain number of patients in recovery within 2 years
Activity trajectories for 4 key measures:– • 1st outpatient appointments • Elective admissions • A&E attendances • Non-elective admissions Activity Target Actual Total activity * reduction numbers * 1st OPA 5% reduction -1,454 27,634 Elective admissions 2% reduction -439 21,511 A & E attendances 6% reduction -2,239 35,080 Non-elective 6% reduction -861 13,496 admissions
* Calculations are base on forecast outrun for 2012/13 Actual increase Total numbers Dementia (diagnosed) Increase to 60% 474 2057 (prevalence) (currently at 36.9%) Mental health (IAPT) 13% +206 1,652 (receiving 1st (access) (current cumulative at Tx) 11.69% at Q3)
Goal Description
Goal 1 A 10% reduction the levels of obesity against the expected prevalence
Goal 2 A reduction in the proportion of people with undiagnosed disease from 30% to 10%.
Goal 3 A “levelling up” of health outcomes so that all residents experience the same health care outcomes
Goal 4 A reduction in excess winter deaths of 50%
Goal 5 A reduction in unplanned admissions to hospital for people with Long Term Conditions of 50% Measure Current SAS Target National Actual Total target number number Excess Expected 17% EWD ratio 17% EWD -7 EWD 71 winter deaths 2012/13 = ratio 19.70% ratio
Flu >65 = >65 = 75% >65 = 75% 2,123 22,961 vaccination 68.1% Carers = 70% Carers = 124 335 Carers = 70% 44.1%
COPD 1.3% 1.5% 1.7% 286 2,169 Hypertension 14.8% 16% England 1,718 23,190 (base on pop. (equates to 8% increase model 144,593) on registers) 26.7% Best practice pathways – T & O, Gastro, Urology, dermatology etc.
Optimisation of community services
Management of unexplained variation within general practice
Elective admissions – improved pathways and optimisation of treatment, decision aids
Quality premium plan Introduction of EUCS – AEC, MIU, ICT/social care
Roll out of risk stratification & case management
Nursing home targeted support
Primary care management of minor illness
Falls
Item 12 Enc 10
Stafford & Surrounds and Cannock Chase Clinical Commissioning Group Joint Quality Committee Meeting held on 29th January 2013 At Greyfriars Therapy Centre, Stafford, ST16 2ST
1.0 Present Action Margaret Jones (MJ(Chair)), Lynn Tolley(LTo), Jonathan Bletcher(JB), Sharuna Reddy(SR), Jane Chapman(JC), Adele Edmondson(AE), Lisa Evans(LE), Anne- Marie Houlder(AMH), Allison Heseltine(AH), Anna Onabolu(AO), Jo Corbett(JCo), Laura McGarvie(LMcG(Notes)) 2.0 Apologies Val Jones(VJ), Tim Berriman(TB), Marianne Holmes(MH), Mark Doran(MD) 3.0 Declarations of Interest There were no declarations of interest to declare. 4.0 Minutes of the Last Meeting The minutes of the last meeting were approved. 5.0 Action Log The Action Log was updated. • Failure to appoint to a clinical quality lead in SaS was noted. To ask Membership Boards for further expressions of interest. • It was noted that the EDS conference scheduled for 12 February has been postponed until 26 April. • Reports relating to Mental Health Services deferred to next meeting in view of MD’s absence. • Reports relating to District Nurse r/v and Nursing Home assurances deferred to February meeting in view of VJ’s absence.
6.0 Allison Heseltine Presentation Allison Heseltine gave a presentation around HACI trajectories for the next 12 months.
MRSA
Zero tolerance for MRSA bacteraemia whether community or acute acquired.
C Diff
Upper limit for SaS CCG 33 cases, for CC CCG 32 cases without affecting the quality premiums for next year. All cases of “acquired” c-difficile in our area which could have been generated from outside the patch and across the borders, acute hospital settings or outpatient’s settings i.e. out of hours, community providers are counted. The figures which suggest a reduction of up to 25% over the previous years.
Antibiotic guidelines have been updated but the Staffordshire patch area still remains the worst target area within the West Midlands for the prescribing of cephalosporins in the South and co-amoxiclav in the north.
RCA’s are undertaken for all cases and the data is fed into the contracts for the Acute Trusts. RCA’s are also being explored for community cases in future.
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Item 12 Enc 10 The figures for MSFT have not been seen this low before and the target is being challenged with NHSCB as this may be based on a statistical blip.
All trusts to have action plans to report to CQRMs on a quarterly basis.
All to be held to account for prescribing especially GPs who should be asked to review PPI, cephalosporin and quinolone prescribing.
JC asked if benchmarking is available. SR said that this is available and it was agreed that SR will send the benchmarking data to JC for review.
It was noted that the figures for October had increased at both a local, regional and national level.
AMH asked if the contract was still going to be changed to show the instances related to bed days as discussed prior at the HQAC meeting. AH was unsure of this currently but did remind the committee that the figures will in future also include those patients who have been asymptomatic.
