Commissioning health care in 2008/09

Key findings from our analysis of primary care trusts as commissioners of health care

May 2010

About the Care Quality Commission

The Care Quality Commission is the independent regulator of health care and adult social care services in . We also protect the interests of people whose rights have been restricted under the Mental Health Act.

Whether services are provided by the NHS, local authorities or by private or voluntary organisations, we make sure that people get better care. We do this by:

• Driving improvement across health and adult social care. • Putting people first and championing their rights. • Acting swiftly to remedy bad practice. • Gathering and using knowledge and expertise, and working with others

About Her Majesty's Inspectorate of Prisons

Her Majesty's Inspectorate of Prisons for England and Wales (HMI Prisons) is an independent inspectorate which reports on conditions for and treatment of those in prison, young offender institutions and immigration detention facilities.

HM Chief Inspector of Prisons is appointed from outside the Prison Service, for a term of five years. The Chief Inspector reports to Ministers on the treatment of prisoners and conditions in prisons in England and Wales.

The Prisons Inspectorate also has statutory responsibility to inspect all immigration removal centres and holding facilities. In addition, HM Chief Inspector of Prisons is invited to inspect the Military Corrective Training Centre in Colchester, prisons in Northern Ireland, the Channel Islands and Isle of Man.

© 2010 Care Quality Commission and Her Majesty’s Inspectorate of Prisons

Published May 2010

This document may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the document title and © 2010 Care Quality Commission and Her Majesty’s Inspectorate of Prisons.

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 2 Contents

Summary 4 Recommendations from this report 5

1. Background 6

2. What's going well? 7 Management systems 7 Clinical governance 8 Service plans and framework 9

3. What needs to improve? 11 Monitoring performance 11 Personalised care 12 Continuity of care 12

4. The future: new systems of assessment 14

Appendix A: Primary care trusts included in our sample 15

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 3 Summary

This report reviews the key findings from our These inspectorates published a joint report on analysis of primary care trusts’ (PCTs) work as their findings for a sample of PCTs in 2006/07, commissioners of prison health care in 2008/09. leading to a follow-up report in 2007/08, which It relates to a sample of 21 PCTs that commission made recommendations in 10 areas. health care for prisons that received an announced or full (not targeted) unannounced This report shows where things have improved, or inspection by Her Majesty’s Inspectorate of not, since 2007/08. It also indicates some of the Prisons (HMIP) in that year. areas that CQC’s new systems of assessment will need to take into account from April 2010. PCTs became fully responsible for commissioning prison health care in 2006. This has been In general, our findings suggest that PCTs have reflected in how the Healthcare Commission, until made progress and are getting on top of 31 March 2009, and now the Care Quality embedding systems for management and clinical Commission (CQC) have coordinated their governance, although they need to continue to assessments of prison health care commissioners improve. We saw improvement in a number of with HMIP’s inspections of prisons. areas – such as electronic information management – where we highlighted concerns in Progress on the 10 areas for improvement 2006/07 and were generally told that these had from our 2007/08 findings already been identified as priorities for 2007/08. Putting all the necessary management systems in Regular needs assessment place still needs to develop further, but it is Better moving in the right direction.

Clarity about resources We have not yet seen such clear progress in PCTs Better making sure that people experience good quality Measurement of care that is responsive to their needs. Nor did we performance No improvement see progress in specific areas, such as services provided for drug misusers, since PCTs' Information management arrangements for monitoring quality still do not Better go consistently to this level of detail. This is the Staff training third year in a row that we have found that PCTs Better need to do more to be able to ensure good quality care in these areas. Monitoring of staff training Better We recommend that PCTs should now raise their focus beyond getting management systems in

Strategies for equal access place and ensure that they are giving top priority Better to monitoring the quality of care that they Complaints commission. They should particularly address the No improvement continuity of prisoners' health care during transfer and release, which is inadequate and seems to be Involvement of prisoners getting worse rather than better. Although this No improvement may not be a problem that PCTs can solve on Drug treatment systems their own, they must take the lead role in ensuring improvement. No improvement

Arrangements for transfer and release Worse

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 4 From April 2010, providers of health care in prisons will be subject to a new system of statutory registration, with enforcement powers if standards of care fall below required levels. CQC and HMIP will work closely to check that providers meet these required standards, including those for coordinating care along the offender pathway. PCT commissioners will have an essential role in this new system and in working with us to make sure that the various roles for promoting good quality care work well together.

