Written evidence from Dr Foster Intelligence
Dr Foster Intelligence is joint-venture company half-owned
by the Department of Health. Dr Foster provides clinical benchmarking
services to hospitals and commissioners. It also publishes information
about outcomes achieved by different healthcare providers in the
UK. Dr Foster is committed to achieving a more patient-centred
and transparent health service and consequently operates to a
high level of transparency and accountability itself. Oversight
of the company is provided by an independent ethics committee.
2. DR FOSTER
2.1 Dr Foster Intelligence supports the introduction
of revalidation and believes that it is an important step in ensuring
high quality healthcare.
2.2 We understand the reasons for delay in the
introduction of revalidation and agree that the system must be
proportionate, cost effective and supported by clinicians if it
is to work. That said, we are concerned at the length of time
it is taking to implement a system of revalidation.
2.3 We have recommendations in relations to revalidation
in two areas:
2.3.1 We believe if it is to be cost effective,
revalidation must be looked at in the broader context of initiatives
to improve the quality of health services through monitoring of
standards. If done in a way that complements these broader initiatives
it will prove cost effective. Quality improvement initiatives
are often specific to the devolved administrations within the
United Kingdom. However, there is sufficient commonality of approach
to be able to take useful steps to ensure that revalidation is
developed in line the broader objectives of quality improvement
2.3.2. We believe that a large part of the cost
of revalidation is collection of data in the areas of patient
feedback and clinical outcomes. However we believe that by using
existing data resources more effectively the costs can be managed.
3.1 There are a number of policies and initiatives
currently to monitor and improve quality in the NHS. These include:
3.1.1 The outcomes framework and transparency
This outcomes framework a proposed set of outcome metrics
and supporting measures defined by the National Institute of Clinical
Excellence that will be used to judge the overall quality of the
NHS. Another proposed policy aligned with this, is a plan to encourage
greater transparency around outcomes. This is intended to ensure
accountability not just to national government but also to local
populations and individual patients.
3.1.2 Regulation (CQC in England, the Healthcare
Inspectorate in Wales etc.)
The healthcare regulators monitor a wide range of data and have
responsibility for ensuring quality of healthcare providers.
3.1.3 National clinical audit (can be UK wide
but participation is voluntary)
These are a range of specialty specific audits (data collections,
databases and benchmark reports) designed to track measures of
quality for secondary care specialists and allow comparison of
outcomes between clinicians.
3.2 There are some clear principles that underpinning
all of these initiatives as well as revalidation. These principles
- Clinicians should be auditing and comparing measures
of clinical efficacy and safety including both outcome and process
- Clinicians should have access to data about what
patient think about the services they provide and understand where
there expectations are not being met.
- Data should be shared with colleagues and clinicians
should receive feedback from colleagues about their practice.
- Appropriate comparative measures of performance
derived from these data should be published. There remains different
views as to the appropriate level of transparency in health systems
but where transparency is regarded as important, revalidation
can play an important role in supporting it.
1. Where clinical audit already exists and specialty
associations have recommended outcomes for monitoring, it should
be mandatory to review this evidence as part of NHS appraisal.
This could be introduced now.
2. Where there are no relevant national audit
standards and outcome measures, such standards should be developed.
The use of local audit - as for example, proposed for GP revalidation
- is of limited benefit. We would like to see a timetable for
establishing national standards for audit that include an element
of outcome measures for all doctors.
4. GETTING THE
In the areas of clinical outcomes and patient safety
the key data resources are:
- Primary care clinical data.
- Routinely collected hospital data (HES, PEDW,
- National clinical audit data.
4.1 There are a number of ways in which these
data are not well suited to revalidation. The key issue are:
4.1.1. Primary care clinical data
There are no requirements on GPs to systematically
record any data on their clinical systems. These systems exist
for the benefit of the GP to support the administration of their
practice and the management of patients. However, these data provide
the most extensive source of information with which to understand
the clinical quality of practice.
A requirement on GPs to meet minimum data recording
standards is also increasingly recognised as vital to underpin
the broader management and quality monitoring of the health system.
Revalidation provides an important mechanism through which it
will be possible to develop consistent and accurate records of
4.1.2 Routinely collected hospital data
Routinely collected hospital data is being proposed
as a source of data for revalidation by some specialty associations.
A number have put forward clinical indicators that can be derived
from these data. However there are a number of aspects of the
data that mean it is not as effective as it might be in supporting
either revalidation or, more broadly, monitoring of quality. In
- There is no accurate record of the doctor or
anaesthetist performing any procedure.
- There is no "present on admission"
flag to distinguish the diagnoses with which the patient presented
at hospital from those which may have resulted from treatment.
- There are inadequate rules around the coding
of complications such as Deep Vein Thrombosis.
Modest investment in the development of routine data
sources could greatly reduce the costs of ensuring doctors have
the data they need to support revalidation.
A related issue with routine data is lack of clinician
involvement in the recording of these data which can result in
inaccuracy and mistrust of the data. Secondary care providers
need to take steps to ensure clinicians take an active role in
ensuring information is recorded correctly.
4.1.3. National Clinical Audit
The key problem with National Clinical Audit data
is the cost of completing the data, the consequent lack of completeness
of many records and the lack of independent checks to identify
where data is incomplete.
Stronger requirements on clinicians to participate
in audit would help. We would also like to see routine comparisons
between the hospital's routine records and the clinical audit
record to ensure completeness and accuracy.
1. Minimum standards for data recording on clinical
systems are established for GPs
2. A review of routine hospital data is implemented
and the data set is adapted to enable it to best support revalidation.
3. National Clinical Audits are required to regularly
compare themselves with official records of activity to identify
where data is not being recorded