Policy responses and statements
- Name of organisation:
- Department of Health
- Name of policy document:
- Consultation on the proposed framework for
Quality Accounts
- Deadline for response:
- 10 December 2009
Background: The Department of Health
has launched a public consultation on the proposed framework for Quality
Accounts. Quality Accounts will be legally required of all providers
of NHS Healthcare from June 2010 (subject to the successful passage
of the Health Bill). For the acute sector, the duty applies next year
and it will apply to primary care and community services subsequently.
Quality Accounts are annual reports to the public on the quality of
the services which an NHS organisation delivers. By producing a Quality
Account, each NHS provider, led by their board, is committing to improve
the quality of services it delivers and inviting the public to hold
them account.
This consultation sets out the recommendations for the regulations
and guidance supporting Quality Accounts in the first year, and is
based on findings from a series of engagement, testing and design exercises
over the past year.
Responses to this consultation will inform a report setting out the
regulations and guidance for NHS organisations to use when producing
their first Quality Accounts in 2010.
COMMENTS ON
DEPARTMENT OF HEALTH
PROPOSED FRAMEWORK FOR QUALITY ACCOUNTS
The Royal College of Physicians of Edinburgh is pleased to respond to the
Department of Health on Proposed Framework for Quality
Accounts.
Q1: Do you agree that the inclusion of a mandatory statement from
the board is the best way to demonstrate board accountability for the Quality
Account?
The Royal College of Physicians of Edinburgh welcomes the principle of a mandatory
statement from the board and agrees that this will make board accountability
for the Quality Account clear, and reflect the central place of quality in
healthcare. However, it is important to recognise that the board statement
in itself does not necessarily demonstrate the delivery of improvements and “in
summarising the trust’s view of the overall quality of the services that
it provides” (paragraph 2.7) may not draw attention to areas of weakness.
Also, the proposals as drafted make no explicit reference (either in relation
to the board statement or to the other mandatory components) to the inclusion
of timelines for delivery against the priority improvement areas. We would
recommend that this is added
Q2: Some providers may be individuals, partnerships or bodies which
are not incorporated and do not have a formal board structure. We would
welcome views on how the provisions of the regulations should apply to such
bodies
Statements from providers without a formal board structure would be served
best by a statement from the chief executive or equivalent. As a general
principle, the other provisions of the regulations should apply to these providers
exactly as they do to NHS providers with a formal board structure, including
the elements of external comment and scrutiny. It is important that the
quality of services provided should be as transparent to patients and other
stakeholders as anything the NHS offers directly.
Q3: Do you agree that at least three priorities for improvement, agreed
by the board and their rationale for selection should be included in Quality
Accounts? Do you think that providers should report on previously set
improvement targets using indicators of quality and including historical data
where available?
We support the principle of boards agreeing local priorities for improvement
and explaining the rationale for their selection in Quality Accounts. We
strongly agree that providers should report on previously set improvement targets
(including historical data where available) and should do so until targets
are met. They should also monitor performance thereafter to ensure targets
continue to be met. In terms of the number of priorities (and the number
of indicators as defined in question 4) we have mixed views. It could
be argued that, for large organisations, a minimum of 3 priorities and 3 indicators
covering each of the domains of quality is insufficient to demonstrate a broad
commitment to improving quality across a range of disciplines. There is also
the potential for selection of “easy” targets. On the other
hand, it is important, particularly in the current financial environment, to
encourage realistic priorities and targets where clear measurement of improvement
is achievable. On balance, the inclusion of at least 3 priorities, with
3 indicators, but the flexibility to add more if providers wish, is probably
appropriate.
Q4: Do you agree that at least three indicators covering each of the
domains of quality should be included in Quality Accounts?
See response to question 3.
Q5: Do you think that the inclusion of the statement from the board
to state they have reviewed the available data on the quality of care in
their services provides an assurance of the quality of services provided?
Although useful in showing what proportion of a provider’s activity
is being reviewed, and offering an indication of broad quality improvement
plans being in place, a simple statement from boards that they have reviewed
the data does not in itself provide an assurance of the quality of services
provided, or demonstrate factually the specific improvements that have taken
place. Therefore, though not specifically covered in your question, we would
support the suggestions for external review and analysis of the data, as outlined
in paragraph 2.17.
