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1 BOARD PAPER – NHS ENGLAND Title: Quality and Clinical Risk

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1 BOARD PAPER – NHS ENGLAND Title: Quality and Clinical Risk BOARD PAPER – NHS ENGLAND Title: Quality and Clinical Risk Committee Clearance: Bruce Keogh – National Medical Director Cyril Chantler – Chair, Quality and Clinical Risk Committee Purpose of paper: To update the Board on the last two meetings of the Quality and Clinical Risk Committee. Key issues and recommendations: To note the work undertaken by the Committee in the last two meetings in relation to: o the process of medical revalidation; o patient safety; o managing winter pressures; o the quality and clinical risks within the Board Assurance Framework (BAF); o the role of measurement in improving quality and identifying quality/clinical risks; o Quality Surveillance Group (QSG) meetings; and o the Committee’s meeting schedule for 2014. Actions required by Board Members: To note the work of the Quality and Clinical Risk Committee, and to consider the committee’s recommendations made in relation to the topics outlined above. 1 Quality and Clinical Risk Committee 1. The Quality and Clinical Risk Committee has met twice since the last update to the Board, on the 16 December 2013 and the 24 February 2014. The minutes from the meeting held on 16 December are attached at Annex A. 2. Since the last update to the Board, the Committee’s membership has been extended – Geoff Alltimes, Associate Director of the Local Government Association, has joined the Committee, along with two interim patient and public voice representatives – Neeta Mehta and Linn Phipps. Recruitment for permanent patient and public voice representatives is underway. 16 December 2013 3. At the meeting on 16 December, the process of Medical Revalidation, patient safety, preparation for winter pressures and the Board Assurance Framework (BAF) were discussed. Medical Revalidation 4. The process of medical revalidation was initially discussed at the Committee’s meeting in October 2013, from the perspective of NHS England as Senior Responsible Owner (SRO) for the system-wide revalidation programme. In December, the Committee considered medical revalidation from the perspective of NHS England as a designated body. 5. Given that NHS England Area Team Medical Directors were responsible for carrying out appraisals and making recommendations to the General Medical Council (GMC) for around 42,000 General Practitioners (GPs), the Committee felt it was vital that there was sufficient resource made available to support the programme. The Committee was concerned to hear that there was uncertainty around the continuation of funding for 2014/15, as there was a risk that without sufficient support and resource, a GP may be revalidated locally by NHS England, and subsequently found to be unsuitable. 6. The Chair highlighted the importance of securing resource immediately to mitigate this risk at December’s Board meeting, and actions are now underway to secure resource and employ staff to provide the support needed for this process. Patient Safety 7. The Committee considered NHS England’s responsibilities in terms of patient safety at its meeting in December – many of these responsibilities had been transferred to NHS England following the abolition of the National Patient Safety Agency (NPSA) in June 2012. 2 8. Committee members felt that the work underway to improve the functioning of the National Reporting and Learning System (NRLS) – the system for reporting harm in England – was vital. The NRLS received a large amount of information, and it would be important to ensure that it was properly dealt with and analysed going forward – Committee members did not feel this was happening at present. 9. Equally important was the focus on understanding and improving the low reporting rates from primary care to the NRLS. Currently, just 0.4% of reports received by the NRLS came from primary care, with 99% coming from acute, mental health, learning disabilities and community services. 10. The Committee concluded that it would be important to consider patient safety on an on-going basis – six monthly agenda items have been scheduled. Winter Pressures 11. Prof Sir Bruce Keogh gave the Committee a verbal update on the plans put in place to cope with winter pressures. The Committee felt that the plans – which included the establishment of Urgent Care Working Groups and the transfer of £400 million to support the system – appeared to be comprehensive, and represented real progress on previous years. The Committee will return to this topic at a future meeting, reflecting on lessons learned this winter, with a view to informing plans for 2014/15 and beyond. Board Assurance Framework (BAF) - discussed on 16 December 2013 and 24 February 2014 12. The BAF was initially discussed in December, and was introduced as the framework used by NHS England to identify and manage strategic risks. There were a number or risks included in the BAF that were directly related to quality, however, the Committee felt that all of the risks included had the potential to impact on quality and outcomes. 