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MedicalDirectors’Bulletin. Sections P1 Voicepiece P2 Quality Accounts consultation Quality markers for end of life care P3 Setting quality standards for the NHS P4-5 South East Coast Quality Observatory P5-6 The quality and productivity challenge P6 Swine flu update P7 Indicator development P8 EWTD update News you can use P9-10 News in brief

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Issue 96 September 2009

Consulting on quality This month, there are two specific issues I would like to draw to your attention. The first relates to the formal consultation on Quality Accounts, which started on 17 September. Ara Darzi’s report made it explicit that Quality Accounts would be a key vehicle for making information on quality available to the public. But how will they contribute to improving quality in our NHS? Public disclosure of information on provider performance has been advocated as a mechanism to drive improvement through a variety of means, including public and professional accountability, patient-informed choice or the commissioning process. The published evidence suggests that public disclosure does not generally drive improvement through the resulting actions of patients or commissioners. Rather, it is the

organisational response that providers put in place to improve their record on quality that drives improvement. Consequently, the primary purpose of Quality Accounts is to encourage boards to assess quality across the totality of services they offer. If designed well, the accounts should assure commissioners, patients and the public that trust boards are regularly scrutinising each and every one of their services. The proposals outlined in the consultation document (see page 2) are the result of engagement, testing, and detailed design work over the last year by the DH; Monitor; the Care Quality Commission; NHS East of England and others. For us as medical leaders, the challenge is how to refine a format and methodology for the accounts that is concise, yet provides assurance that quality issues are being analysed and addressed across the full spectrum of an organisation’s activity. We should

also consider how the preparation and presentation of Quality Accounts could be used to reduce the duplication of data flow between NHS organisations. So please review, analyse and constructively criticise the proposals outlined in this consultation and send us your feedback by 10 December. The second issue relates to swine flu and staff vaccination (see page 6). My worry is that, if the virus takes hold, staff will become ill and sickness absence will increase, making it even more difficult to provide the sort of service we would wish to offer. Historically, the uptake of seasonal flu vaccine has been low. If swine flu takes off, our staff will have a professional and social responsibility to seriously consider vaccination to maintain levels of service under increased demand. Please could you give this your thought as the pandemic picture develops. Professor Sir Bruce Keogh NHS Medical Director


MedicalDirectors’Bulletin. Sections P1 Voicepiece P2 Quality Accounts consultation Quality markers for end of life care P3 Setting quality standards for the NHS P4-5 South East Coast Quality Observatory P5-6 The quality and productivity challenge P6 Swine flu update P7 Indicator development P8 EWTD update News you can use P9-10 News in brief

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Issue 96 September 2009

Consultation on Quality Accounts The DH has launched a public consultation on the proposed framework for Quality Accounts, and everyone interested in improving quality in the NHS is invited to respond. Quality Accounts are annual reports to the public on the quality of the services that an NHS organisation

delivers. By producing a quality account, each NHS provider, led by their board, is committing to improve the quality of services it delivers and inviting the public to hold them to that responsibility.

2010, subject to the successful passage of the Health Bill. The duty applies to the acute sector next year and will then be applied to primary care and community services.

All NHS healthcare providers will be legally required to produce quality accounts from June

This consultation sets out the recommendations for the regulations and guidance supporting

Quality Accounts in the first year, and is based on findings from a series of engagement, testing and design exercises over the past year. Responses to this consultation will

Links and info Participate in the consultation on the DH website

Quality markers for end of life care Quality markers for end of life care were published at the end of June, setting out what constitutes good care and helping to deliver service improvements. The markers emphasise issues, such as communication across sectors, which is key to delivering a seamless service that is organised around the individual. The focus is on structure and process, rather than outcomes, which will be addressed in future versions.

inform a report setting out the regulations and guidance for NHS organisations to use when producing their first Quality Accounts in 2010. The consultation closes on 10 December 2009.

It is not mandatory for service providers to implement the markers – which were originally set out in the end of life care strategy – but they are recommended as a tool for PCTs and SHAs to identify good care, or to help deliver improvements. Boards of individual commissioners or provider organisations will be able to define and track progress. Some of the markers are already in place, such as ensuring people approaching end of life are offered a

care plan, and appropriately assessing the needs of carers. As a result, many organisations may already be compliant with the quality markers if they are following, for instance, the NICE guidance on supportive and palliative care for adults with cancer or other end-of-life tools. Some gaps – such as bereavement and spirituality – are still to be addressed.

