The Scottish Government

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Health in Scotland 2003

CHAPTER 5 HEALTH QUALITY

NHS Quality Improvement Scotland

NHS Quality Improvement Scotland (NHS QIS) was established in January 2003 to achieve better co-ordination and integration of work on clinical effectiveness and quality improvement. It brings together five organisations:

• Clinical Resource and Audit Group (CRAG)

• Clinical Standards Board for Scotland (CSBS)

• Health Technology Board for Scotland (HTBS)

• Nursing and Midwifery Practice Development Unit (NMPDU)

• Scottish Health Advisory Service (SHAS).

NHS QIS also supports and facilitates the work of the Scottish Intercollegiate Guidelines Network (SIGN) and the Scottish Medicines Consortium (SMC).

Its role is to improve the quality of healthcare in Scotland by setting standards, monitoring performance and providing advice, guidance and support to NHSScotland on effective clinical practice and service improvements. In addition to inheriting the functions of its predecessor organisations, NHS QIS has been given some major new responsibilities including investigating serious service failures, leading on patient safety issues, liaising with the National Patient Safety Agency (NPSA) in England and Wales, and supporting the implementation of clinical governance.

During its first year of operation, NHS QIS focused on three priorities. The first was developing an integrated structure to enable its existing functions and new responsibilities to be delivered effectively. An integration plan was published in May 2003 and is in the process of being implemented. The second was developing a vision and identity for the new organisation. This is being incorporated into a strategic framework which will be issued for wide consultation early in 2004. Thirdly, it has continued the work inherited from the predecessor organisations, while exploring any immediate opportunities to improve co-ordination of related projects. During the year several projects were completed, including:

• technology assessments on prevention of relapse in alcohol dependence and on troponin testing for acute coronary syndromes

• national overviews and local reports on the performance of NHSScotland on healthcare associated infection, adult renal services, clinical governance (following a second round of review visits) and breast and cervical screening

• reports on visits to services for older people and people with learning and physical disabilities

• publication of the tenth report on clinical outcome indicators, further best practice statements and an evaluation of their impact.

During 2004, NHS QIS will take over the risk management standards and assessment elements of the Clinical Negligence and Other Risks Indemnity Scheme (CNORIS), integrating them with its clinical governance standards.

Patient Safety

In December 2002, the Health Department issued a consultation paper Learning from Experience: How to Improve Safety for Patients in Scotland. One proposal was that NHS QIS should be given lead responsibility for improving patient safety in Scotland, working in liaison with the National Patient Safety Agency in England and Wales.

The consultation responses endorsed this proposal and the overall approach set out in the paper. The recommendations of a multi-disciplinary, short-life working group under the chairmanship of Dr John Reid, Medical Director, Forth Valley Acute Hospitals NHS Trust were endorsed by the board of NHS QIS in November 2003.

The approach being adopted in Scotland is designed to ensure that the profile of patient safety will be raised at all levels and in all parts of NHSScotland and that this issue should be seen as an integral part of the clinical governance agenda designed to deliver consistently safe and effective clinical care. To this end, the agenda needs to be owned by healthcare professionals and by each NHS Board with NHS QIS supporting local work, undertaking some key national tasks and quality assuring the system as a whole.

As a first step a review of current reporting systems, both national and local, has been commissioned to find out what is already in place, how current efforts can be strengthened, for example through standardisation of reporting processes, and which areas require national data collection and/or national dissemination of lessons. Particular attention will be paid to existing systems in high priority areas, including:

• the Serious Hazards of Transfusion programme

• surveillance of healthcare associated infection

• the Scottish Audit of Surgical Mortality (SASM)

• the ordering, prescribing, dispensing and administration of medication.

NHS QIS will attempt to foster the development of an open and fair culture in which staff feel able to meet their responsibilities for identifying, reporting and responding to safety issues in practice. A key aspect of the patient safety agenda is to ensure that lessons are learned from adverse events and 'near misses'. It will seek to identify such lessons and, in conjunction with other agencies including NES, it will promote delivery of staff training programmes to meet these needs. NHS QIS will also maintain close contact with NPSA to learn from its experience in reporting, education and training and to identify areas for collaborative work.

Recent reports on the tragic deaths of children serve to highlight the need to share personal information when people are vulnerable. Normally, the consent of the patient or, in the case of a child who lacks capacity, the person with parental responsibility is needed before identifiable personal information is disclosed to third parties. There has been a widespread perception that the law and professional codes limit the sharing of information and complicate clinical practice. These arrangements are designed to maintain personal privacy and protect the confidence between clinician and patient, while upholding the rights of individuals to proper protection for their well-being.

However, a balance is necessary: clear messages are emerging that health professionals must share information in circumstances that require them to act in order to safeguard the interests of vulnerable people. There should be free flow of information within the care team to support patient care, unless there are compelling reasons which have the patient's support. Information sharing encompasses clinical and care audit. In July 2003, SEHD published new guidance on sharing personal information about patients: NHS Code of Practice on Protecting Patient Confidentiality sets out the principles which are to be applied.

Each professional must balance the risks and consequences of not sharing information against sharing that information, understanding how the law and codes of practice work in favour of their patients, other patients and the public. Good information practice is part of good clinical practice, supported by awareness-raising, training, standard setting and review.

This is necessary in order to integrate efforts aimed at ensuring child protection and providing appropriate care for vulnerable people. Decision support for difficult judgements is also important and NHS Boards are putting into place, either individually or in collaboration, central sources of expertise and single points of access for all agencies. The basics of good management, including well-run meetings, minute taking, agreement on action, clear responsibilities, sound relationships and senior management links, are as important as awareness of the law and best practice in relation to appropriate sharing of personal information.

Patients and the public in Scotland must have confidence that an open, transparent, accountable and accessible system is in place for dealing with suspected or actual poor performance by all health professionals and teams.

There is an increasing perception that provisions in Scotland for handling concerns over health professionals' practice are not always adequate. Responsibility for handling such concerns lies with the employer. However, there are currently no consistent procedures for monitoring or auditing these provisions or for ensuring accountability or central reporting. External Clinical Advisory Teams, which can be called in to assist in more difficult cases, have to date not always proved effective. Inadequate processes can result in unnecessary and often lengthy suspension of medical staff.

Health professionals need support for their duty to report their concerns if they believe that the health or professional performance of colleagues is a threat to patient care. Health professionals who, as individuals or teams, find themselves the subject of such concerns need to know that they will be treated promptly, fairly, consistently and objectively and will be supported in line with best practice. They need to know that they will have access to and will have support for pursuing any remedial action which may be required.

Employers need a framework of guidance to support local action. This must be consistent across all professional groups in Scotland and with procedures for dealing with complaints and disciplinary matters. Support is needed not only for building capacity to deal with poorly performing health professionals and teams but also for creating access to a national resource for help in dealing with challenging situations. A key component of this framework is a standard reporting system to allow central monitoring and audit of activity through the staff governance section of the Performance Assessment Framework.

The Executive, through discussions with stakeholders to establish how best to take this important agenda forward, has secured a consensus across all professions on the need to have robust procedures for handling poor performance. It will be consulting on new arrangements to tackle poor performance of health professionals. These arrangements are due to be taken forward during 2004. NHS QIS and NES will be involved in this process. Colleagues in the Department of Health in England, the National Clinical Assessment Authority and the General Medical Council will also help in establishing a robust system for Scotland.

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