A team of professionals from neighbouring trusts spotted potential problems at Mid Staffordshire two years before the inspectors. We explore whether the peer review model might be adopted elsewhere

In his closing statement to the inquiry into failures at Mid Staffordshire Foundation Trust, lead counsel Tom Kark made some observations about the peer review undertaken by a team now known as West Midlands Quality Review Service.

This small organisation had been able to pinpoint the risks posed by the trust’s A&E department a full two years ahead of the Healthcare Commission.

‘Peer review is extremely powerful at shining a spotlight on services right across a health economy and across a region’

In a single day in 2006, a team of nurses, doctors and managers from neighbouring organisations had gone into the hospital to review policies and procedures in A&E and assess not just how these measured up to acknowledged best practice but also whether they were used in clinical practice.

Mr Kark suggested that inquiry chair Robert Francis might wish to consider extending and embedding the peer review model in the system of healthcare regulation.

A licence to snoop

With the inquiry’s report imminent, HSJ went to find out how peer review works in practice and explore whether it is a model that might be adopted elsewhere – and if so whether this should be a formal part of regulation.

So at 8.30am on a cold winter morning, 16 trained peer reviewers are gathered in the education centre at George Eliot Hospital in Nuneaton. Sitting at four tables are teams of four that each include a nurse, a consultant, a manager or commissioner and, on one table, service users and a GP.

They are here to review long-term conditions services not just at the hospital but also right across the North Warwickshire health economy. During the course of two days, they will review policies and procedures, meet the care teams, tour the wards and clinics, meet patients and quiz GPs, community providers and commissioners.

As Sarah Broomhead, the Quality Review Service’s quality lead, jokes: “They have a licence to be nosey.”  

None of them is paid but all (except the patient representatives) can use the day as part of their continuing professional development. All (including one of the two service users who is also a staff nurse) have day jobs in the NHS in the West Midlands.

They will report on the service, outlining what is working well and what could do with some attention, using a standards framework drawn from NICE and other guidance.

Day two of the review will involve meeting with primary care, out of hours care, social services, the ambulance service and commissioners before a final feedback session.

A report of their findings will go to the West Midlands Quality Review Service steering group and then to the trust and clinical commissioning group boards. It will also feed into a wider review that is going on across the entire West Midlands. Finally, the service will organise “good practice sharing” events and publish reports on its website.

HSJ was given access to the various parts of the review and to all participants – patients, reviewers, clinicians and the trust management.

Positive feedback

The feedback was that peer review is extremely powerful at shining a spotlight on services right across a health economy and across a region. Reviewers saw their role as providing an independent level of quality assurance, and perceived they were there to help drive up quality of care and improve patient safety. 

Clinicians enjoyed the process, relishing the chance to share with peers and learn from each other; reviewers valued it and talked about taking back learning to their own day jobs and organisations.

Vinod Patel, consultant lead for diabetes at George Eliot Hospital, was clear about the benefits of peer review. He expected it to highlight his service’s strengths and weaknesses but was confident that it would not give him any surprises and he welcomed the spotlight.

“You are talking to colleagues,” he says, “and they are assessing you against best practice that we all agree should be in place. My team has spent about 40 hours in all getting ready for this review but it has not been in a panicked way,” he adds. “It has really helped us pull everything together in a way that we have not done before.”

‘My team has spent about 40 hours in all getting ready for this review. It has really helped us pull everything together in a way that we have not done before’

Others highlight the same point. Amanda Best, here today as a reviewer but who has also been on the receiving end of peer review in her role as a commissioning manager for long-term conditions in Stoke on Trent, says: “Peer review is very helpful in carrying out gap analysis. We knew we needed extra community service provision in stroke; it gave us the evidence.”

Dr Patel brings up Mid Staffordshire spontaneously: “Could peer review prevent another Mid Staffs? Yes. It stops you becoming complacent.”