Links and info Read more on the DH website


MedicalDirectors’Bulletin. Sections P1 Voicepiece P2 Quality Accounts consultation Quality markers for end of life care P3 Setting quality standards for the NHS P4-5 South East Coast Quality Observatory P5-6 The quality and productivity challenge P6 Swine flu update P7 Indicator development P8 EWTD update News you can use P9-10 News in brief

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Issue 96 September 2009

Setting quality standards for the NHS The National Institute for Health and Clinical Excellence (NICE) has started work on setting the first quality standards for the NHS. These will be developed using a pilot process and are expected to be published in early 2010. NICE quality standards are a set of specific, concise statements that act as markers of high-quality, costeffective care across a pathway or a clinical area. The first four clinical areas of focus, referred by the National Quality Board, are stroke, dementia, neonatal care and venous thromboembolism (VTE). High Quality Care for All highlighted the difficulties clinicians faced in keeping up with the best evidence, and expanded NICE’s role to include setting and approving more independent quality standards for the NHS. These should clarify what high-quality care looks like with regard to clinical effectiveness, patient safety and patient experience.

The quality standards are based on the best available evidence and will be accompanied by a measurable element or indicator to allow for assessment of quality and quality improvement. The development work will be undertaken by a group of relevant clinical and public health experts, appropriate professional groups, generalists (including commissioners) and lay representatives. The group will consider the cost impact of the standards to the NHS before consulting and field-testing the statements prior to final publication. Bruce Keogh says: ‘The quality standards that are being developed by NICE will give patients and NHS and social care staff absolute clarity on what high quality care in these four areas looks like.’

Links and info Read more on the NICE website

Tackling VTE in the NHS At a leadership summit on Venous Thromboembolism (VTE) in the NHS in June, Chief Medical Officer Sir Liam Donaldson launched a new VTE e-learning tool to raise awareness and reduce the impact of the condition on people’s lives. e-VTE was developed by the Chief Medical Officer’s VTE Implementation Working Group, in partnership with e-Learning for Healthcare (e-LfH, and is available to anyone with an interest in VTE prevention. It enables clinicians to take appropriate action in assessing the risk of VTE for an individual and then advise on appropriate preventative measures. Other resource materials given to the summit attendees are now available on the DH website, including the e-LFH VTE module and VTE Resource Book. Videos, photos and speaker presentations will also be uploaded in this section. • Visit the e-VTE website • Download the summit resources


MedicalDirectors’Bulletin. Sections P1 Voicepiece P2 Quality Accounts consultation Quality markers for end of life care P3 Setting quality standards for the NHS P4-5 South East Coast Quality Observatory P5-6 The quality and productivity challenge P6 Swine flu update P7 Indicator development P8 EWTD update News you can use P9-10 News in brief

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Issue 96 September 2009

South East Coast Observatory: making the most of data As part of the drive for higher quality services across the NHS, quality observatories will be formed by each SHA to provide benchmarking for a range of clinical areas, support the development of local metrics and promote a culture of measurement for improvement. Having been up and running for about three years, the South East Coast Quality Observatory is a front runner. Head of the Quality Observatory, Samantha Riley, explains how they work. What is the aim of the observatory? Our job is to make it easy for people across NHS South East Coast to use data and information to help them improve patient care. We do that by demystifying data so it can be used by clinicians and managers in trusts and PCTs. The aim is to create a culture of continuous improvement and evidence-based

Samantha Riley, Head of the South East Coast Quality Observatory.

Below: the South East Coast team.

decision making. The work of the Quality Observatory will be critical in helping to deliver the quality, innovation, productivity and prevention framework. This will support improvements in quality and achieving savings.

training on how to interpret information and design useful measures. We try to present our analysis in a way that’s easy to understand – you certainly don’t have to be a statistician to use our tools!

Who can use the quality observatory? We provide a free service to pretty much anyone working for the NHS in the South East Coast. We aim to provide high-quality, well-presented analysis that shows how organisations – and, in some cases, individual clinicians – are currently performing compared to others. We update our analysis on a regular basis to help clinical teams understand the impact of their actions to improve quality. The team also provides advice and

What are some of the projects the observatory has worked on? So far we have developed over 60 benchmarking tools and dashboards for a wide range of areas. Recently, we have looked at analysing innovative practice. After hearing about an orthopaedic surgeon who discharged 50 percent of his patients the day after their hip replacement operations, we undertook analysis to show the varying lengths of stay for patients of orthopaedic surgeons across the South East Coast. We also looked at other indicators, such as re-admissions and complication rates – it’s important to look at a balanced set of data to understand the whole picture. Continued on page 5


MedicalDirectors’Bulletin. Sections

Continued from page 4

P1 Voicepiece

The Quality Observatory has also supported the Safer, Smarter Nursing Metrics programme, developing bespoke, ward-based dashboards for some trusts. These provide a visual representation of performance against key indicators over time. Ward staff find this information easier to understand than the spreadsheets they were using before, and are finding the dashboards really motivational.