JC asked if the RCA’s are recorded at a level for either practices or GPs. MJ said that this is not officially recorded but this is reported to the Pharmaceutical leads to raise further. It was noted that the process for RCA’s is that a form is sent to the practice for completion and this is then returned to the medicines management team.
MJ thanked AH for attending and asked AH to share the results of the challenge when available. This was agreed. 7.0 Sharuna Reddy Presentation SR gave a presentation which followed on from AH presentation around “Antibiotic Stewardship”.
Actions noted from the presentation were as follows: • AE will help develop a local campaign around antibiotics and there use which will follow on from the National Campaign. • Patient and Pharmacy Education to be explored around the guidance and need for antibiotic prescribing. • Alternative antibiotics to be explored for the treatment of diabetic foot ulcers • liaison with microbiologists on reporting cephalosporin or quinolone sensitivities
8.0 Provider Quality Reports and Highlights The absence of reports for SSOTP and SSSFT were noted by the Committee for information and will be picked up as part of the February meeting.
MSFT Report Breast Cancer Review is taking place on 14th and 15th February. The patient experience element within the report is now being RAG rated and it was noted that one ward has been highlighted as problematic but work is underway to improve this situation.
SI’s – There has been a drive by Cluster to reduce the number of Outstanding SI’s to “0” by the 31-01-13. LTo has spoken to the Cluster and an email has been issued to all providers to inform them that all outstanding SI’s must be closed by this date otherwise a performance contract notice will be served.
Falls – LTo has spoken to Katie Montgomery within SSOTP around the provision
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Item 12 Enc 10 of staff training for falls. A lot of work is on-going on this subject with 1:1 bookings implemented along with other mechanism’s to reduce the figure. From a contractual point of view we will have the same report as last year but we are currently in liaison with providers to obtain 12 months rolling data.
CQUINs – There is a meeting scheduled to take place tomorrow (30/1/13) to discuss the MSFT CQUINs. It was agreed that we need to start this work earlier for the next year’s agreements to be reached but these will all be signed off for this coming year.
AE asked if EDS was included within the contracts. LTo said that a line has been included but it was asked that AE investigates that this covers the requirements.
MJ raised concern with regard to the patient experience summary and the issue of patients noting “noise at night”. LTo said that this has been staff orientated and on occasions staff training has been implemented. This has been an issue in particular with Cannock Chase Hospital and this will be raised further at the next CQRM.
JB asked if all contracts have been completed to the same level. LTo confirmed that she was currently leading on this a big push forward was being taken so that the deadlines are reached on time.
LE said that a point of agreement has now been reached around the CQUINs list and a short list has now been devised. LE confirmed that some of the “short list” CQUINs included:
Provision of general dementia staff training for SSOTP was noted to be delivered.
Case Management – still looking to focus on LTC’s i.e. COPD as this is the highest rate in the South. This will also look at admission avoidance and implementation of pathways.
End of Life (EoL) – A suggested plan has been devised that everyone who is terminally ill has a care plan which specifically notes preferred place of death, this would then be outcome measure. AE said that this would tie in with the Advance Directive initiative and feedback which has been previously received.
9.0 Serious Incident (SI) Report Issues have been noted around the 45 day breaches on overrunning Sis and there is a big push for closure.
LTo said that the data graphs currently within the report, specifically those on Slips, trips and falls are not an accurate reflection or representation on the actual figures and LTo will raise this with Janine Lake to ensure that more accurate data is received for the next meeting.
It was noted that there has been increased media attention on recent incidents which have occurred and a “Risk Summit” has been convened to take place tomorrow (30/01/13) to discuss the issues of SI’s. VJ will be in attendance at this meeting.
10.0 Safeguarding DoLs are now going through the transfer of bodies’ procedure to transfer responsibility from PCT to Local Authorities.
3
Item 12 Enc 10
21 patients currently subject to DoL across South Staffordshire. There are currently no LSIs in the CCGs area.
It was noted that Hampton Court nursing home establishment has closed with effect from 02/01/2013. New information is to be obtained around Shenstone Hall nursing home as they are in receipt of a new owner/provider. A meeting has been arranged to discuss Marquis Court.
DHR – no new cases. The case in Penkridge has now closed.
11.0 Prescribing and Medicines Management SR Controlled Drug (CD) Initiative SR said that as part of the CD initiative two reports had been produced, and it was noted that excess prescribing of more than 30 days’ supply of controlled drugs had been highlighted. This was in some instances non-formulary prescribing of drugs. The medicine’s management team were raising these issues direct with practices.
The prescribing rates are now higher than the PCT average but it was assured that this was nothing to be concerned around.
Nurse prescribing for controlled drugs will also be followed up with practices via SR.
The paper was noted by the Board for information.
QIPP Indicators It was agreed that SR will produce a full report for the next meeting. SR
Patient Group Directives (PGDs)
Currently the PGDs have been initiated by the PCT and these now need to be Meds transferred to the CCGs for legal compliance. These will be rewritten by the Manag’nt Team Medicines Management Team and presented to the GBs for ratification.
