House of Commons - Public Accounts - Forty-Seventh Report

Select Committee on Public Accounts Forty-Seventh Report

2 Progress in improving quality and safety

8. 82% of PCTs surveyed by the National Audit Office considered that clinical governance had helped raise the quality of patient care, for example through improved staff training and better complaints management.[25] The Department told us that the Quality and Outcomes Framework (QOF), which is part of the new GP contract, shows that the quality of primary care is improving.[26] Under the QOF, introduced in April 2004, GP practices score points for achievement against a range of 146 evidence-based indicators and are paid according to the points achieved. These data, however, are primarily collected for payment purposes, linking remuneration to evidence of the quality of service. In 2006, each practice on average achieved 96% of the points available—or 1011 out of a possible 1050.[27] Although the QOF is focused on inputs rather than outputs, the Department believes there is good clinical evidence, that for between 60 and 70% of the QOF measures, these inputs will result in improved outcomes.[28] The Department also told us that patients are becoming increasingly satisfied with the local primary care services provided.[29]

9. Front-line staff surveyed by the National Audit Office reported a variety of day to day pressures which acted as barriers to the effective implementation of clinical governance and pursuit of quality goals, such as lack of time, financing and staff.[30] Some PCTs had, however, managed to get over these barriers so they should not necessarily prevent clinical governance progressing. Nonetheless, the Department was reviewing the progress of each PCT as part of a fitness-for-purpose programme, where each PCT will agree with its Strategic Health Authority how it will improve its performance over the next year.[31] PCTs also need to work together where PCT boundaries are not coterminous with Local Education Authority boundaries and gaps in the provision of healthcare could arise.[32]

10. Clinical governance links between PCTs and independent contractors such as GPs and pharmacists are undeveloped.[33] Contractors consider that they are not getting adequate support from PCTs to embed quality and safety into their procedures and raise the levels of clinical governance.[34] Strategic Health Authorities found the independence of contractors a major challenge in working with PCTs to implement clinical governance.[35] Under practice-based commissioning, greater diversity of providers will bring greater complexity to the implementation of clinical governance.[36] In order to build quality and safety into commissioning the Department recognised the need for openness and transparency in commissioning decisions; appropriate channels for whistleblowers to voice concerns; and vigilance in the monitoring of incentives offered to contractors.[37]

11. The Department recognised that PCTs need to rise to the challenge of providing adequate support to help independent contractors, particularly in terms of developing skills in new areas.[38] Looking forward, independent contractors would be engaged more clearly in contracting and identifying quality and safety in both primary and secondary care under practice-based commissioning.[39] Contract management and commissioning skills needed to be improved across PCTs and within the NHS as a whole, and outside agents from the private or independent sectors might be used to help improve commissioning.[40]

12. It takes 7-9 years to train a GP and costs around £250,000,[41] but arrangements for ensuring that their professional skills are up to date rely largely on self-assessment and peer review.[42] The Chief Medical Officer's July 2006 report Good doctors, safer patients highlights the actions that are available to PCTs to investigate and deal with concerns about GP performance.[43] Although more than three-quarters of primary care spending is directed at independent contractors, the level of intervention with poorly performing GPs is very low, with only 66 GPs out of 35,000 currently under suspension.[44] Mechanisms for monitoring quality and safety have contributed to better identification of poor performance, but PCTs do not have direct line management of independent contractors.[45] So although PCTs now have greater powers to take action with poorly performing GPs, many PCTs have failed to take local action to address their concerns,[46] reinforcing doubts about monitoring and control of the quality of GPs.[47]

13. The Department believed that GPs were held to account more than they used to be, but had nonetheless been concerned about the willingness of PCTs to manage performance at a local level. As a result, medical regulations had been reviewed and the Chief Medical Officer's paper Good doctors, safer patients had drawn up a list of 44 recommendations to change the regulatory framework within which doctors operate.[48] The Government's response to these recommendations was published on 21 February 2007.[49]

14. 94% of GPs responding to the National Audit Office survey have incident reporting systems in place.[50] However, only 4% of GPs routinely reported adverse incidents to the National Patient Safety Agency, with more than three quarters saying they did not.[51] The Healthcare Commission's 2006 report on the state of healthcare found that safety received less attention in primary care than in acute trusts and that the systems for reporting were generally not as well developed and less widely used.[52] The Department is currently working with the Royal College of General Practitioners to develop guidance to encourage and support GPs in the reporting of incidents. It is setting up patient safety action teams at strategic health authorities to improve communications and thus make incident reporting easier.[53]

15. Although it suggested that in the NHS it has not traditionally been considered possible to improve quality and reduce costs at the same time, the Department believes that clinical governance will drive out significant efficiency savings throughout the NHS.[54] The NAO's survey of GPs found that 15% of GPs considered that clinical governance had helped them to deliver efficiency savings.[55] 20% of PCTs considered that clinical governance had delivered efficiency savings across five broad areas (Figure 2) and a further 66% considered that it might have delivered efficiency savings though they had not been fully assessed.[56] The Department considered that although GPs regard quality and safety as central to their activities, activities such as listening to patients, responding to complaints, and learning from incidents are not necessarily recognised as being about clinical governance.[57]

16. The Department took some assurance from the Healthcare Commission's assessment under the Standards for Better Health. In 2005-06, 92% of PCTs considered themselves to be compliant with the Department's Standards for Better Health.[58] This assessment system, which requires PCTs to assess their own performance, replaced the 'star-rating' system which had been used until 2004-05.[59] The use of self-assessment in the NHS contrasts with the direct inspection of schools by Ofsted. The Department, however, is concerned to strike the right balance between holding people to account, line management and providing GPs with the autonomy to maximise productivity. It was therefore using levers for quality improvement, such as practice-based commissioning and patient choice.[60]

Figure 2: Examples of how clinical governance has helped PCTs deliver efficiency savings

Area	Example reported	% of PCTs reporting
Prescriptions/procurement management	Streamlining prescribing so that it is more cost effective Better management of equipment/prosthetics procurement	12.9 1.3
Risk Management	Reduction in litigation Reduction in infection rates Reduction of incidents / near misses More systematic use of resources	3.3 2.5 2.1 3.3
Links with secondary care	Reduction in unnecessary hospital attendance Improved referral and appointment systems	4.6 2.5
Service redesign	Development of patient pathways Application of lessons from clinical audit/best practice Redesign of delivery such as podiatry services Efficiencies generated by application of evidence-based practice	3.3 3.8 4.6 1.3
Resource issues	Better utilisation of staff through training More effective use of information	4.6 0.4

Source: C&AG's Report, Health Services Management Centre census of PCTs, Autumn 2005

17. At a higher level, we also found that no Chief Executive from any of the PCTs had been called in by the Department for failing to meet their statutory duty of quality.[61] The Healthcare Commission had powers enabling it to recommend the application of 'special measures' to the Secretary of State when it had a concern regarding quality of care in a part of the NHS.[62] The Commission's Annual Health Check had identified 24 PCTs about which it had serious concerns over quality and financial performance,[63] and where action had been taken by each PCT board and Chief Executive with supervision from the Strategic Health Authority.[64]

25 Q 55; C&AG's Report, paras 16, 2.33 Back

26 Q 1 Back

27 C&AG's Report, para 2.13 Back

28 Q 80 Back

29 Qq 1, 24 Back

30 C&AG's Report, para 15 Back

31 Q 20 Back

32 Qq 21-22 Back

33 C&AG's Report, para 14 Back

34 Qq 47, 51-52, 59 Back

35 Q 7; C&AG's Report, para 2.11 Back

36 Q 11 Back