Charles Dobson

1
Quality care, closer to home

• Charles Dobson
• NHS Medical Directorate, Department of Health

2
Overview

• The context
• What is quality?
• Care closer to home
• Commissioning for quality
• High quality care for all the improvement model
• Developments in accreditation
• Individual appraisal and revalidation
• So where do PwSIs fit in?
• Balancing risk and innovation PwSI
  accreditation
• Next steps

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EFFECTIVENESS
What is quality?
EFFECTIVE
A positive environment
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Care closer to home

• Our health, our care, our say (2006)
• Why
• Changes in expectations people want services to
  fit round them, not the other way round
• Changes in technology more clinical activity
  can be delivered safely in the community
• Increasing demands on the healthcare system,
  requiring strategy focussed on prevention and
  support in community (Wanless report)
• Search for better value for money as growth rates
  slow down
• How
• Pivotal role of practice based commissioning/indic
  ative practice budgets to promote redesign of
  care pathways
• Shift of resources from secondary to community
  care
• Investment in community facilities

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Commissioning for quality and innovation (1)

• Health and Social Care Act 2008 replaced the
  previous duty of quality
• (for all NHS organisations) with
• registration requirements for providers,
  initially in secondary care
• a duty on commissioners to seek continuous
  quality improvement, defined as follows
• 1) Each Primary Care Trust must make
  arrangements to secure continuous improvement in
  the quality of health care provided by it and by
  other persons pursuant to arrangements made by
  it.
• (2) In discharging its duty under subsection (1)
  a Primary Care Trust must have regard to the
  standards set out in statements under section 45
  of the Health and Social Care Act 2008.

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Commissioning for quality and innovation (2)

• World Class Commissioning sets out 11
  commissioning competencies including
• engage with public and patients
• collaborate with clinicians
• prioritise investment
• promote improvement and innovation
• Use of financial incentives to drive quality
  improvement (CQuIN)
• up to 0.5 of contract income held back and tied
  to achievement of specific quality improvements
• choice of quality indicators for local decision

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High quality care for all the quality
improvement model
Quality improvement
Service innovation
Quality indicators Local National
Local needs and priorities
National standards
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Developments in accreditation
Existing schemes/schemes under development

• Psychiatry
• Radiology
• General practice
• Stroke services

• Several schemes for individual subspecialisms
• eg ECT
• Pilots completed, national roll-out under way
• Pilots being evaluated, decision on national
  roll-out
• later this year
• Planning under way for pilot looking at possible
• synergies between accreditation of stroke
  services
• and revalidation of individual physicians

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What is accreditation for?

• Quality assurance?
• Quality improvement?
• Or both?

• Emphasis on assessment against national (minimum)
  standards
• Summative assessment methods attainment of
  standards needs to be supported by robust
  evidence
• Can act as proxy for registration of provider by
  Care Quality Commission
• Standards will include developmental elements and
  scope for local variation
• Emphasis on peer review to identify opportunities
  for quality improvement
• Formative assessment methods

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Individual appraisal and revalidation

• Response to serious critique of previous
  arrangements in the Shipman Inquirys 5th report
• Proposals in Trust, assurance and safety seek to
  combine elements of
• quality assurance (summative appraisal)
• quality improvement (formative appraisal)
• Legislative underpinning now largely in place
  (Responsible Officers, Section 60 orders etc)
• Standards and processes under development
  (Medical Royal Colleges) and pilots will start
  shortly

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So where do PwSIs fit in?

• Key element of moving care closer to home
• Builds on natural strengths of general medical
  and pharmacy practice
• Allows individual GPs and community pharmacists
  to develop specialised interests in a community
  setting
• Cost-effective way of achieving pathway redesign
  (eg intermediate step up/step down services
  between primary and secondary care)

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Balancing risk and innovation

• Accreditation of PwSI services gives assurance to
  PCTs (and patients) that services remain safe and
  effective
• Vital to accredit individual skills and service
  setting
• Although primary aim is quality assurance,
  assessors and service providers can take
  opportunity to use the assessment process to
  identify areas for further quality improvement
• Should be particularly helpful as component of
  individual revalidation

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Next steps

• Refresh of specialty specific guidance is almost
  complete available on PCC website or on CD
• Deadline for reaccreditation of existing services
  is 31 March 2009
• Once proposals from Medical Royal Colleges more
  fully formed, will look again at interaction
  between PwSI accreditation and revalidation to
  ensure no duplication
• PCTs have to take account of guidance but
  duty of quality improvement is not optional!