Performance management of contracting and contractors

1
Performance management of contracting and
contractors

• Philip Leech
• consultant adviser for primary care,
• Department of Health

2
Performance management

• What is it in the context of today?
• Trying to look ahead what will it deliver
• to patients
• to PCTs
• to providers

3
Where are we, where we are going

• Current arrangements
• Defining and measuring performance
• Implementation, accreditation and regulation
• Market driven failure

4
What we believe

• the best way of protecting patients is to build
  on and strengthen the existing arrangements for
  promoting the quality of clinical care,
  collectively known as clinical governance
• the vast majority of healthcare professionals are
  already seeking to give high-quality care to
  their patients for them, clinical governance
  arrangements are intended to provide support,
  encouragement and time for reflection on their
  clinical practice

5
But..

• a small minority exhibit behaviour or clinical
  performance which puts patients at risk.
  Clinical governance needs to be sufficiently
  robust to maximise the chance of identifying
  these clinicians so that prompt action can be
  taken to protect patients. But no system can
  give an absolute guarantee of safety, especially
  (as the Shipman Inquiry fully recognised) when
  faced with an individual as devious and malign as
  Shipman.

6
Clinical Governance

• Protected Time for Regular Team Meetings
• Significant Events Premature Deaths New
  Cancer Cases Unpleasantness In The Waiting
  Room
• Summaries to Clinical Governance Team
• Comms

7
What Happened

• Focus on the facts
• No blame
• Its the system
• What went well
• What was OK
• What could have gone better
• What should we do next time?

8
PCTs do have a range of mechanisms

• for identifying individual GPs whose performance
  is of concern. These include
• Monitoring of routine data including QOF scores
• Annual clinical governance reviews
• Analysis of complaints
• Concerns from other professionals

9
But where are the measures?

• Objective measures are difficult to construct. If
  we wish to assess practice performance against
  the whole range of functions they perform we will
  need indicators that cover
• Clinical quality
• Organisational performance
• Patient experience
• Compliance with regulatory requirements
• Resource utilisation

10
One PCT approach
11
Essential Ingredients

• Clear evidence and clear focus
• Examples From the field
• Time to consider solutions
• Reality of working at street level
• Systematic recording of information
• Rapid feedback
• Appropriate resources
• Skilled management

12
Data Used For Prescribing Analysis

• Name of prescriber
• Drug name, formulation and strength
• Quantity prescribed
• Number of items prescribed
• Cost of prescribing
• No patient information is collected - name of
  patient, age of patient, diagnosis or dosage

13
Method

• Analyse prescribing by practice for Morphine,
  Diamorphine and Pethidine injections only.
• Compare Cost and Items per 1000 Patient unit
  between practices and the PCT average.
• Identify practices above the norm (PCT average).
• For these practices identify the injections that
  are above average.
• Produce a detailed report itemising all
  prescriptions prescribed.
• Produce a trend graph for the injection(s)
  detailing the number of ampoules prescribed in
  the past 24 months.

14
QOF and Assessment

• http//www.connectingforhealth.nhs.uk/delivery/pro
  grammes/qof/docs/establishing_accuracy_in_qof_data
  .pdf
• QOF blood pressure
• BP CHD, BP LVD, BP Stroke or TIA, and BP
  Diabetes.
• QOF records
• QOF indicator exceptions
• nww.qmastraining.nhs.uk
• QOF group exceptions
• QOF cytology

15
QOF and Assessment
Many indicators can be matched against other hard
data sources, such as PACT. For example, do
cholesterol indicator reports from QMAS match the
extent of prescribing for cholesterol lowering
drugs? Assessors will be able to use hard
information to see patterns of care emerging that
define the ability and intentions of the practice
to managing patient care in the QOF. The factual
way that the QOF Assessor Validation reports
define patient care should be backed up by using
other data within and without the QOF.
16
QOF and Assessment
The case for looking at hypertension has been
made in this guidance similar criteria could be
applied to diabetes matching appropriateness of
diagnosis against date of diagnosis, laboratory
test results looking at glycosylated Hb and
blood glucose results. Assessors can also look at
achievement for flu immunisation for the over 65
population. Both a high and low achievement
should be set against high achievement in other
QOF fields, where that achievement has relied on
high exception reporting.
17
NCAS

• the model recommended by NCAS involves
  investigation by a multi-PCT resource (the
  Performance Advisory Group) to establish the
  facts and decision by a senior PCT committee (the
  Decision Making Group) typically chaired by the
  medical director. Options include imposing
  restrictions on the practice, removal from the
  PCT list, application to the FHSAA for national
  disqualification as a GP, and referral to the
  GMC for possible erasure from the register.
• Shipman 5 has also recommended giving PCTs powers
  for some lesser actions e.g. warnings and
  requiring remedial action

18
Dr v practice

• A similar framework could in principle be adopted
  to deal with unacceptable performance by the
  practice. However, in this case the action would
  have to be taken via the contract, e.g. by
  declaring the practice to be in breach of its
  contractual obligations and requiring remedial
  action.