P2 Quality Accounts consultation Quality markers for end of life care P3 Setting quality standards for the NHS P4-5 South East Coast Quality Observatory

P8 EWTD update News you can use

Another big piece of work was developing a set of measures for dementia services, which is now being used by the DH to support the implementation of the National Dementia Strategy. We compared diagnosis rates for every GP practice and saw huge variation. Aggregating down to a PCT level showed that only 30 to 40 percent of the predicted number of people with dementia were being picked up. This finding was especially challenging for the PCTs that appeared to have disinvested in dementia services.

P9-10 News in brief

We are currently finalising an inpatient survey tool and a Quality Outcomes

P5-6 The quality and productivity challenge P6 Swine flu update P7 Indicator development

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Framework benchmarking tool. People will be able to access both of these via the website we are hosting on behalf of all quality observatories to encourage sharing of ideas and information. Who’s involved in all of these projects? A huge range of people contribute to our work, including consultants, GPs, nurses and allied health professionals. We also work closely with library services because they have expertise in searching for research papers and evidence. Do you face any particular challenges? The main challenge is interpretation: we have to educate people in understanding analysis so they don’t jump to the wrong conclusion, which is easy to do. We also get more than enough requests for our 12-person team to manage! But, as more quality observatories are established, we hope to share the work.

Links and info Visit the Quality Observatory website and select South East Coast to learn more

Issue 96 September 2009

The quality and productivity challenge Meeting the NHS’s quality, innovation, productivity and prevention challenge will be no mean feat for the NHS, but it is crucial if quality care is to be maintained in a tough economic climate. Jim Easton is the NHS National Director for Improvement and Efficiency. He says: ‘We need to drive quality and productivity and prevention, using innovation as a link. ‘It’s understandable that what’s happened in the international economy is going to be a cause of concern for the people who work in the NHS. ‘But they should realise that we are the recipients of a tremendous vote of confidence from the Government. Even with this support, the growing demands for healthcare and our determination to pursue our quality objectives, represent a huge challenge.’ Jim believes the NHS should assume it will need to release efficiency savings of between £15 billion and £20 billion over three years from 2011. Continued on page 6


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Swine flu update The priority at-risk groups to be offered the first doses of the swine flu vaccination have been announced. These groups have been identified because they are at the highest risk of severe illness should they contract the swine flu virus. Frontline health and social care workers across the UK will be offered the vaccine at the same time as the first clinical at-risk group because they are at increased risk of infection and of transmitting that infection to vulnerable patients. Once the vaccines have been licensed by the European Medicines Agency (EMEA), the following groups should be prioritised for vaccination, in the order: • individuals aged six months and up to 65 years in the current seasonal flu vaccine clinical at-risk groups • pregnant women, subject to licensing conditions on trimesters • household contacts of immunocompromised individuals • people aged 65 and over

Issue 96 September 2009

Continued from page 5 in the current seasonal flu vaccine clinical at-risk groups.

The DH is working with the British Medical Association and NHS organisations on a comprehensive swine flu vaccine implementation plan for this first stage of the programme. Once this has been agreed, ensuring that frontline staff get vaccinated to help protect them and their patients from the swine flu virus will be crucial, and all eligible staff are strongly encouraged to have the vaccine. The DH has produced a practical guide to support PCTs in planning for and responding to the potential capacity challenges for primary care associated with the swine flu pandemic.

Links and info • Read the guidance for PCTs on the DH website • Access the latest clinical information and guidance on swine flu on the DH website

The first step in taking this work forward at local and national level is to establish what is captured in the Operating Framework. The service then needs to identify the key changes that will deliver the agenda and implement them, at scale and at pace. ‘There are already many excellent examples of service models that do this, but our track record of spreading them is still limited,’ Jim says. ‘The key is to spend time in local organisations, with partner organisations and with national stakeholders. ‘When I talk to staff they tell me about waste and duplication in the service, about opportunities to improve care that would also be more efficient, so we need to harness and support that energy and those ideas.’ So how does Jim see the NHS five years from now? ‘Our aspiration is to have delivered on our promise of quality, while sustaining the NHS on a sound footing, then begin to look at new ambitions for the future. The NHS’s long-term success is dependent on driving quality and funding quality.’ • Read David Nicholson’s letter outlining how we can all contribute to the quality and productivity challenge