Recommendations from this report

In 2010/11, we expect PCTs to:

1. Be able to demonstrate that information systems are being used for regular review of clinical standards and that these reviews are followed up with action where needed.

2. Further develop the sophistication of the information that they collect on the quality of service provision and on health promotion. This will improve their ability to detect and correct unsatisfactory practice and ensure that individual services that they commission are achieving their objectives for quality of care.

3. Be able to demonstrate that they act on complaints (and the absence of complaints) in the ways that they commission and monitor services. We encourage PCTs to share their knowledge and experience about what works in making prison health care personalised and how they involve prisoners in delivery and planning.

4. Give priority to continuity of care at transfer and release and to be able to demonstrate that health care services for each prison in their area join up effectively with other services. We encourage PCTs to share knowledge and experience of what works in managing the common problems in this area.

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 5 1. Background

This report summarises the findings from CQC's contact with PCTs in 2008/09. It will be of particular interest to PCT commissioners, so that they can compare local performance with national findings. As with our previous reports, these findings are from a sample rather than all PCTs. There are 21 PCTs in our sample this year (see appendix A).

HMIP inspects all prisons regularly, and assessing health care services forms a key part of the inspections. CQC contributes information to HMIP about NHS trusts' performance, and uses HMIP's findings in its assessments. CQC also collects information from PCTs about how prison health services are commissioned and monitored specifically for HMIP's inspections that are announced in advance, or for their full unannounced inspections.

In April 2010, NHS trusts that provide prison health care must register with CQC. Independent providers must also register from October 2010. Once registered, these providers will be subject to statutory requirements for the quality and safety of care. CQC and HMIP are developing a new memorandum of understanding to set out how we will continue to work closely together in monitoring and checking standards of care in prisons.

Although registration applies to providers, PCT commissioners also have a major role. • Where CQC and HMIP detect a problem in prison health care, we will seek to involve PCTs as one of the key ways to address it and promote improvement, rather than rushing to use our enforcement powers. • CQC intends to develop ways of taking providers' performance into account in the way it reports on commissioners.

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 6 2. What's going well?

PCTs have made progress in three broad areas: Governance systems similarly appear to have • Management systems. become well established, with every PCT in our sample holding regular partnership boards and • Clinical governance. other meetings to review the service. We explored • Service plan and frameworks. this further by asking about the membership of partnership boards, types of other meetings, if the Management systems prison governor is involved, and whether the PCT lead and professional executive committee or In 2006/07, when PCTs first became wholly board members visited the prison. Our findings responsible for commissioning prison health care, were that this was variable: for example, some not all of them could even describe to us how PCTs’ leads visited the prison weekly, others they developed and monitored a budget for it. By quarterly, others not at all. These differences may 2008/09, the PCTs that we asked could all just be due to local arrangements, but it is more describe arrangements, and these were embedded likely to reflect how deep the relationships below through partnership boards. All these PCTs were partnership boards go which, by their nature, are able to describe formal service level agreements, high level and senior. contracts and contract monitoring. We asked 14 PCTs about budget trends and 10 reported that spending was increasing, while four said that it was steady.

Figure 1: Partnership boards are in place and senior

Members of the prison partnership board Other senior prison staff Commissioners Strategic health authority representatives Health Protection Agency representatives Provider services Care Service Improvement Partnership representatives Prison finance representatives Heads of health care Independent monitoring board representative PCT chief executive

Public health representative

Other PCT directors

PCT finance director or representative PCT director of commissioning Prison governor Number of PCTs

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 7 Figure 2: Meetings below partnership board vary

Ro u tin e meet in g s b etwe en thePCT and the prison Routine meetings between the PCT and the prison Local implementation groups Mental health groups

Contract monitoring meetings Prison senior management team meetings Prison health service delivery groups Commissioning groups

Governance groups

Prison health operations groups D rugs & T herape tics Drugs and therapeutics or IDTS groups 0 1 2 3 4 5 6 7 8

