The Francis report makes challenging reading for commissioners. It is clear that although the successive reforms to the NHS may have amounted to mitigating circumstances, the commissioners, and indeed other interested parties, failed to take adequate steps to prevent the problems at Mid Staffordshire, or to uncover and prevent them from continuing. The report recognises that the system is on the cusp of change but “the experience of Stafford shows an urgent need to rebalance and refocus commissioning into an exercise designed to procure desired standards of service for patients as well as to identify the nature of the service to be provided”.
There are extensive recommendations for steps that commissioners should take to ensure that they are commissioning quality services, and in many ways these reiterate some of the messages arising out of the Winterbourne View scandal. Commissioners cannot simply assume that services are good. Investigations need to go beyond a simple acceptance of assurances that all is well without looking at the underlying evidence and indeed seeing what happens on the ground. Mr Francis QC makes the point that this aspect of the Healthcare Commission’s investigation was key in enabling it to see the reality of what was going on.
The importance of gathering together feedback from a wide range of sources is emphasised. This will involve close liaison with GPs – which should be easier for CCGs – to get feedback from their experience of patient outcomes and experience. Similarly, the involvement of patients and patient representatives is needed to enable adequate monitoring to take place. Considerable emphasis is placed on the need for commissioners to identify enhanced quality standards with appropriate incentives. CCGs will also need to support the Commissioning Board and other commissioners in this regard. The recommendation about public involvement and engagement in commissioning is vague and it is unclear whether this is regarded as being satisfied by the current lay member provisions of the CCG constitutions.
All of this will involve a greater degree of monitoring and analysis of the information obtained from providers. The question implicit in the criticisms of previous reorganisations is the extent to which the current reforms will prejudice the tracking of this information as the PCTs are replaced by CCGs. It is crucially important for there to be effective handover of the soft intelligence about all providers and about all service lines: just because a provider is generally excellent does not mean all of its services are excellent. There are important questions for the CCGs about the extent to which their ability to do this is robust, and whether the CSUs will be able to provide the level of support needed.
Clearly much greater emphasis needs to be placed on quality rather than the quantity or financial elements of commissioning. This may require a more flexible response from the Commissioning Board and Monitor in terms of pricing and the management of NHS finances.
There are also uncomfortable messages for others involved in the health system. Overview and scrutiny is given encouragement, but the role of the Health and Wellbeing Boards could become just as important as a forum for discussion about issues in relation to local providers.
Mr Francis QC also suggests changes to the overall regulatory framework with the functions of regulating governance of healthcare providers and fitness of persons to be directors, governors or equivalent persons to be transferred from Monitor to the CQC. The report proposes that the fundamental standards (see our article on clinical governance) should be policed by a single regulator, the CQC, monitoring both this, and the governance and financial sustainability which will enable a provider to deliver compliant services on a sustainable basis. It is further recommended that inspection should remain the central method for monitoring compliance with fundamental standards and that a specialist cadre of hospital inspectors should be established.
The report recommends that the NHSLA should set more demanding levels for financial incentivisation, and arrangements should be made for the more effective sharing and recording of information. The functions of the former NPSA with regard to incident reporting and analysis need to be well protected and defined.
Seminar: The Mid Staffordshire Public Inquiry - essential lessons for the health and social care sector
In the coming weeks Bevan Brittan is hosting a series of seminars across its offices to consider the implications of the Inquiry more fully. Following these we will issue more detailed briefings on what the Inquiry's conclusions mean for different players in the system. The scheduled dates for these seminars are as follows:
Bristol: 20 February 2013Birmingham: 26 February 2013 London: 1 March 2013
Please click on the above dates and locations to view further details and to register for the seminars.