House of Commons - Public Accounts - Forty-Seventh Report

Select Committee on Public Accounts Forty-Seventh Report

1 Accountability for quality and safety

1. A statutory 'duty of quality' for all providers of NHS services was introduced in 1999 following the tragic Shipman, Bristol Royal Infirmary and Alder Hey cases.[2] The Chief Executives of NHS trusts are accountable to trust boards for delivering this statutory duty of quality, which is largely discharged through clinical governance. Clinical governance is a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care.[3]

2. This approach sees quality and safety not only as the professional responsibility of individuals, but also as a responsibility to be embedded at all levels of an organisation. Whilst such measures cannot guarantee that cases such as Shipman will never happen again, the Department believes that having the right systems, processes and culture in place will make it easier for them to be detected, and provide assurance to patients that the services they receive are safe and of sufficient quality.[4]

3. Between 2001 and 2002, 303 Primary Care Trusts (PCTs) were established[5] with responsibility both for providing primary care services, and for commissioning services from independent contractors and other providers on behalf of their local health economy. The 303 PCTs varied considerably in the geographical and socio-economic nature of the areas they served, with the size of population covered ranging from 64,000 to 367,000.[6] In 2005-06, £23 billion was spent on primary care services, 78% of which was spent on commissioning services from independent contractors and other providers, including some 35,000 GPs.[7] 800,000 people use primary care services each day, with nine out of ten NHS patients diagnosed and treated entirely within primary care.[8] About 20% of people who work in the NHS now work in primary care.[9]

4. Accountability for PCT performance, including quality and safety, rests with the Chief Executive who is directly accountable for all the services the trust provides, whether provided directly or commissioned from other providers.[10] PCT Boards are responsible for setting the strategy and monitoring the performance of the trust. A Professional Executive Committee (PEC) assists the Board in the management of the PCT by providing clinical leadership and advice on quality and safety.[11] The Chair of the PEC is a member of the PCT Board and the PEC members are elected by their peers. Membership of the PEC can vary but will normally comprise a majority of primary and community care professionals.[12] PCT line management responsibilities for commissioned services are diffuse with limited power over individual contractors despite PCT Chief Executives being accountable for the quality of care (Figure 1).

5. The relationship between the PCT Board and PECs is important to overall progress in improving quality and safety. The involvement of PECs appears to some to have been an afterthought, however, and PEC members are generally less positive about the progress that has been made.[13] The GPs among those PEC members that responded to the National Audit Office survey (29% of the respondents) consistently gave lower achievement scores.[14] PECs are intended to engage GPs in the leadership and management of PCTs and, prompted by the NHS Alliance's 2004 report Making a Difference—engaging clinicians in PCTs, the Department has recently reviewed both their form and function.[15] The Alliance report found that PECs did not have a clear remit and that PEC members often lacked leadership and strategic skills.[16] After a three month consultation period,[17] the Department published guidance to strengthen PECs, to be implemented by PCTs by 1 October 2007.[18]

6. In October 2006, the number of PCTs was reduced from 303 to 152.[19] This significant organisational change forms part of the wider NHS reform agenda and is intended to enable PCTs to fulfil their responsibilities for implementing key national initiatives such as patient choice, payment by results, and practice-based commissioning and for managing independent contractors such as GPs, dentists and pharmacists.[20] The new PCT configurations are intended to lead to benefits for patients, and the Healthcare Commission's next Annual Health Check is expected to provide evidence of quality and safety improvements across primary care.[21]

7. Weaknesses in contract management and communication links between PCTs and independent contractors do not give confidence that quality and safety will be addressed as the NHS moves towards a greater diversity of providers under practice-based commissioning.[22] This new system will involve GPs taking responsibility for commissioning services, with practices holding an 'indicative budget' from the PCT which enables them to 'buy' services for patients from a range of providers.[23] If commissioners do not specify the requirements for quality and safety into contracts at the time of commissioning healthcare services, there is a real risk that the principles and accountability for quality and safety will not be in place for those commissioned services.[24]

Figure 1: Roles, responsibilities and accountabilities for quality and safety of primary care services

Note 1: These figures include all care provided directly by Primary Care Trusts, which include some secondary care (such as community health services).

Note 2: The Appointments Commission is a national body. It has nine regional commissioners, each of whom appoints the chairs and non-executive directors of the various health bodies in that region

Source: National Audit Office and Department of Health

2 Qq 23, 25 Back

3 C&AG's Report, para 1.5 Back

4 Qq 1, 25 Back

5 Q 44 Back

6 C&AG's Report, para 1.11 Back

7 Qq 26, 27 Back

8 C&AG's Report, Figure 2 Back

9 Q 78 Back

10 Qq 2, 91; C&AG's Report, summary para 1 Back

11 Qq 95; C&AG's Report, para 1.12 Back

12 C&AG's Report, Figure 5 Back