Number of PCTs

Clinical governance Ensuring that there are enough appropriately trained staff is an area that has improved each Clinical governance is PCTs’ systems for year in our findings, although there are still issues, monitoring and checking standards of safety and such as high turnover and difficulty in quality in health care. recruitment. For example, two out of 21 PCTs highlighted recruitment problems in 2008/09, As our previous findings from samples of PCTs compared to four out of 16 in 2007/08. All but showed, all have systems for reviewing and one PCT had a workforce plan (compared to only investigating serious untoward incidents – when two in 2007/08), and all but one could something goes wrong that could cause harm. demonstrate that they monitored training Only one PCT described this as an area needing (whereas in 2007/08 half of the sample had no significant further development. Similarly, all but system). one PCT could demonstrate that professional clinical advisors were involved in their In 2006/07 and 2007/08, we said that the clinical commissioning processes – although not all of information available to PCTs was poor, which these advisors had experience of prison health meant that they were unable to review standards care. And only one PCT could not effectively of care effectively. PCTs told us that they would describe robust arrangements for reviewing address this in 2007/08, and by 2008/09 almost deaths in custody. All of the PCTs we asked had all PCTs that we asked either had electronic arrangements for the responsibility for controlled information systems in place or were in the drugs and for monitoring their use, with only one process of rolling it out. This is good progress but saying that the arrangements did not follow it is not universal – two PCTs still had not even through into frontline staff's awareness of developed plans. In addition, we have yet to see responsibilities. how better information will follow through into better monitoring and the ability to detect and ensure action on shortfalls.

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 8 Figure 3: Use of IT is becoming more widespread

PCT response to ‘Is there an IT system within the prison?’

No, plannedN o, planned forfo rfuturefutur e

C ur r entlCurrentlyy being deve l o beingp e d /

developed/procuredprocured

Yes

0 1 2 3 4 5 6 7 8 9 Number of PCTs (n=12)

• 76% had completed a recent health needs assessment, all others had plans to do so, and Recommendation 1 the use of demand projection models is developing. This is much better than in In 2010/11 we expect PCTs to be able to 2007/08, when 78% had not carried out a demonstrate that information systems are needs assessment, half of which did not even being used for regular review of clinical have plans. standards and that these reviews are • Equity of access to health care had become as good as in the community – but in five cases followed up with action where needed. (20%) the PCTs could not actually demonstrate this through any monitoring system. Service plans and frameworks Figure 4: PCTs’ answers to “Does the local We recognise the improvements that PCTs are area agreement explicitly include this prison?” making in their frameworks of plans and strategies. However, there is still a need to go further. 17%

Starting from a low baseline in 2006/07, we have 44% seen clear progress in our sample of PCTs so that by 2008/09:

• Only one did not have a prison health delivery

plan in place. 30% No • 39% had a local area agreement that included prison health care – not good enough, but Yes better than the 27% in 2007/08. Unknown/unclear

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 9 Figure 5: Arrangements identified by PCTs for palliative and end of life care

Own palliative care suite

Bespoke/individual basis

End of life coordinators/teams

Transfer to other premises

Link to end of life strategy/policy/plan

0 1 2 3 4 5 6 7 Number of PCTs

Figure 6: Methods identified by PCTs to ensure the needs of black and minority ethnic prisoners are met

Impact assessments

PCT diversity committee

Translators/interpreters

PCT diversity policy/plan

Staff training Community mental health development workers Assessments of

health needs 0 1 2 3 4 5 6 7

Number of PCTs

Plans for individual types of service, or for groups Mental Health in England, which is an of patients, also seem to have improved since improvement on 2007/08 findings. 2007/08. • PCTs were generally able to demonstrate It is encouraging that these systems are arrangements for palliative and end of life increasingly in place. However, without data and care, and for meeting special needs. monitoring, it is not yet possible to know whether they are actually effective (see • All but one PCT could demonstrate how they recommendation 1). meet the needs of patients from black and

minority ethnic groups, and a majority of

those that commented on it said that they

used the strategy of the National Institute for

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 10 3. What needs to improve?