Spotting systematic failure

It is a message that is repeated by others. Dr Charles Ashton, who until recently was medical director of Worcestershire Acute Hospitals trust, told HSJ: “The doctors and nurses at Mid Staffs knew things were not good. This process of putting peers on the ground and talking to people – staff and patients – very quickly allows you to build up a picture of what is going on and what the service feels like.

‘Could peer review prevent another Mid Staffs? Yes. It stops you becoming complacent’

“So if you ask me, would medical revalidation prevent another Shipman? No. He was a psychopathic individual who looked plausible and was good at ticking boxes. Could this prevent another Mid Staffs? Yes. It was a systematic failure and the people delivering the care knew it.”

Dawn Wardell, director of nursing at George Eliot Hospital, who has also both reviewed and been reviewed, argues that peer review benefits everyone.

“From a receiving point of view it is always important to have someone from outside come in to give you a different insight,” she says. “The fact that this is peers gives it clinical credibility. They are able to ask insightful questions and challenge appropriately and have a good debate. They know what they need to look for.”

There is also a good deal of sharing of ideas and cross-fertilisation between clinicians, she adds.

Two-way benefits

Reviewers also gain skills and knowledge, both from the training and from carrying out reviews. “It’s helped me in my own job,” says Ms Wardell. “As a reviewer you learn how to provide feedback, how to measure against standards and assess evidence. You are also seeing other things that you might not have tried. My nursing teams have come back from reviews with new ideas and taken them forward.”

She particularly values the Quality Review Service care pathway review, as it gives an insight into cross-boundary issues.

But do the reviews actually result in change? In the case of Mid Staffordshire Foundation Trust, the evidence would suggest not.

Nevertheless, the team has been carrying out reviews since 2002 when it had a remit for cancer and care of critically ill children. Since 2009, when it was established as a regional service, it has worked on priorities set by chief executives in the region. These have included renal services, urgent care, critical care, stroke (acute phase), vascular services, mental health services, learning disabilities, dementia, care of vulnerable adults and now long-term conditions.

In 2010 and 2011, three quarters of the organisations taking part in peer review said it was useful in improving services and more than half said they had addressed immediate concerns raised by the visit report. Nine out of 10 said being a reviewer was useful in developing their own services.

‘It is up to organisations what they do with our reports’

Jane Eminson, Quality Review Service acting director, is clear that her remit does not extend beyond highlighting the strengths and weaknesses of a service and pointing out any areas that need immediate action. “We do encourage sharing of good practice and we do run good practice sharing events but it is up to organisations what they do with our reports,” she says.

A place in regulation?

Which brings us to the nub of the question: how could or should peer review be embedded in the healthcare system?

“We would say ‘do not make us a regulator’,” says Ms Eminson. “The minute you bring peer review into regulation, it begins to have a top down approach, of something being done to you.”

She and Ms Broomhead argue passionately that one strength of the service is its collaborative approach, from setting the priorities for reviews with clinicians and chief executives, to the time given freely by reviewers and clinical teams in preparing for visits.

‘The minute you bring peer review into regulation, it begins to have a top-down approach, of something being done to you’

“People have to be free to say ‘this is what we are struggling with’, and a national, regulatory system would lose the flexibility to respond to local needs,” says Ms Broomhead.

It is also very good value for money. The service’s core budget (which it has never spent in full) is £594,000. It has delivered all the quality reviews since 2009 at a cost of less than 10p per population head.

So yes, peer review may be a very powerful tool for quality assurance and service improvement. But as Ms Eminson says: “The Care Quality Commission and Monitor should expect trusts and health economies to have a system of quality assurance in place to cover all their services. We are one option for providing that quality assurance.”

While they – and the rest of the NHS – wait on Robert Francis’ report, expected in February 2013, they have asked commissioners to support the service and have offered to carry out bespoke reviews for them rather than the region-wide model used for previous work.

Over the course of the year West Midlands Quality Review Service may quietly fade away. It could see it emerge in a new form for commissioners. Or it may be that the NHS starts beating a path to its door.