MedicalDirectors’Bulletin. Sections P1 Voicepiece P2 Quality Accounts consultation Quality markers for end of life care P3 Setting quality standards for the NHS P4-5 South East Coast Quality Observatory P5-6 The quality and productivity challenge P6 Swine flu update P7 Indicator development P8 EWTD update News you can use P9-10 News in brief

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Issue 96 September 2009

Indicator development governance arrangements The Indicators for Quality Improvement (IQI) were launched in May 2009, bringing together, for the first time, quality indicators from many different sources. In July 2009, data underpinning these indicators was published on the NHS Information Centre (NHS IC) website to allow NHS organisations to compare themselves with others. NHS staff can look at a range of quality indicators from across different aspects of the care they provide and, with support from analysts, they can use this information to improve services for patients. To view the data, users need to register their details on the NHS IC website. The information can then be downloaded at the lowest level of aggregation available, currently for around three-quarters of the indicators in the menu. The other quarter will be available in future releases, as it is sourced from suppliers.

Many NHS professionals are already viewing the indicators in the menu, with an average of 1,700 daily hits to the front page of the site.

Work in progress

The IQI are an evolving resource and, at the moment, do not comprehensively reflect the health and social care system. The initial menu of indicators is from existing national sets, so there are gaps across care pathways and within the dimensions of quality (safety, experience and effectiveness). The NHS is encouraged to use locally determined indicators in addition to those from IQI for many purposes, including their quality accounts, Commissioning for Quality and Innovation (CQUIN) schemes and clinical dashboards. Over time, these may enter the IQI as they meet established assurance criteria. The Measuring for Quality Improvement (MQI) team is working with an advisory group made up of a

number of key stakeholders – including clinicians, professional organisations, healthcare regulators, and informatics and analytical experts – to better understand the current indicator development landscape and how to best manage long-term governance for this important area. This will feed into work to create appropriate principles and models for national indicator development by the end of the year. This is the start of a long process to produce a comprehensive library of indicators for NHS staff. The evolution of the IQI, through establishing governance processes for indicator development, will provide indicators across the entire health and social care system for the future.

Links and info • Read more about the IQI on the NHS IC website • To make a suggestion for a new IQI indicator, email the NHS IC via the link on their site


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The time has come Since 1 August, the European Working Time Directive (EWTD) has been in effect for all staff, with only a few specialist services securing more time to be fully compliant. ‘It has been a challenging process,’ says National Clinical Lead for EWTD, Dr Wendy Reid. ‘Achieving compliance for the last group of junior doctors required local commitment, strong clinical leadership, partnership with the Academy and royal colleges, NHS employers, the British Medical Association (BMA) and Skills for Health, as well as co-operation and teamwork between the SHAs and trusts.’ The transition on 1 August was accomplished alongside the annual changeover in medical training programmes. However, there is still work to do as the Directive becomes embedded. For example, SHAs will continue to review the challenging areas and Medical Education England is leading an inquiry into the impact of EWTD on medical training.

Issue 96 September 2009

News you can use The communications team in the Quality Framework has been making short films to demonstrate how the expertise of frontline staff can be used to improve the quality of care. The team has shown the films – of an endoscopy clinic in Derby and community matrons in West Yorkshire – at conferences and stakeholder engagement events. They can also be downloaded from the DH website and YouTube channel.

Medical directors may want to ensure that all junior doctors are supported, informed and understand their position regarding indemnities. Junior doctors, for instance, need to know that it is in their interests to check they accurately record the hours they work, and that opting out is an individual right and wholly voluntary.

Links and info • Find more information on the NHS Employers website • Download guidance for junior doctors from the BMA website • Download resources from the Healthcare Workforce website

In the next few months, the team will be making films about quality accounts, radiography and early discharge after orthopaedic surgery. If you know of a team in your organisation that would be an interesting subject for a quality film, email Jane Dwelly, Head of Communications, NHS Quality Framework. The communications team has also assembled a cuttings pack of media coverage of the Indicators for Quality Improvement release. Download it from the High Quality Care for All website.