Our findings show that PCTs need to improve in than half could cite specific work on smoking three broad areas: cessation, nutrition or physical activity. There • Monitoring performance. clearly is good practice happening on health promotion and good information within some • Personalised care. prisons. However, the information that PCTs have • Continuity of care. about this is still not always sufficiently detailed and developed to enable them to check the Monitoring performance quality of services at the level that people actually experience them. PCTs have made progress in putting contracts and service specifications in place. In 2006/07, only one PCT in our sample collected performance data PCTs may learn from: systematically, but in 2008/09 all PCTs were doing so, with half also collecting outcome data HM Prison Hewell Grange/ Worcester PCT and six collecting quality and outcomes Good information is recorded to enable framework type data. However, many PCTs in our monitoring of levels of long-term conditions sample indicated that this is still a development in the prison, and of individual prisoners' care. area, with some PCTs more advanced than others.

We were surprised that some PCTs claimed not to Recommendation 2 receive information on the quality of prison dentistry. And we were disappointed that drug In 2010/11, we expect PCTs to further misuse services have adopted the best practice develop the sophistication of the model of the Integrated Drug Treatment System information that they collect on the quality in only six out of 21 PCTs (and often only in one prison per PCT) – although we recognise that this of service provision and on health largely reflects progress with the national roll-out promotion. This will improve their ability to of the system. We found that all 21 PCTs could detect and correct unsatisfactory practice demonstrate health promotion activity, but fewer and ensure that individual services that

Figure 7: Health promotion initiatives applied they commission are achieving their to the prison population objectives for quality of care.

General mental health and self-harm

Substance misuse

Vaccinations and blood-born viruses

Sexual health

Healthy eating and exercise

Smoking cessation

0 1 2 3 4 5 6 7 9 10 11 8 Number of PCTs

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 11 Personalised care Our findings indicate that commissioners do not all ensure that services are responsive to In 2006/07, the PCTs in our sample were unable complaints, and do not all take complaints into to give us evidence showing how they involved account in their commissioning and contract prisoners in care processes or planning. Our monitoring processes. 2007/08 findings indicated that more processes had been put in place, and our findings in PCTs may learn from: 2008/09 suggest the same – there is no particular evidence from our sample that involvement has HM Prison Hull/ Hull PCT become deeper or more embedded. Most PCTs A dedicated PALS worker at the prison (but not all) use processes such as surveys, which ensures that prisoners’ complaints are is encouraging. However, the information that we addressed quickly and effectively. collected does indicate how prisoners' views, experience of care and health potential drives the HM Prison / Wakefield District commissioning process. The picture is more one in PCT which PCTs are trialling approaches such as There is an expert patient group to oversee forums, workshops and extending Patient Advice and deliver information to prisoners on and Liaison Services (PALS) in order to find out managing their own health. what works. Instead of receiving a vision of how to ensure personalised care through commissioning, PCTs continued to tell us how difficult they find it to involve people in prisons. Recommendation 3

We are not critical of this. There undoubtedly are In 2010/11, we expect PCTs to be able to challenges, and we recognise that PCTs are demonstrate that they act on complaints seeking to go further but, in doing so, they are (and the absence of complaints) in the entering new territory. ways that they commission and monitor We do, however, question the way PCTs are services. We encourage PCTs to share their learning from prisoners' complaints in their knowledge and experience about what commissioning processes. Complaints are an works in making prison health care important indicator of dissatisfaction and of personalised and how they involve providers' performance, which is often only just prisoners in delivery and planning. acceptable. However in our sample of 21 PCTs:

• Four had no way of knowing what complaints might have been made about prison health care in their area in the last year. Continuity of care

• Four did monitor complaints, and reported In 2007/08, over half of our sample of PCTs told that none had been made about prison health us that they had systems in place to promote care in the last 12 months. continuity of care when prisoners were transferred • In the others, rates of complaints were or released, although this seemed very variable. In monitored and varied significantly, with prison our 2008/09 sample of PCTs the situation is health care in one PCT receiving 300 per year, worse: while others received single figures (complaint • Only one had a policy. rates may of course indicate either quality of • Most PCTs could outline some processes that service or accessibility of the complaints they used (although one could not describe process). any to us at all), but these did not • Only four PCTs could refer to cases where systematically cover all prisoners, all areas and they had actively investigated complaints. services within the PCT, or all prison services.

• In general, PCTs indicated a wide range of issues that were not working well.