It was noted that a designated Doctor, Pharmacist and Nurse are required to review, agree and sign-off the new PGDs.
It was agreed that Val Jones will be the Nurse, Sam Buckingham / Sharuna Reddy can be the Pharmacist and the Doctor can either be Dr Tim Berriman, Dr Anne-Marie Houlder, Dr Margaret Jones or Dr Marianne Holmes.
It was recommended that the PGDs are sent to the Governing Bodies for both Cannock Chase and Stafford & Surrounds CCGs before the 1st April 2013 for sign off and compliance to be reached. MJ asked if any new PGDs were required. SR said that required medicines are now covered.
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Item 12 Enc 10
12.0 Patient Experience AE gave a verbal update that looked at how the patients’ engagement can be captured. At practice level, PPGs may be able to capture concerns from the wider patient community.
AE was asked if a template is in use to capture this information. It was noted that the datex system was also being explored with the view to capturing MP letters etc. that had been received.
AE has conducted visits to practices to establish how this information could be captured. Could patient comment boxes be used to capture issues and themes? It is easier to capture written comments rather than verbal.
LE asked whether the patient experience forum could be used to capture patient comments direct. JB said that the comments would be difficult to capture as they can be received in small numbers.
JC said that the PPGs could be approached to ask if a version of the form currently used could be used to capture GP soft intelligence.
MJ asked if a further understanding of the datex system is required on how it works and what capabilities it can provide. It was agreed therefore that the CSU should be invited to attend this meeting to give an overview on the capabilities and working of the datex system.
AMH asked if people like Julie Bailey (Cure the NHS) are monitored as a tool for soft intelligence. MJ stated that caution is needed as a CCG should not be seen to be giving support to one particular organisation over another.
The CCGs should work on enabling all patients and groups to have easy access to provide feedback to the CCGS.
MJ asked for AE to come back to the next meeting in a months’ time with an update around this item. This was agreed.
13.0 Public Health The board noted for information the Bowel Screening programme quality assurance team visit recommendations paper. It was asked that this paper was brought back to the March quality committee MARCH meeting for further review of the actions relating to the three month Mtg recommendations. This was agreed. 14.0 Any Other Business There was no further business to note. 15.0 Date of Next Meeting The date of the next meeting was agreed as 21st February 2013 @ 2:00pm. The venue will be Boardroom, Greyfriars Therapy Centre, Frank Foley Way, Stafford, ST16 2ST
5 Item No: 13 Enc 11
REPORT TO THE Clinical Commissioning Group Governing Body Meeting TO BE HELD ON: Monday 15th April 2013
Subject: Governing Body meetings in Public Board Lead: Margaret Jones Officer Lead: Andrew Donald
Recommendation: For Approval √ For Discussion For Information
PURPOSE OF THE REPORT:
• To propose moving to 10 Governing Body meetings in Public
KEY POINTS: • CCG is now the statutory body responsible for commissioning services for the Stafford and Surrounds population • Transparency and openness with the public is a key role for the CCG • The move to 10 Governing Bodies per year delivers on the goal of transparency of decision making Relevance to Key Goals
A 10% reduction the levels of obesity Not applicable against the expected prevalence
A reduction in the proportion of people Not applicable with undiagnosed disease from 30 – 10 %. A “levelling up” of health outcomes so Not applicable that all residents experience the same health care outcomes
A reduction in excess winter deaths of Not applicable 50%
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Item No: 13 Enc 11
A reduction in unplanned admissions to Not applicable hospital for people with Long Term Conditions of 50%
Implications Legal and/or Risk CQC Patient Safety Patient
Engagement Financial Sustainability Workforce /
Training
RECOMMENDATIONS / ACTION REQUIRED: The CCG Governing Body is asked to: The Governing Body is asked to: • Note the report • Approve the move to ten Governing Bodies in public commencing in May 2013
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Have partners / public been involved in design? Are partners / public involved in implementation? Are partners / public involved in evaluation?
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Item No: 13 Enc 11
Report to Stafford and Surrounds CCG Governing Body
Governing Body
1.0 Purpose
• To propose moving to 10 Governing Body meetings in Public
2.0 Proposal
The CCG became statutorily responsible for the commissioning of healthcare services on the 1st April 2013.
Part of that responsible will be to ensure that decision making on service provision is made in an open and transparent manner.
To date the CCG has held meetings in public bi-monthly whilst going through the authorisation process and whilst this demonstrates a level of transparency it potentially causes confusion about how, when and where decisions are made.
It is therefore proposed that the CCG Governing Body holds all its monthly meetings in public.
It is further proposed that the Governing Body holds ten meetings per year which excluding August and December.
The proposed dates are shown below:-
20th May 2013 17th June 2013 15th July 2013 16th September 2013 21st October 2013 18th November 2013 20th January 2014 17th February 2014 17th March 2014
All meetings will commence at 2.30pm and will finish at 5pm.
3.0 Recommendation
That the Governing Body confirm their support for the above proposal.
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