Health secretary Jeremy Hunt instigated special measures in 11 hospitals earlier this month after an NHS England report on higher-than-expected hospital death rates uncovered ‘fundamental breaches of care’ such as poor governance, inadequate staffing levels and high mortality rates at weekends.
The report by Professor Sir Bruce Keogh, NHS England´s medical director, reviewed care at 14 hospitals with mortality rates which have been consistently high for two years or more.
It followed the Mid-Staffordshire report published earlier this year and listed key failings, such as hospitals’ professional and geographic isolation, failure to act on data or information that showed cause for concern, the absence of a culture of openness, a lack of willingness to learn from mistakes and ineffectual governance and assurance processes.
Sir Bruce has made it clear that CCGs will not only have a key role in getting the hospitals named in the report back on track but will also have a role in actively monitoring hospital quality within the next two years.
Early warnings and improved data
Although the report set up specific tasks for the CCGs overseeing the 11 hospitals (see box below), there were implications for all CCGs in the Keogh Report. In future, local commissioners are more likely to hold hospitals more closely to account for the services they provide. In the report, Sir Bruce sets out the measures needed to put things right casting these as a series of ‘ambitions’ for the next two years.
Under the first of these, CCGs will need to assure themselves that early warning systems for deteriorating, high risk patients are in place at trusts and ensure that they are able to make best use of hospital data by employing a specialist to lead on data monitoring. In common with other NHS organisations, they will have to ensure their staff are motivated and to harness the leadership potential of patients.
On early warning systems, Sir Bruce set out his first ambition: ‘We will have made demonstrable progress towards reducing avoidable deaths in our hospitals, rather than debating what mortality statistics can and can´t tell us about the quality of care hospitals are providing.’
As part of this Sir Bruce wants all trusts rapidly to embed the use of an early warning system and have clinically appropriate escalation procedures for deteriorating, high-risk patients – in particular at weekends and out of hours. CCGs and regulators will have to assure themselves that such systems are in place.
Ambition two relates to the use of data by trusts and commissioners: ‘The boards and leadership of provider and commissioning organisations will be confidently and competently using data and other intelligence for the forensic pursuit of quality improvement. They, along with patients and the public will have rapid access to accurate, insightful and easy to use data about quality at service line level.’
The review found that providers and CCGs are struggling to understand and take full advantage of the enormous and very rich set of data available on quality, as it is held in a fragmented way across the NHS and is difficult to us to benchmark performance.
It also found a deficit in the ‘high level skills’ and ‘sophisticated capabilities’ necessary at board level to draw insight from the available data and then use it to drive continuous improvement. Too often boards were honing in on data that reassured them they were doing a good job rather than pursuing data that revealed inconvenient truths thereby missing opportunities for improvement.
With reference to provider boards the inquiry said that they should ensure that they have the people who know what data to look at, how to scrutinise it and then use it to drive tangible improvements, for example through chief quality officers as in the US. This applies to providers but is easy to see how it could also apply to CCGs.
Staff & patients
The report also calls on all NHS organisations to ensure greater engagement of staff and patients to help drive up quality
Ambition eight states: ‘All NHS organisations will understand the positive impact that happy and engaged staff have on patient outcomes, including mortality rates and will be making this a key part of the quality improvement strategy’. They – including CCGs – need to be thinking about innovative ways of engaging their staff.
The report also says that all NHS organisations – including CCGs -should seek to harness the leadership potential of patients and members of the public as they fulfil their respective responsibilities whether as commissioners or providers.
Review into the quality of care and treatment provided by 14 hospital trusts in England – Professor Sir Bruce Keogh, 16 July 2013
What the affected CCGs must do
CCGs’ roles in supporting the hospital trusts named in the report range from expanded spot checks to advising on staffing.
Basildon and Thurrock University Hospitals NHS Foundation Trust
Local CCGs will carry out regular, unannounced assessments to ensure compliance with the trust´s infection control plan. They will also work with the local area team to improve the trust´s urgent care pathway and work with HealthWatch on a review of patient engagement.
Blackpool Teaching Hospitals NHS Foundation Trust
The CCG will support the trust on developing communication with staff below matron level, on serious incident reporting and on innovative ways of recruiting and retaining medical and nursing staff.
Buckinghamshire Healthcare NHS Trust
CCGs will help improve functionality of NHS 111 and support the introduction of more metrics in board reports.
Burton Hospitals NHS Foundation Trust
CCGs will support ‘divisional’ and quality structures at the trust, including a trust-wide quality dashboard (quality at a glance) and complete a joint trust-wide sustainability review by September 2013.
The CCG will also check all resuscitation trolleys to ensure they are fully stocked, organised and there are no out of date drugs or fluids in their programme of announced and unannounced visits.
Colchester Hospital University NHS Foundation Trust
The trust will work with the CCG and community health providers to develop care pathways for end of life care. The CCG will review the inclusion of metrics to measure performance against timed limited targets. The CCG is also monitoring a revised complaints handling process to improve patient focus.
East Lancashire Hospitals NHS Trust
The CCG will work more closely with the trust and GPs for collecting and learning from patient stories and improving patient feedback. The CCG will also share action on a number of specific complaints raised to the review panel during public listening events and will engage with social services in ensuring a coordinated approach to health and social care.
George Eliot Hospital NHS Trust
The CCG will monitor sepsis care bundle performance and management.
Medway NHS Foundation Trust
The learning and outcomes of serious incidents and complaints reviews will be reported to the CCG quality committee. Medway CCG will also be involved in redesign of unscheduled care and critical care pathways and facilities.
North Cumbria University Hospitals NHS Trust
The CCG and area teams will agree quality standards on support for staff and effective, honest communication from a middle and senior management level as well as the implementation of Care Closer to Home and strengthening of links with tertiary centres to ensure long-term sustainability of small specialist services e.g., radiotherapy and vascular
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
The trust will work with the CCG to urgently address the provision of stroke services out of hours.
Sherwood Forest Hospitals NHS Foundation Trust
The CCG programme of unannounced visits will cover adequacy of out-of-hours staffing levels. The CCG will also be involved in developing a clear strategy for Newark Hospital´s future use and best use of the facilities there.
Tameside Hospital NHS Foundation Trust
CCGs will input into developing an updated, single, cohesive quality strategy that takes account of external reports, mortality concerns, feedback from patients and staff, clinical audit recommendations, current identified risks and current trust performance and help develop a single, outcome-focused quality dashboard.
The Dudley Group NHS Foundation Trust
The trust, NHS England area team and Dudley CCG will work together to improve the area’s urgent care pathway plan to address capacity challenges. The trust will continue to work with the CCG and local area team on urgent care planning and management as part of the wider urgent care strategy work. The CCG will also be involved the delivery of a patient experience strategy including metrics.
United Lincolnshire Hospitals NHS Trust
The CCG will have urgent discussions with the trust to tackle sub-optimal staffing and put in place action and ensure that there is a safe, stable environment to deliver services in.