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 12 The issues that PCTs in our sample were struggling with included how to manage out of area transfers, sudden transfers, release of patients not registered with a GP (who are sometimes given their own medical records, to make their own arrangements), and difficulty in monitoring continuity – especially if the prison does not use a person's NHS number in their IT system. Their difficulties included not being able to make links with specialist services such as mental health, but most of the examples that we collected are with primary care, which is an area of health care that the PCTs themselves control. These areas are wide ranging, but the problems are common and well-known for this group of people. They suggest a significant risk that people may be left without continuity of care once they leave the prison health care service, for which the PCT is responsible. While other areas of the service have been prioritised and improved, this issue seems to be getting left behind.

PCTs may learn from:

HMP Shrewsbury/ Shropshire County PCT There is a good process of pre-release health review, involving the prisoner, their health documentation and other information.

HMP Featherstone/ South Staffordshire PCT Good systems have been developed to ensure that prisoners are able to access health services on release.

Recommendation 4

In 2010/11, we expect PCTs to give priority to continuity of care at transfer and release and to be able to demonstrate that health care services for each prison in their area join up effectively with other services. We encourage PCTs to share knowledge and experience of what works in managing the common problems in this area.

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 13 4. The future: new systems of assessment

CQC and HMIP will continue to work closely together as the new system of provider registration comes into effect, and as CQC introduces a new process for assessing commissioners from 2010/11. This will ensure a harmonised, consistent approach that does not duplicate activity. It will also recognise the crucial role that PCTs play in planning, monitoring and continuously improving the quality of prison health services through their commissioning role. We will seek to develop our approach to working with PCTs further, to make sure that where there are concerns about prison health care services, all efforts to promote improvement are coordinated as affectively as possible, and enforcement is only used where necessary.

This report recognises that PCTs are making progress, although there still remains much that is needed. CQC is currently developing its approaches to the assessment of commissioners, in order to replace the current Department of Health standards – Standards for Better Health – which expired in March 2010. One area that will be explored is how the performance of providers may reflect back on commissioners and bring together the individual assessments. The approach will also be coordinated with the NHS’s World Class Commissioning, the comprehensive area assessment and the Government's Vital Signs performance indicators. The Department of Health’s framework for developing offender health services, Improving Health, Supporting Justice: the Offender Health Delivery Plan, is likely to be particularly helpful in driving improvement in the areas that we have highlighted in this report. Our aim will be to take account of this national framework in our systems of assessment and to coordinate our activity with it.

Care Quality Commission and HM Inspectorate of Prisons: Commissioning health care in prisons 14 Appendix A: Primary care trusts included in our sample

Prison Primary care trust HMP Risley (Male Category C), Thorn Cross Warrington PCT (Juvenile) HMP Erlestoke (Male) Wiltshire PCT HMP Leicester (Male) Leicester City PCT HMP Leeds Leeds PCT HMP Wealstun (Cat C Male) Leeds PCT HMP Long Lartin (Male Cat A), HMP Worcestershire PCT Blakenhurst (Male local), HMP Brockhill (Male Cat C), HMP Hewell Grange (Male Cat D) HMP Wymott, HMP Garth, HMP Preston Central Lancashire PCT HMP Shrewsbury (Male, Local, Cat B), HM Shropshire County PCT Young Offenders Institute (YOI) Stoke Health (Juveniles closed) HMP Bedford (Male, Category B) Bedfordshire PCT HMP Verne prison, Guys Marsh, Shepton Dorset PCT Mallet, young offenders unit HMP Leyhill, Eastwood Park (female South Gloucestershire PCT remand, YOI and juvenile) HMP Kennett (Category C) Sefton PCT HMP Hollesely (Category D, male) Suffolk PCT HMP & YOI New Hall and HMP Wakefield Wakefield District PCT HMP Hull Hull PCT HMP Kirkham, Farms YOI and Castle North Lancashire PCT HMP/YOI Askham Grange (female open) North Yorkshire and York PCT HMP Everthorpe East Riding of Yorkshire PCT HMP Styal Central & Eastern Cheshire PCT HMP Brinsford, Male / YOI South Staffordshire PCT HMP Featherstone South Staffordshire PCT HMP Wellingborough Northamptonshire Teaching PCT HMP Grendon, Springhill, Aylesbury Buckinghamshire PCT

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