Out of the darkness: how quality assessment can improve out of hours care

A group of social enterprise out of hours providers are using a quality assessment programme in a bid to improve performance and build patient and public confidence in out of hours services.

The 2004 GP contract led to primary care trusts commissioning primary care out of hours services. Commissioners monitor performance of their providers against the 13 national quality requirements. The Care Quality Commission has described how providers have had problems meeting the standards and commissioners have struggled to understand them and to be able to tell whether they were being met or not.

As recently as 2009, the Primary Care Foundation found only 6 per cent of out of hours services achieved the 95 per cent target for definitive clinical assessment in 20 minutes.

Of further concern to many within out of hours care is the disparity between standards for daytime general practice and the out of hours services. How many GP practices are able to say they phone back patients with clinical problems within 20 or 60 minutes 95 per cent of the time, and that they prioritise and complete each call within a set time? Yet out of hours services win and lose contracts against such criteria.

For patients, services may appear good because they are speedy. However, the focus on the measurable time-based quality requirements has distorted assessment of quality. 

In 2007 a group of social enterprise out of hours providers discussed how they could improve quality and evidence. Urgent Health UK is a federation of social enterprise out of hours providers which serves 13 million people.

The engine for this improvement is external audit and an expectation of achievement driven by sharing good practice and expulsion for failure. Over the years Urgent Health UK has developed its audits with NHS Audit South West.

The federation’s 10 benchmark standards address most issues that a clinical service providing safe, effective clinical care and good patient experience would expect. With external audit, this also has teeth (see box, below).

The programme rolls over three years. Yearly assessments are full, high level or self-assessment. It is implemented and overseen by NHS Audit South West. The Urgent Health UK board reviews and agrees the plan annually.

The approach has already delivered improved risk awareness and risk management and incident reporting systems.

Organisations with effective systems share learning with other members via documents, visits, workshops and during the annual conference. Quarterly and annual reports enable members to benchmark themselves against other services. Members must respond to audit recommendations in a timely way, particularly high and medium risks.

Standard 10 defines Urgent Health UK’s approach to both achievement and compliance. If members do not respond then the board takes steps to encourage the member to improve.

Valuable tool

The Urgent Health UK first quarter report shows the number of audit recommendations versus outstanding recommendations for all members (see graph, attached right). Each recommendation has a priority. By the end of the year members are expected to have addressed all high risk, most medium risk and a significant number of low and very low risk recommendations. Urgent Health UK board discussion considers whether recommendations are being effectively addressed and has the authority to expel members for failure to address recommendations.

Important challenges in delivery have been: complexity of coordinating the wide range of audits across members; not interfering with the management and delivery of services in lean organisations; ensuring the audit process is seen by all staff as a valuable tool.

These have been overcome through clear agreement of expectations around the audit process and communication and flexibility around the programme.

NHS Audit South West has also provided expertise, tools and advice to assist members in improving management of risk, complaints and information governance and in increasing awareness of requirements around information governance statements of compliance and Care Quality Commission registration. Central to this was forming effective relationships between the auditors, management and clinical leads within Urgent Health UK and member organisations while sustaining the independence of the external auditors. 

Senior auditor Phil Rogers offers the following practical advice for organisations wishing to improve out of hours service: “Don’t forget the core support services and processes that are there to ensure that services are safe and effective, such as risk management, complaints and incident management and clinical audit.”

He adds: “Keep an eye on the basics, such as training records, HR recruitment checks and safe medicines management. Keep processes documented and understood by all staff, but simple and tailored to the organisation’s needs. Above all, ensure effective communication between management, staff and clinicians.”