CCGs have made a good start to ensuring quality care - and must now learn from each other. By Alison Moore
One of the big challenges for clinical commissioning groups is likely to be ensuring that the communities they serve receive quality healthcare.
For small organisations this process of quality assurance can feel daunting - especially in the wake of the Francis report which has focused attention on failings in healthcare and how they can be detected and prevented. Commissioners are inevitably part of this wider picture.
But the evidence from a survey of CCGs in the West and East Midlands, and Yorkshire and Humber regions, carried out by internal audit and counter fraud specialists Emias, is that CCGs have made a positive start on this.
‘Quality visits are becoming an important part of this picture with commissioners regularly involved in visits’
Already nearly two thirds of CCGs surveyed have their own quality strategy rather than simply inheriting one from a PCT and 80 per cent had designated a lay member as quality lead, with even more having the quality committee designated as a sub-committee of the main board.
With CCGs operating on a limited budget, there is a real determination to ensure that resources and tasks are shared where possible. Half of the CCGs questioned were sharing quality teams and over 90 per cent were involved in collaborative commissioning arrangements, with more than three quarters of these having a formal memorandum of understanding which covers quality assurance.
The CCGs were also drawing on a range of sources to get a picture of quality at the providers they commissioned from: these included CQC reports, local authorities and feedback from patient groups. Generally, they felt they were getting the information they needed to review whether quality included in contracts was being met.
Quality visits are becoming an important part of this picture with commissioners regularly involved in visits, although there is some variation in how they are carried out - for example, whether the provider is told in advance what areas will be visited.
But lead and co-ordinating commissioners all had arrangements to allow reactive visits when there were concerns about quality - and had carried out such visits. The picture was more mixed for CCGs which were not leading on a particular contract.
Kevin Watkins, associate director, commissioning, of Emias, says the overall picture is positive, possibly due to the hard work of a lot of committed people and the widespread recognition before the Francis report was out that NHS organisations needed to focus on quality. Quality has also been inherent in the Quality, Innovation, Productivity and Prevention approach and is the focal point of Commissioning for Quality and Innovation (CQUIN) schemes.
“But I have still been pleasantly surprised,” he says. “We have found a great deal of evidence of collaborative working between commissioners and providers, and this is beginning to show itself in the CQUINs which are being agreed.”
But there are areas of concern. Around 30 CCGs took a three minute survey devised by Emias at last year’s NHS Alliance conference. They were unanimous in feeling concern about the quality of care being provided in care homes and less than 20 per cent felt they received sufficient assurance about this.
As commissioning of beds by the NHS in care homes has become more common, this has risen up CCG’s quality agendas. But this may also reflect the impact of the Winterbourne View case which highlighted failings - and criminal activity - in how some vulnerable patients were treated. Mr Watkins warns that improving quality in care homes through contract monitoring will be a challenge for CCGs.
But CCGs are keen to learn from each other in all areas of quality assurance, he says - which is behind Emias’s plans for a CCG quality forum which will allow colleagues from different CCGs to discuss common problems and solutions. It is also offering a benchmarking service so CCGs can see how they compare with their peers on key aspects of quality assurance.
With limited management budgets and resources, CCGs don’t want to reinvent the wheel and sharing of good practice offers the way ahead. For example, there is variation in how quality visits work and swapping experiences could help CCGs decide what would be best for them in terms of planning and carrying out visits. This could be as simple as how to document visits and ensure that follow-up actions are carried through.
Smorgasboard of things to try
“There is an awful lot that can be learned from getting people together who are in the practice of quality monitoring and getting them to talk about it,” he says. “This is the beginning of a process of saying let’s share best practice.”
The advent of CCGs has also been a challenge to organisations such as Emias. It has reorganised so that key members of staff specialise in CCGs rather than covering all NHS organisations. And it is joining other bodies which provide internal audit services in a collaborative group called NHS Audit England.
Moves to offer these services to CCGs have been met with enthusiasm. Chief officer of Nottingham North and East CCG Sam Walters, says the benchmarking is incredibly useful and sharing best practice offers added value.
“It’s a smorgasbord of things we can try,” she says. “We have less management resources than our predecessors and will have to be slicker.”
GPs are often a driving force for monitoring quality, she adds, because they hear from patients every day about their issues with the system. “They want to know that the safeguards are there,” she says.
Chief nurse for three CCGs in South Nottinghamshire Cheryl Crocker is enthusiastic about the chance to swap experiences and best practice with peers as it allows everyone to see where they excel but also where they could learn from others who have tackled similar issues. She says working with Emias has given her a sense of where her organisation needs to focus its efforts to provide more assurance; important when CCGs have limited staff and resources.
Positive actions the CCGs have been able to take includes acting on patient feedback to develop CQUIN targets. For example, patients were concerned that X-rays were taking some time to be reported to GPs by an acute provider and they were often making appointments to discuss them - and then finding the information was not available, she said. A CQUIN to encourage speedy reporting has now been devised.
“We have not got time to reinvent the wheel - if someone else has done it, let’s adopt it,” says Cheryl Crocker.
Kevin Watkins on quality
There is no doubt that the public’s expectation regarding the quality of services they receive has been raised following the publication of findings from reviews by Robert Francis QC and the Winterbourne View investigation.
The financial squeeze that all public sector spending is facing is biting hard at many trusts and their commissioners. Into this arena step clinical commissioning groups, brand new organisations achieving statutory body status just weeks after the second Francis report was published, complete with 290 recommendations. Is this a “perfect storm”?
Maybe not. The evidence from work Emias has completed at 14 CCGs in the Midlands and South Yorkshire, reviewing quality monitoring arrangements, indicates that a solid foundation has been laid down by CCGs in shadow form on which to build a positive response to the Francis inquiry.
The commitment of commissioners to improving quality was impressive - visits to A&E late on a Saturday night to carry out a quality visit are all in a day’s work for some chief nurses. It is this commitment which must be harnessed effectively.
Passion breeds best practice and as CCG chief nurses and their quality staff respond to specific quality issues, so the potential for a variety of good practices to emerge increases. The quality assurance forum we are initiating in the Midlands will provide a conduit for best practice to be shared, as well as a mechanism for debating difficulties facing CCGs in driving improvements in quality and identifying ways in which these challenges can be met.
CCGs need to learn from each other and in our experience are eager to do so. We have already been able to share best practice across our CCG client base through the production of a number of information papers covering areas such as conflicts of interest and QIPP management.
We are also delivering workshops on a variety of subjects that all of our CCG clients are invited to attend to increase the opportunity for networking and shared learning.
As a member of NHS Audit England, we are working with fellow NHS audit colleagues across the country to explore opportunities to extend the benchmarking work we have already undertaken. We firmly believe that the quality assurance forum will prove a significant contribution to something we are passionate about - helping CCGs to be a success.
Kevin Watkins is associate director of commissioning at Emias