What went wrong with commissioning in Mid Staffs?
Practice-based commissioning was in place during the Mid Staffs scandal. Alisdair Stirling explores its failings
‘Why didn’t GPs raise concerns?’ shadow health minister Andy Burnham asked during the 2011 public inquiry into the Mid Staffs
A lack of communication between GPs, PBC consortia and the trust itself was a key problem identified in last month’s landmark Francis report.
The introduction of PBC in 2004, between major NHS structural changes in 2001 and 2005 sets the context for this NHS failure.
In his report, Robert Francis described the NHS changes announced in 2001 as ‘somewhat dramatic’; 100 primary care groups
became 303 PCTs within a year and the roles of 100 health authorities were replaced by 28 SHAs. Then in 2005, it was announced
PCTs were to be reduced from 303 to 152 and SHAs from 28 to 10.
Mr Francis described these years as a time of ‘perpetual flux’ that has continued ever since. Quality of care and patient safety, while asserted in DH documentation and policies, were ‘very difficult in practice’, said Mr Francis.
Steve Powell, chair of Stafford and Surrounds PBC consortium, one of the two PBC consortia in the area at the time, told the inquiry PCTs were not supportive of PBC. Under fundholding, GPs had met regularly with trust chief executives but this engagement diminished when fundholding was abolished in 1997.
In his written evidence to the inquiry, he added: ‘If clinical matters did arise at commissioning meetings, and the trust was able to front a clinician, we would discuss them, but this was not common.’
A scandal not articulated
Geraint Griffiths, locality director for PBC at South Staffs PCT, told the inquiry he was surprised GPs hadn’t flagged up issues they later reported to the Healthcare Commission when it carried out its investigation. He told the inquiry: ‘Probably the most difficult area on which to reflect is why the matters highlighted by the HCC had not been recognised by GPs.’
He added: ‘I had good relationships with both consortia in Staffordshire and regularly met with the leaders and their constituent practices. It is more than surprising that the views expressed in their letters to the PCT in April 2008 did not come out in any of those discussions.’
Francis found that PBC consortia had no system for collating complaints or concern, or for encouraging GPs to raise them.
Individual GP practices dealt with complaints or other problems relating to individual patients on a case-by-case basis. Concerns were not analysed in any way to identify common themes. GPs may have been unclear as to the routes by which to communicate concerns to the PCT and instead tended to raise issues concerning individual patients directly with the trust’s consultants.
Commissioning without quality
World Class Commissioning had been introduced in 2007; however as the Francis report points out, the 2008 Darzi review heard that the commissioning process was ‘not as yet effective’. Amongst a catalogue of deficits, Darzi identified that commissioning decisions were not driven or influenced by quality. Francis notes that GPs ‘did not connect their participatory role in the commissioning process with information they were picking up from their work with patients’.
This was backed up by evidence from Gary Belfield, acting director general for commissioning and system management at the DH from July 2009 until September 2010. Mr Belfield said that the intention had been that GPs would be in a position to influence quality of care through commissioning. This intention was not realised. And Mr Belfield accepted the GP quality role was not made explicit.
Julie Wood, interim commissioning development director at NHS Clinical Commissioners and a former PCT chair, argues that this is the key difference between commissioning then and now. ‘The difference now is the statutory responsibility of CCGs for both finances and quality. That didn’t exist before. As a PCT chair, I wasn’t statutorily responsible for quality. The fact that this is now enshrined in law makes the difference. PBC was about delegated authority from the PCT - usually with a very restricted remit. Clinicians were not leading on commissioning as they are now. The new system will be better.’
In his evidence, Mr Belfield accepted GPs were not provided with sufficient data to enable them to make informed decisions on quality. At a local level, the lack of data was blamed on the PCT and SHA as well as the trust. Professor David Colin Thomé’s 2009 review of the lessons learnt for commissioners and performance managers following the Healthcare Commission’s investigation found ‘a closed culture with a lack of data and information that allowed poor care to continue undetected’. He also cited how, locally, PCTs and the SHA did not seek out data to ensure quality of outcomes.
Mr Powell, who was business partner at a local practice as well as chair of the PBC consortium, told the inquiry that because PBC was then in its infancy, and because the vast majority of patients in the area used Mid Staffordshire, there was ‘no opportunity for GPs or PBC to review other hospitals as a benchmark and see a difference in conditions or care.
‘The explanations we were given for the alarm bells were that these were a result of coding issues and misinterpretation of Dr Foster statistics,’ he added.
Problems with the data GPs did get to see were illustrated by Dr Roger Beal, a GP in Stafford and chair of Western Staffordshire PCT’s professional executive committee. He told the inquiry: ‘On one occasion we found data in which 10 men had been coded as attending the trust to receive gynaecological treatment.’
Ms Wood says access to quality data for CCGs is built into the new system: ‘It is now expected that CCGs will get the data they need. It will remain the CCGs’ responsibility, but how much they do in house is up to them. Many will get their commissioning support unit to do the analytics for them. The CSU can do this at scale and provide comparisons across different CCGs.
‘In CCG-land you have got to be clear about how to monitor all the information available to you.’
Mr Belfield also accepted that the standard form of contract issued to PCTs by the DH was much less explicit on quality than it was on national targets such as access, and that PCTs in 2007/8 might well not have introduced their own quality metrics.
According to Mr Powell, contract review meetings with the PCT were ‘largely ineffective’. Andrew Donald, accountable officer for Stafford and Surrounds and Cannock Chase CCGs, says contracting has moved on. ‘We use our contracts to lever change when there’s a problem. For example, we can fine hospitals if they miss targets such as 18 weeks’ waiting. Airlines have systems for assessing near misses and for me personally we need to get that level of transparency on quality with our providers.’
Another problem highlighted by Mr Francis is that ‘a large proportion of local GPs were not actively engaged in the [PBC] consortia’.
Mr Donald says the actual figures were that only five or six out of a total of 14 practices were involved in PBC. Mr Donald, who did not work in the area during the period investigated by Mr Francis, says: ‘Now we have board meetings every month with all 14 lead GPs and 14 practice managers in attendance. There are detailed discussions about quality and safety. Its about cohesion. If you’ve got all the practices involved you’re also getting standardisation. The problem with PBC was that it was voluntary.’
Ms Wood argues that CCGs have to ensure practices are engaged: ‘What didn’t happen in Mid Staffs was intelligence coming through the system. CCGs have to make sure the practices are on board so they can pick up the soft or hard intelligence on quality.’
Once the reforms finally kick in on
1 il, there will be many new concurrent systems commissioners must grapple with. The Mid Staffs scandal serves as the
ultimate lesson not to become too focused on the business of the organisation at the expense of patient care.
Alisdair Stirling is a freelance journalist