NHS quality accounts: quality is becoming an accountable business

Trusts are less than six months away from the publication of the first tranche of quality accounts - one of the next stage review’s most eye-catching inventions - but their purpose is just beginning to emerge.

There are undoubtedly going to be some areas where the PCT isn’t really in a position to provide quality assurance

Perhaps the most challenging requirement in the Department of Health’s latest draft guidance on quality accounts - which was expected to be finished this week - is for each trust to declare how many of its service lines it has reviewed for quality of care.

NHS medical director Sir Bruce Keogh, who has taken up the quality baton at the DH from former health minister Lord Darzi, says the rigour this move will bring was absent from the “dry run” quality reports published last year by foundation trusts and trusts in the East of England.

“There was a missing ingredient. When I looked at any of the quality accounts I couldn’t reassure myself from them that the whole organisation was functioning well in terms of quality,” he says.

“What we’ve [had] to grapple with is how we write something in that would assure the reader the board is focusing on issues of quality in each and every clinical service line, not just selected lines.

“What it will do - given the accounts have to be signed off by the trust board and agreed by other partners - is focus boards’ attention on what’s going on in the wards and clinics of that institution, in a way that hasn’t happened in some hospitals,” Sir Bruce says.

The demand has worried some, as has the requirement for primary care trusts to “endorse” and assure the accuracy of their providers’ accounts.

King’s Fund senior policy fellow Catherine Foot says: “Assurance is really important but we shouldn’t underestimate the challenge it potentially presents.

“There are undoubtedly going to be some areas where the PCT isn’t really in a position to provide quality assurance [where it does not have sufficient data]. It may be hard for some people,” she warns.

Monitor’s proposed rules for foundations go even further than having to comply with the DH guidance, requiring trusts to get external auditors to provide assurance. They will require “an opinion on the processes and systems in place to collate data in the quality account” and “a limited assurance opinion on the accuracy of up to three performance indicators in the quality account”.

The proposals reflect the view that quality accounts should eventually bring the strict, legal accountability of financial accounts into patient care. It has been pointed out that accounting officers can face a prison sentence if they mess up in finance, and there has been talk that one day those who fall short on quality should face the same punishment.

There is plenty of opposition to that approach, though, and to extensive national determination of what should be in the accounts.

Health Foundation clinical director Martin Marshall, a former DH deputy chief medical officer, says: “The biggest risk is quality accounts simply become another variation on annual reports, which people produce because they have to but with no passion.”

Professor Marshall says the big issue is “whether this is something owned by those producing the accounts, or something imposed”.

The Foundation Trust Network, which is planning an event for members looking for extra guidance, is pressing for potentially less expensive alternatives to formal external audit. These might include having accounts reviewed by a panel of experts.

Network director Sue Slipman says: “Foundation trusts are interested in this - they want it to be more than the latest initiative.”

But she adds: “The problem about having another stream of auditors is [that] the costs are potentially huge.

“One of the problems is, how much is everybody going to be able to justify taking away from frontline services for this kind of stuff? There’s a danger of throwing a lot of money at it.

“We have got to do it in a way that doesn’t become resented by organisations.”

For example, both the Foundation Trust Network and King’s Fund believe that quality accounts should be driven by public and patient engagement.

Some foundations last year managed to consult hundreds of members.

Public engagement

Ms Foot believes where local involvement networks are strong enough, this could be genuinely challenging to trusts.

“What is important is it does reflect a genuine quality improvement strategy, and involve conversations with local people and staff,” she says.

“The public and patient groups should be saying, ‘we understand why this is a priority, but why haven’t you also put this indicator in?’”

On the ground, South Tees Hospitals Foundation Trust medical director Mike Bramble supports the view that public engagement is an important function: “Quality accounts are about the public’s perception of what we are doing. It’s an affirmation we are committed to improving patient care.”

South Tees, which already has strong quality and safety improvement programmes, has this year opted to put fairly commonly used indictors in its account - mainly due to lack of time. They include infection control and patient experience. The trust has started looking for more localised priorities for the 2010-11 account. “We have identified 12 priorities and are asking the public to rank those, so we can pick five or six,” Professor Bramble says.

In the South East Coast region, the quality observatory is providing trusts with information on a range of indicators, meaning they can pick whichever are most relevant and have easy access to information backing them up.

Observatory head Samantha Riley says: “It’s important for trusts to be clear about the area they’re trying to improve, and make sure the indicators are fit for purpose.

“The other benefit of this is we can provide them with regular benchmarking.”

Sir Bruce Keogh is keen to see as much local variation as possible, while the system develops over the next few years.

He says: “Last year there was quite a lot of commonality that was derived, in my view, from what was already in the system - for example information from the annual health check and notable targets.

“In an ideal world all of these measures would be developed by the clinicians running the service lines themselves - though the trust board would then have to be very challenging about the content.”

But despite the vogue for local variation on indicators, Sir Bruce says standardisation may eventually be needed to bring quality up to the same legal standing as finance.  

That, he suggests, is the “direction of travel” as experience of using quality accounts reveals what works and what does not.

He says: “It took hundreds of years for financial accounts to be standardised. Financial institutions from around the world agreed on how they should be, and we will be looking for that same sort of consensus and what’s useful and what is not.”