19
NPSA

• . The key insights from An Organisation with a
  Memory are that
• clinical error usually results from human error
  provoked by underlying system weaknesses
• the NHS has traditionally been weak in learning
  collectively from errors some serious clinical
  errors are repeated time and time again in
  different parts of the NHS
• promoting active learning from mistakes requires
• moving from a blame culture to a safety
  culture in which clinical staff are encouraged
  to report errors and near misses so that learning
  can take place
• systematic processes for reporting and analysing
  errors, establishing the underlying causes, and
  ensuring that lessons are put into practice.

20
A system model of accident causation (after
James Reason)
Some holes due to active failures
Hazards
Other holes due to latent conditions

Losses
Successive layers of defences, barriers,
safeguards
21
The National Health Service (General Medical
Services) Amendment (No. 4) Regulations 2001 (the
2001 Amendment Regulations) (1)

• obligatory for a PCO (then the HA) to carry out
  certain checks before admitting a doctor to its
  list. HAs were required to check, as far as
  practicable
• references provided by the applicant
• information given by the applicant relating to
  his/her medical qualifications and his/her
  registration

22
The National Health Service (General Medical
Services) Amendment (No. 4) Regulations 2001 (the
2001 Amendment Regulations) (2)

• contents of his/her declaration about any past
  criminal or disciplinary record.
• This declaration was now required to be
  significantly fuller than previously whether
  there was any past or ongoing fraud investigation
  involving the doctor.

23
The Health and Social Care Act 2001 powers (and
obligations) on HAs to remove a doctor from their
list on the grounds that

• the doctors continued presence on the list would
  be prejudicial to the efficiency of the medical
  services which doctors on the list undertook to
  provide (an efficiency case)
• the doctor had been involved in an incident of
  fraud or attempted fraud (a fraud case)
• the doctor was unsuitable to remain on the list
  (an unsuitability case).

24
Issues for the future

• The number of providers
• there are over 8.500 practices. The practical
  challenges of regulating and inspecting such a
  large number of providers are clearly
  significant.
• To some extent, the provider is also an
  individual, the GP. Clearly this is the case for
  all single-handed GPs but more generally reflects
  the fact that most providers in primary care
  are small independent partnerships.
• determining a practice is failing will
  sometimes be equivalent to asserting the
  clinician is failing as well (with the
  implications this has for their employment in the
  NHS).

25
The old story, new twists

• variations in the quality of primary care
  providers.
• introduction of a wider set of providers
  competing for patients (along with increased
  incentives on existing providers) increases the
  need to provide assurance that performance
  standards are high.
• market led approaches to primary care are also
  likely to increase the number of business
  failures and voluntary exits (e.g. retirement)
  that will require handling.

26
strong need for a clear accreditation process

• Given the number of primary care providers there
  are also issues around the capacity to undertake
  regulation. The Healthcare Commission cannot
  feasibly investigate all practices on any
  meaningful basis. As a result we will need to
  consider options for implementation. These could
  include
• A new peer review process building on the RCGPs
  existing practice accreditation scheme
• Assessment by PCTs operating under license from
  the RCGP or Healthcare Commission

27
Subtle ways patient empowerment

• an increasing recognition of the importance of
  information to enable patients to make informed
  choices in dialogue with clinicians and to take
  better control of their own health see for
  instance the Departments three-year information
  strategy Better information, better choices,
  better health
• the development and roll-out of Expert patient
  programmes for patients with longer-term
  conditions such as asthma and diabetes to help
  them to take active control of their own
  treatment
• a systematic approach to the use of information
  from patient satisfaction surveys, involving all
  hospital trusts and administered by the
  Healthcare Commission, to assess and improve
  services over one million patients have taken
  part in the surveys so far
• a specific duty on all organisations to involve
  patients and the general public in the planning
  and development of services

28
Subtle ways patient empowerment

• the development of Patient Liaison Services
  (PALS) and the Independent Complaints Advocacy
  Service (ICAS) to help patients, their carers and
  families to navigate services, find solutions
  when things go wrong and (where necessary) raise
  a formal complaint about services. Both these
  services act as a powerful lever for change by
  providing feedback and highlighting best
  practice
• the provision of direct mechanisms to enable
  patients to report patient safety episodes
  directly to the NPSA and adverse drug reactions
  to the Medicines and Healthcare Products
  Regulatory Agency (MHRA)
• the proposed provisions in the NHS Redress Bill
  for financial recompense to those who suffer as a
  result of avoidable errors in the NHSiv. This
  places the emphasis on putting things right for
  patients as a matter of course, provides an
  alternative to litigation, and will contribute to
  the culture of learning in the NHS.

29
Performance management of contracting and
contractors

• Philip_at_primarycareleads.com