Q6: Do you think boards should include an explanation of how the review
of services was conducted, and how patients and the public were involved?
This is essential, but the explanation of methodologies used needs to be in
lay terms that the public will be able to understand. This part of the
Quality Account will have the added benefit of building the knowledge base
(currently limited) in relation to how best to involve patients and the public
in these kind of processes.
Q7: For the statements on participation in clinical audits, please
provide your view on their suitability for inclusion as nationally mandated
content in Quality Accounts. In addition, please identify
whether the description of the statement is well defined or open to interpretation
and provide any other comments on the proposed statement.
We strongly support the inclusion of statements on participation in clinical
audits as key component in the nationally mandated content of Quality Accounts. However,
we have a number of comments on the detail and practicality of the statements
as currently drafted:
- It may be very difficult to identify and list all the national audits that
a Trust could potentially have participated in (first bullet point in the
draft statement) – this is a continually evolving field and only a
proportion are covered by HQIP programmes.
- For the same reason, it may be impossible to define the percentage of patients
in a Trust not covered by available national audits (third bullet point in
the draft statement).
- Where Trusts do participate in a national audit they may only be asked/expected
to audit the care of a percentage of eligible patients. It would be
better, therefore, for a Trust to state that they were asked to audit n%
of eligible cases and whether they managed to comply or not (second bullet
point in the draft statement).
- Given these challenges it may be better, to begin with, to invite Trusts
to report the national audits they are engaged in and build up the detail
as the Quality Accounts process develops.
- Conversely, the statement on local audit needs to be strengthened to give
some indication of the level of activity but also the quality of the activity
(perhaps by referencing the use of nationally agreed standards for audit
as defined by HQIP and giving examples of successful local audits that have
led to improved practice).
Q8: For the statement on participation in clinical research, please
provide your view on their suitability for inclusion as nationally mandated
content in Quality Accounts. In addition, please identify whether the
description of the statement is well defined or open to interpretation.
The College is a strong advocate of clinical research and supportive of any
development that draws the attention of boards to the value of research to
the NHS. We recognise however that, in asking providers to make a statement
about participation about research, there is an intrinsic bias in favour of
teaching hospitals with a large percentage of consultants on academic contracts. In
contrast, District General Hospitals may struggle to access funding for research
and any comparisons made between providers as a consequence could be misleading.
It is important therefore to place any statement about research in this wider
context, otherwise there is a real risk that lack of research activity is taken
to be a surrogate marker for poor clinical care when in fact there is no direct
link. In terms of the statement itself, a single recruitment figure (even
if expressed as a percentage of potential recruits, rather than a number as
drafted) is almost certainly not valuable and will not drive change. To be
meaningful, this requires more information including areas of research and
type of research.
Q9: For the statement on the use of the Commissioning for Quality
and Innovation (CQUIN) Payment Framework, please provide your view on their
suitability for inclusion as nationally mandated content in Quality Accounts. In
addition, please identify whether the description of the statement is well
defined or open to interpretation and provide any other comments on the proposed
statement.
We would agree that such a statement should be included where applicable and
the description seems well defined. However, we are unclear at this stage how
central this will be to the wider Quality Accounts initiative.
Q10: For the statements from the Care Quality Commission (CQC), please
provide your view on their suitability for inclusion as nationally mandated
content in Quality Accounts. In addition, please identify whether the
description of the statements are well defined or open to interpretation
and provide any other comments on the proposed statement.
We agree that a statement on CQC status, and related reviews, adds valuable
information to the Quality Account and should be mandated. The proposed
statement is clearly defined. However, we would suggest this should be
highlighted earlier in the document and linked more explicitly to the development
of the local priorities included in the Quality Account.
Q11: Do you agree that Local Involvement Networks (LINks) and PCTs
should be given the opportunity to comment on a provider’s Quality
Account and that providers should include this response in their account?
Should this include local authority Overview and Scrutiny Committees?
We agree that LINks should be given the opportunity to comment on a provider’s
Quality Account and would see this as a positive move towards greater public
and patient involvement in quality improvement. We also agree that PCTs should
comment, but it is important that this element of the process is undertaken
in a spirit of shared ownership which will facilitate greater transparency
between providers and purchasers. In this respect, it would be helpful if the
Quality Accounts could include some reflection on the effectiveness and quality
of the local commissioning process itself. We have some concerns about
the practicality of involving local authorities but, if this can be achieved
without causing undue delay or bureaucracy, would be supportive of their inclusion
in the process.