Links and info • View the film on Improving endoscopy at Derby • View the film on Improving the discharge process for the frail and elderly


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Annual Medical Directors’ conference:

26-27 November 2009 This year’s Medical Directors’ conference is shaping up to be an essential meeting for NHS leaders who are serious about using quality and innovation to increase productivity. It will be the second year that Bruce Keogh has hosted a conference for NHS medical directors. The agenda provides a combination of inspiring keynote speakers and practical workshops about the main matters concerning all NHS leaders. There will also be the chance to network and share learning with colleagues from across the country throughout the event and, of course, at the dinner at the end of the first day. Attendance is by invitation only. All medical directors have received a letter of invite from Bruce Keogh, and will soon be able to register and choose their workshops online. • See the diary on page 10 for venue details

Issue 96 September 2009

NEWS IN BRIEF Review of pre-registration nursing education

The Nursing and Midwifery Council (NMC) is reviewing pre-registration nursing education, focusing on how nursing programmes across the UK need to change to enable future nurses to meet the needs of patients and clients safely and effectively. The NMC is urging all nurses and managers to visit its website and provide feedback on: the development of the competency framework; possible new requirements for teaching, learning and assessment; and the four nursing fields of practice (adult, children’s, mental health, and learning disability). • Find out more on the NMC website

Keeping equality in the spotlight

Lay members are being asked to join representatives from patient groups, NHS staff, social care and voluntary organisations on the new Equality and Diversity Council, set up to make sure that the NHS acts on equality and diversity issues. The Council, chaired by NHS Chief Executive David Nicholson, will also help organisations work with communities to deliver personalised

services. Its first meeting will take place in October. • Read more on the DH website

Quality Improvement Fellowships The Health Foundation is looking for senior NHS leaders who are clinically qualified and have a strong track record of achievement in the field of quality improvement to apply for Quality Improvement Fellowships. Fellows will be able to spend a year working with the Institute for Healthcare Improvement in Cambridge, Massachusetts, USA. The aim is that, on returning to the UK, they will integrate their learning at their employing organisation in order to impact on service improvement and promote quality improvement nationally. The deadline for applications is 16 October 2009. • Find out more on the Health Foundation’s website • Or email awards@health.org.uk

Guide to good practice in clinical perfusion

This guide was developed in response to a critical heart surgery incident in


MedicalDirectors’Bulletin. Sections P1 Voicepiece P2 Quality Accounts consultation Quality markers for end of life care P3 Setting quality standards for the NHS P4-5 South East Coast Quality Observatory P5-6 The quality and productivity challenge P6 Swine flu update P7 Indicator development P8 EWTD update News you can use P9-10 News in brief

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2005, which led to the publication of the Gritten report two years later. This guide provides a framework for the safe administration of fluids and drugs associated with heart-lung bypass. • Read the guide • Order hard copies from the DH Orderline, quoting 296489

Reference guide to consent to treatment

The updated Reference guide to examination for consent or treatment is now available. It provides a guide to the legal framework that all health professionals need to take account of in obtaining valid consent for any examination, treatment or care they propose to undertake. • Download the guide from the DH website

Improving cancer inpatient care

NHS Improvement has worked closely with 40 trusts in testing and piloting ideas to improve the quality of cancer inpatient care. Transforming Care for Cancer Inpatients – Spreading the Winning Principles and Good Practice identifies four principles that, if shared, could make significant improvements in quality, efficiency, patient experience

and promoting value for money. • Read more about it

The Big Care Debate

You have until the end of October to have your say on the proposed reforms to the care and support system, as set out in the Green Paper, Shaping the Future of Care Together. • Visit the care and support website to submit your thoughts on the proposed reforms

New Horizons consultation

Don’t forget to have your say on New Horizons, the proposed vision for mental health services. The 12-week consultation closes on 15 October 2009. • Have your say via the DH website

Hepatitis C awareness campaign

The latest phase of the DH hepatitis C public awareness campaign, Get tested. Get treated, will begin on 5 October 2009 and run until 31 March 2010. It will continue to target former injecting drug users and the South Asian population, groups which are at increased risk of infection. From 21 September 2009, there will be communications for primary

Issue 96 September 2009

healthcare professionals, as well as press advertising and advertorials in trade publications, to prepare for the public campaign. • Download resources, including the Hepatitis C Quick Reference Guide, from the NHS website • Read more about hepatitis C on the DH website DIARY Patient Safety First week Date: 21-27 September 2009 Local, regional and national activities will raise awareness and encourage everyone working in healthcare to take at least one new step that supports putting patient safety first. • Visit the Patient Safety First website to get involved • Send your stories to the website’s community forum page or email them to info@ patientsafetyfirst.nhs.uk Medical Directors’ conference Date: 26-27 November 2009 Venue: Millennium Gloucester Hotel, London.

NHS Medical Diector bulletin September 2009  

Professor Sir Bruce Keogh's bulletin from September 2009 featuring the South East Coast Quality Observatory