13. A revised BAF, containing fewer risks (17 as opposed to 35) was discussed on 24 February. The Committee agreed that where the risk was the responsibility of the Medical or Nursing Directorate, the Committee should audit that risk and the mitigating actions put in place in detail, beginning with risk 1 – major quality problems. 14. The Committee should also audit other risks where there was a quality dimension and quality-related mitigating actions – for example, the risk on information and data sharing. The development of the BAF would be an iterative process and the Committee would continue to advise and contribute to its development on an on-going basis, working with the Audit Committee as necessary. 3 15. The Committee had two particular points to feed in to the development of the BAF at this stage: An important issue that was not captured in the BAF was the relationship between NHS England and professional bodies. The Committee agreed that in order to harness professionalism within the NHS, it would be necessary to work in partnership with professional bodies, involving and engaging with them in a more meaningful manner at present. The Committee will consider NHS England’s role in providing clinical and professional leadership at a future meeting, and this topic may need to be reflected in the BAF. Of particular concern to the Committee was the risk around complaints listed in the revised BAF. There was confusion and inefficiency in the health and care system as people did not know how or where to complain. Complaints were often made to NHS England as people did not know where else to go. It would be important to ensure a clear, system-wide process for dealing with patient complaints in an efficient and timely manner was established. The National Quality Board (NQB) was considering this topic at their meeting on 25 February, and the Committee will seek an update on conclusions made by the NQB. Within NHS England, a process for dealing with complaints needed to be established – this should ensure that the complainant received a timely response and helpful information on how complaints are handled in the system. 24 February 2014 16. In addition to the BAF, the Committee discussed the role of measurement in improving quality and identifying quality/clinical risks, a report from Midlands and East Quality Surveillance Group, and its meeting schedule for 2014. A seminar on measuring quality was held prior to the meeting to inform the Committee’s discussions going forward. The role of measurement in improving quality and identifying quality/clinical risks 17. The ability to identify and monitor risks in the NHS was contingent on being able to measure quality. The Committee considered a number of problems associated with measurement of quality, which had the potential to compromise NHS England’s ability to identify quality/clinical risks and to drive continuous quality improvement. These included a lack of alignment of activity in the system; gaps in knowledge about quality in key clinical areas and care settings; and the deficit in commissioners’ skills to confidently use and scrutinise data. The Committee was particularly concerned that NHS England did not have sufficient knowledge about the quality of certain services it commissioned – particularly specialised services and primary care. 4 18. In specialised services particularly, the Committee identified the lack of knowledge of the quality of services as a significant risk. The Committee will consider this risk in further detail at a future meeting. 19. In primary care settings, where around 90% of patient contact occurred, there was little information available on the quality of services provided, and it was thought there was widespread variation in quality. The Committee will consider these issues as part of the agenda item on the development of the Strategic Framework for Commissioning of General Practice at a future meeting. 20. The Committee felt that within NHS England, there was a lack of alignment in the work underway related to measurement for quality. Working within available resources, it would be necessary for those working on measurement for quality across the organisation to work more collaboratively than at present. It would be beneficial to develop a strategy to guide the organisation’s work and that of its partners, which would seek to systematically address the issues that had the potential to compromise NHS England’s ability to meet its responsibilities in terms of quality. 21. The skills and capabilities needed at Board level in provider and commissioner organisations to use data to drive quality improvement and identify quality/clinical risks was discussed. The Committee was concerned that there was a deficit in the skills required at Board level to understand and use data to improve quality, which could compromise the system’s ability to meet its responsibilities relating to quality. Some organisations in the United States had appointed Chief Quality Officers for this purpose.
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