Professor Manjit Obhrai and Dr Anne-Marie Houlder explain how GPs in Mid Staffordshire are ensuring quality from their acute trust
The Stafford and Surrounds CCG, formerly the practice-based commissioning group has been in existence since 2005. It started as a core group of six practices and has gradually grown to include all 13 practices in Stafford town and surrounding rural areas. In addition Stafford has now developed a federated approach with our neighbouring CCG based at Cannock Chase. Although similar in size- Stafford with a population of 148 000 and 135 000 respectively- our practice and population demography are very different. Stafford is mainly a middle class and affluent area with only small pockets of deprivation in individual wards whereas Cannock is a younger and more traditionally working class area with a mining legacy, although this is changing with increasing investment over the past 10 years.
What does bind us together is that between our CCGs we commission over 90% of the activity from Mid Staffs hospital or Mid Stafford Foundation Trust (MSNHSFT).
MSNHSFT is a two site district general hospital with acute and elective services spread between Stafford and Cannock hospitals.
The A&E is located in Stafford with a small Minor Injuries Unit in Cannock which is open until midnight. Cannock mainly provides elective surgery and outpatient services.
There has been a shift in activity over the past few years since the first Francis enquiry away from the trust of between 7-9%. The Stafford practices have seen a small flow northward to University Hospital of North Staffs and south to Wolverhampton New Cross Hospital, whereas the Cannock practices have seen patient flow change towards Walsall Manor Hospital, Burton Hospital, and New Cross Hospital at Wolverhampton.
Despite the relentless negative publicity that MSFT has received over the past couple of years patients on the whole have remained loyal and activity going through Cannock hospital has changed very little. The local population seem to view Cannock hospital as separate to Mid Staffs hospital even though the two are run by the same organisation and managed and run by the same staff employed by MSNHSFT.
The Francis Enquiry
The PCT, the then PBC, the acute trust and local GPs gave evidence at the recent public enquiry commissioned by the Department of Health and chaired by Mr Robert Francis. Mr Francis is yet to deliver his final report and recommendations and so it would not be appropriate to offer any opinion or conclusions at this stage. However there will be lessons that will need to be learned in terms of awareness of quality and safety issues using the formal and informal routes. It was clear from the first Francis report that there were significant numbers of cases where patients were harmed as a result of poor care. There were questions regarding the poor governance structures both in primary and secondary care as to how these omissions in care were missed. There has already been a major shift in the way commissioners and providers interact to prevent this from ever happening again.
The Clinical Services Implementation Plan or CSIP
Just over a year ago McKinsey were commissioned to look at all the services at MSNHSFT and review the sustainability of those services and the financial viability based on, patients flows, the movement of care into the community and the effects on the wider heath economy and other stakeholders.
This was an enormous piece of work and included input from over 100 individual clinical professionals. The implementation of this work is still ongoing but one great legacy of the project has been the clinical engagement and cooperation between primary and secondary care clinicians.
This is clearly evident at the monthly Care Quality Review Meeting (CQRM) which is now much more clinically focused and is more able to address quality and safety issues.
Until recently the CQRM was chaired by the director of quality and nursing or the PCT medical director from a commissioning perspective and the membership was drawn from the PCT and the acute trust.
The focus within the Directorate Quality and Performance was changed during summer 2009 in order for it to be able to respond more effectively to issues raised at the first the Mid Staffordshire Inquiry.
From 2012 the CCG has started to take a more active role in the CQRM. The meetings are chaired by the CCG clinical lead and the CCG now has a dedicated whole time equivalent person in quality for MSNHSFT assigned to both Stafford and Cannock CCG jointly.
The interface between CQRM chair and acute trust medical director is professionally close.
The findings of the HCC investigations, the reports by David Colin-Thome and George Alberti and the first Francis Inquiry at Mid Staffordshire Foundation Trust have provided significant opportunities for the PCT to learn lessons and implement changes to improve quality and safety.
We will continue to learn lessons as our CCG moves towards authorisation and eventually to achieving statutory body status. One thing we are always cognisant of is that the CCG is not simply a reinvention of the PCT. While there is much that is good about the PCT there are also deficiencies as was evident from the failings at MSNHSFT. Without apportioning blame to either providers or commissioners, it is important to recognise that there very significant and serial failings in care at the MSNHSFT and that these slipped under the radar for reasons that are unclear.
Our governance structures were clearly not strong enough to alert us to these shortcomings. Monitoring the quality of a service needs a robust framework to detect changes in mortality rates and in the numbers and seriousness of serious incidences. These need to be underpinned by appropriate quality indicators. In turn these need to be clearly defined adopting a ‘clinician to clinician’ approach.
This should lead to a better understanding of the operational issues at the trust.
Observers of the our CCG led meetings have commented how they differ from other acute trust CQRM in that they are more operationally and clinically focused in addition to being totally open and transparent.
We believe it is just what the commissioners and the trust need to restore faith in its organisation and give GPs and patients the assurance they need to continue to use the hospital services, help develop new services and regain public and commissioner confidence that leads to financial viability.
In addition to complaints and incidents we need to develop ways of collecting ‘soft intelligence’ from our patients about the service they receive from the hospital.
Each practice within our CCG has their own patient participation group which feeds into a district group chaired by our CCG chair which feeds into a higher level group for the Stafford Cluster.
At our monthly CCG board meetings (where all of our 13 practices send a GP representative and their practice manager) ‘soft intelligence’ is a regular agenda item and any concerns are fed straight into the CQRM.
The quality reports are distributed to all the board members as well as serious incidences(SI) data. In addition to this as the chair of the CQRM I now get real time SI data via my secure email address.
The structure of the CQRM is still being revised and it is not yet perfect. Improvements need to be made. As commissioners we have a pre-meet to discuss the agenda items and to allow us the opportunity to ask the trust for additional information to help the smooth running of this meeting. I have also started to attend the trust’s healthcare quality assurance meeting and the trus’ts mortality meeting to understand the governance processes that help me gain assurance regarding the quality of care provided by the trust. The review meetings monitor compliance with the quality aspects of the contract, including the Commissioning for Quality & Innovation Scheme (CQUINs) which provide financial rewards to providers for evidence of delivery of the quality targets. These have been agreed by GPs from our board with a lead from each CCG negotiating with the trust directly on CQUINs.
In addition to our CQR meetings we also have a programme of visits to the trust. These include at least two unannounced visits and a minimum of four planned visits per year.
In the future it is envisaged that GPs will begin to undertake these visits alongside appropriate management support to seek assurance for the quality and safety of the service provided.
We are comfortable with the current governance structures but stress that we are not complacent and will continue in our efforts to improve and revise these in line with any recommendations from the Francis pubic inquiry. It is our sincere wish that through the united efforts of the commissioners, the trust staff and the local people of Stafford the Trust can continue its progress to a better future without ever forgetting the lessons of its past.
Professor Manjit Obhrai is Medical director MSNHSFT and Dr Anne-Marie Houlder is Clinical Lead Stafford and Surrounds CCG