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Following Francis

22 May 2013

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Robert Francis QC’s weighty report on the scandal at Mid Staffordshire NHS Foundation Trust, published in February, has cast a dark shadow over the entire NHS, just before CCGs officially took over local budgets.

Robert Francis QC’s weighty report on the scandal at Mid Staffordshire NHS Foundation Trust, published in February, has cast a dark shadow over the entire NHS, just before CCGs officially took over local budgets.

The government will want to be seen taking action to ensure such appalling care can never happen again in its hospitals, yet is about to put the NHS in the hands of relatively inexperienced GP commissioning groups.
In light of the shocking findings of the Francis report, will the government introduce yet more bureaucratic burdens on GPs? Could clinical commissioning groups’ (CCGs) hard-fought autonomy be scaled back in favour of more regulations?
The short answer seems likely to be no. The mistreatment of patients at Mid Staffs went on for over four years under the nose of a plethora of regulators and scrutiny groups, and it’s plain to see more regulation or bureaucracy is not the answer – and in fact probably contributed to the problem. At the end of March Health Secretary Jeremy Hunt announced a range of measures based on encouraging a return to compassionate care rather than box-ticking. Yet among his hundreds of recommendations, Francis also suggests CCGs must take more responsibility for the care local providers offer their patients.
When providers fail to comply with new standards it ‘should be a matter
for performance management by commissioners rather than the regulator’. The government’s response to the report echoes this, saying ‘clinical
commissioning groups (as opposed to a single national body) are best placed to examine their own local providers and take action where required’. CCGs will be assisted by a new Chief Inspector of Hospitals, a ‘strong, independent’ ‘whistle-blower in chief’ for the NHS, according to Hunt. 
As ever, the devil will be in the detail as to what this really means in practice for CCGs. The BMA’s GP Committee, perhaps unsurprisingly, is unhappy with what it feels is a fundamental (and unfunded) shift of accountability away from the regulator, the Care Quality Commission (CQC), towards CCGs and grassroots GPs. Many others feel that the Francis report just sets out in pen and ink what all good GP commissioners should be doing anyway, and that keeping an eye out for poor care is now every GP’s responsibility after Mid Staffs.
Dr Joe McGilligan, chair of East Surrey CCG, believes the Francis report is saying that GPs should always be looking for feedback from patients about their experience with a provider, as this ‘soft intelligence’ is crucial to understanding provider quality.
“GPs have access to feedback about providers which enables them to spot patterns early – it’s just that this [the Francis report] makes it a legal responsibility. I wouldn’t say we are now responsible for failings in provision; rather, if you fail
to respond to failing provision, you are failing as a commissioner. If we as GPs are responsible for the referral we should know what the outcomes are likely to be.”
The GP Committee’s lead negotiator on commissioning, Dr Chaand Nagpaul, disagrees, saying the recommendations blur the roles and responsibilities of the CQC with CCGs. “It seems a disproportionate level of responsibility for failings in other parts of the health service. It’s fairly daunting to be accountable for the actions of all providers, especially in areas where you have a provider market and therefore lots of providers. The more you create a market the less you are able to monitor each one.”
At the time of writing, NHS England is preparing to publish its Clinical Commissioning Assurance Framework, a document which may help clarify what exactly CCGs will be legally expected to do and what failings GPs could find themselves liable for. It must also help CCGs develop ways to differentiate between isolated cases of bad practice and the systemic failures that occurred at Mid Staffs.
Dr Mike Dixon, interim president of NHS Clinical Commissioners, shares Nagpaul’s concerns about the duplication of the roles of CCGs and the CQC, but says the duty
on commissioners to be accountable for provider quality is nothing new.
“You could have expected CCGs to monitor quality before the Francis report but they weren’t kitted out to do so – commissioners didn’t feel they were empowered and that they had the data to change services, and that all changed on April 1. In theory I think commissioners should always have been responsible but I don’t think really they were.”
Like Dixon, most clinical commissioners seem optimistic that once clinicians take the reigns and have the power to shape services, the system will be much more sensitive when problems arise.
“Things are changing – where it was once managers talking to managers, we now have clinicians talking to clinicians,” says McGilligan.