Q12: How much time should LINks/PCTs be given to provide a response
on a provider’s Quality Account?
Assuming the proposed content is shared with LINks/PCTs at an early stage,
as suggested in paragraph 2.43, a timeframe of 6 weeks to respond to the formal
draft would seem reasonable.
Q13: For the statements on data quality, please provide your view
on their suitability for inclusion as nationally mandated content in Quality
Accounts. In addition, please identify whether the description of the
statement is well defined or open to interpretation and provide any other
comments on the proposed statement.
Data quality is essential, if the quality account is to be meaningful and
carry weight, and we support the inclusion of the four statements (which seem
clear) where applicable. However, we would emphasise that quality of
data overall is currently poor and, while endorsing the central importance
of the patient NHS number, would have doubts, in the absence of clear targets
and timelines, about achieving full adoption of this for SUS and other quality
systems.
Q14: Do you agree that our proposals for the nationally mandated content
of Quality Accounts meet the objectives set out in the proposal?
The proposals do broadly meet the objectives set out. However, we would
reiterate the point, made in our response to question 1, that the series of
mandated statements will not in themselves necessarily translate into accountable
action or demonstrate evidence of improvements.
Q15: Are there any other areas that should be included in the nationally
required section of Quality Accounts?
We welcome the comment (paragraph 2.6 and elsewhere) that the nationally mandated
component of Quality Accounts will evolve and be subject to revisions over
the first few years. We would not therefore suggest any additional areas
until the current proposals have been tested by experience.
Q16 – Do you agree with the proposed publication methods?
So long as due attention is paid to equity of access (along the lines outlined
in paragraph 2.69) we agree with the proposed publication methods but would
note that there is a cost implication for the production of the quality account
in different languages and formats. It is unclear whether this is included
in the cost estimate referred to in question 21.
Q17 – Do you have any other comments on the proposals?
We welcome many aspects of the proposals, particularly the principle of continuous
quality improvement, the emphasis on Board leadership and assurance, local
determination of priorities, engagement with patients, and public accountability. However,
we do have some concerns that the Quality Accounts will introduce repetition
and overlap with other systems, including the CQC annual health check which
is already in the public domain, and also that they will become another paper
exercise without changing the culture of the Trust or other provider.
Q18 – Some providers may be individuals, partnerships or bodies
which are not incorporated. We would welcome views on how the proposals
would operate for such bodies.
See response to question 19.
Q19 – Do you agree that small providers should be exempt from
producing Quality Accounts? If so, are the proposed criteria the right ones?
Our view is that all providers of NHS services, regardless of size or whether
they are incorporated bodies, should be required to produce an annual Quality
Account which should be reviewed by commissioners and public. However,
we recognise the need for a proportionate approach for smaller providers and
it may be that some of the mandated statements would not apply (e.g. clinical
audit and research) or could be reduced in scope (e.g. fewer than three priorities).
Q20: What are your views on the proposed process for delivering Quality
Accounts in the primary and community care setting?
We would support the plan to conduct a further engagement and testing exercise
with the primary and community care sectors. However, as the current
consultation document is by its nature focused on secondary care structures
and processes, it is difficult for us to comment on a process that has not
been developed at this stage. We would welcome an opportunity to comment
on more detailed plans following the delivery of test reports in summer 2010.
In the meantime, we would make the point that, as PCTs are to comment on Quality
Accounts from secondary care providers, a reciprocal arrangement must be built
into the process for delivering Quality Accounts from primary and community
care.
Q21: Our testing showed that a typical cost for a provider to produce
a Quality Report was around £14,000-£22,000. Do you think
that this is a realistic estimate?
We note from your report on the Quality Accounts testing exercise that 82%
of your respondents were unable to quantify the cost of producing a quality
report. On that basis we find it difficult to assess the validity of
your estimate. However, in general terms, the cost will clearly be dependent
on whether or not the Quality Account can be based on data the organisation
is collecting already, and on the robustness, or otherwise, of existing IT
and quality assurance systems. The true cost also needs to reflect the
additional or displaced clinician time required to produce the Quality Account.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[10 December 2009]
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