“The commissioning process was traditionally managed in two parts – the commissioners talked about quality in one room and the managers talked about money in the other,” says NAPC chairman Dr Charles Alessi. “Now those discussions will be had in the same room by the same people.”
Alessi is confident the changes that came into force on April 1 will usher in a new era of shared responsibility, where no one turns a blind eye to poor care and no one’s concerns about a provider are ignored.
“It’s an end to the old world, where certain people took up responsibility and told people what to do, which is dangerous as it makes people on the front line think it is not their problem or there is nothing they can do. With membership organisations like CCGs that should be less likely to happen – it is everyone’s responsibility.”
But it won’t be enough to simply listen to patients’ feedback via the morning surgery. There will be patients that access services without seeing their GP before or after, and the very worst examples of care at Stafford hospital affected those unable to speak up for themselves.
Ruth Thorlby, senior fellow at the Nuffield Trust, says there is huge variation in how interested GPs are in their patients’ pathways through the NHS, and a more proactive approach is needed. “The people who received the worst treatment at Mid Staffs were often elderly patients who, sometimes literally, couldn’t be heard – and they are the people that GPs need to hear from. It requires GPs to be more proactive, being aware when their patients have accessed certain services; picking up the phone or tracking down their carers – asking ‘how was it?’ While the idea of tracking individual patients’ experience through care pathways makes sense on paper, GPs on the ground might quite reasonably balk at the increasing demand it puts on their workloads. The GPC will no doubt be calling for extra resources to recognise what they say is additional responsibility. After all, heaping pressure on clinicians is what leads to such scandals, says Nagpaul.
“There is no point just adding duties without recognising that CCGs are not resourced or structured to do this. They have a third less resources than PCTs and it is an additional responsibility. Unfortunately CCGs are not immune from the target culture. They have considerable targets, for example the quality premium. We need a fresh look at these central pressures and a commitment to remove performance related pressures on them.”
Nagpaul also feels the recommendations laid out by Francis – of CCGs monitoring their local hospital trust – over-simplify an increasingly complex health service.
“It will be quite a challenge in large urban areas like London, where there is no one CCG that is responsible for a single hospital. CCGs will need systems to feedback from individual GPs, but there needs to be a system that coordinates providers covered by several CCGs.”
Alessi reminds us that with larger CCGs, although likely to be more stable economically, there is a greater risk that not everyone’s voice will be heard. “In the larger CCGs there will need to be sub-CCG structures where any concerns can be raised and discussed in the open,” he says.
The proliferation of services delivered through any qualified provider will
also mean more providers for CCGs to monitor, and also more
providers from the private sector, not famed for their willingness to put
all their data out in the open. “It’s going to be more complicated
when you have more providers with whom you don’t have a historic relationship,” says Dixon. “Obviously the monitoring of quality standards is something we’ll have to liaise with the GPC about because we will very quickly go through our management budgets.”
For all the talk of ‘a change of culture’, the government’s plan also involves financial hits for providers not offering acceptable levels of quality and dignity. Medical Director at NHS England, Professor Sir Bruce Keogh, speaking to The Guardian, said CCGs should withhold all or part of the fees for an operation if the patient has not been treated to the highest possible standards, while the government’s response to the Francis report states: “Commissioners should consider whether it would incentivise compliance by requiring redress for individual patients who have received substandard service to be offered by the provider.”
This could be based on withholding existing quality incentives such as the commission for quality and innovation (CQUINS) payments, or perhaps the introduction of harsher penalties based on new standards of dignity and compassion.
“In a way the Francis report changes everything, as it introduces the idea that outcomes and experience and dignity are as important if not more than other measurements of quality,” says Alessi.
But how such subjective and emotive measures as dignity and compassion can be written into contractual standards remains to be seen. As with so much health policy in recent years, the conversations to follow between GPs, NHS England, the CQC and the Department of Health will arguably be more important than the initial policy statements and intent. 

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