A MANCHESTER CITY COUNCIL REPORT FOR INFORMATION Committee: Health and Well Being Overview and Scrutiny Committee Date: 8 March 2007 Subject: The Annual Health Check – A Guide for Scrutiny Members Report of: Manchester Joint Health Unit Purpose of Report: To provide the committee with an overview of the arrangements for the 2006/2007 Annual Health Check of NHS Trusts and the role that the Health and Well Being Overview and Scrutiny Committee (HWBOSC) can play in this process. Recommendations: The Committee is asked to: i) Note the report ii) Agree a process to submit comments and feedback to local NHS Trusts upon receipt of trust declarations iii) Consider what arrangements should be put in place to improve the process of involving Health and Well-being and Overview Scrutiny Committee in the Annual Health Check in 2007/08 iv) Discuss how the Annual Health Check can inform the work programme of the HWBOSC Contacts Ged Devereux Principal Programme Manager Manchester Joint Health Unit Room 4042 Town Hall Extension Tel: 0161 234 3730 firstname.lastname@example.org Background Documents Healthcare Commission, The Annual Health Check in 2006/2007 – Healthcare commission, September 2006 (available from the Joint Health Unit room 4042 Town Hall Extension) The annual health check: a guide for health overview and scrutiny committees – Centre for Public Scrutiny, November 2006 (available from the Joint Health Unit room 4042, Town Hall Extension) 1. Background The purpose of this report is to explain the role of the Health Care Commission in the scrutiny of NHS Trusts and to inform members of the Healthcare Commission’s annual health check process, which is designed to provide a commentary of the performance of NHS bodies. The Healthcare Commission keeps a check on local healthcare organisations and provides information that answers questions that patients and members of the public ask about their local health services, such as; • How safe and clean is the organisation? • How long will l wait to be seen? • How good is the care that l will receive? • Will l be treated with dignity and with respect? • Does the organisation help me to stay healthy? • How well is the organisation managed? The commissions’ duties are to: • Assess the management, provision and quality of NHS healthcare (including public health); • Review the performance of each NHS Trust and Primary Care Trust; • Publish information about the state of healthcare; • Consider complaints about NHS organisations that have not been resolved locally; • Promote the co-ordination of reviews and assessment carried out by others; • Regulate the independent healthcare sector through registration, annual inspection and enforcement; • Carry out investigations of serious failures in the provision of healthcare. Each NHS Trust has to make an annual health check declaration and Overview and Scrutiny Committees (OSCs) are invited to comment on these declarations before they are submitted to the Commission. Patient and Public Involvement Forums (PPIs) are also asked to submit comments, which will determine how each trust is assessed. 2. The Annual Health Check In 2005, the Healthcare Commission launched the annual health check as part of a new approach to assessment. The system is based on the consideration of performance of local NHS organisations within the framework of national standards and targets set by government. The annual health check replaces the previous ‘star ratings’ assessment system. This new system looks to make better use of data judgements and the experience of others to focus on measuring what matters to people who use and provide services. Within the annual health check there are two kinds of standards set by government. These are core standards and developmental standards. Core Standards – These standards represent the minimum standards for services that must be met in the delivery of services to all patients, by all NHS bodies. The 24 core standards were agreed by the Department of Health in July 2004. The core standards apply to all NHS services, whether they are provided by PCTs, Ambulance Trusts, Care Trusts, Mental Health Trusts, Learning Disability Trusts, specialist or Acute Trusts (including Foundation Trusts). The 24 core standards are divided into 7 domains each addressing a specific area of expertise Domain 1: Safety Domain outcomes: patient safety is enhanced by the use of healthcare processes, working practices and system activities that prevent or reduce the risk of harm to patients Domain 2: Clinical and cost effectiveness Domain outcomes: patients achieve healthcare benefits that meet their individual needs through healthcare decisions and services, based on what assessed research evidence has shown provides effective clinical outcomes Domain 3: Governance Domain outcomes: managerial and clinical leadership and accountability, as well as the organisations’ culture, systems and working practices, ensure that probity, quality assurance, quality improvements and patients safety are central components of all activities of the healthcare organisation Domain 4: Patient focus Domain outcomes: healthcare is provided in partnership with patients, their carers and relatives, respecting their choices, and in partnership with other organisations (especially social care organisations) whose services impact on patient well being Domain 5: Accessible and responsive care Domain outcomes: patients receive services as promptly as possible, have choice in access to services and treatments, and do not experience unnecessary delay at any stage of service delivery or the care pathway Domain 6: Care environments and amenities Domain outcomes: care is provided in environments that promote patient and staff well-being and respect for patients’ needs and preferences in that they are designed for the effective and safe delivery of treatment, care or a specific function Domain 7: Public health Domain outcomes: programmes and services are designed and delivered in collaboration with all relevant organisations and communities to promote, protect and improve the health of the population and reduce health inequalities between different population groups and areas A full list of the standards is available on the Healthcare Commission website www.healthcarecommission.org.uk Developmental Standards – These standards represent a direction of travel and provide a framework for NHS bodies to plan the delivery of services that continue to improve services in line with increasing public expectations. There are thirteen developmental standards that are designed to promote continuous improvement over time. The Healthcare Commission is currently developing its approach to assessing performance against developmental standards. In 2006/07 the commission are focussing on three of these standards: • Safety • Clinical and cost effectiveness, specifically: stroke, cancer, coronary heart disease, mental health, and research and development • Public health 3. The Role of HWBOSC’s The establishment of the Annual Health Check provide scrutiny committees with a further opportunity to scrutinise the performance of local NHS services. However there is no requirement OSCs to comment as part of the annual health check. Although is envisaged that scrutiny involvement will assist in the development of shared understanding between members and local NHS colleagues. There is no standard template for OSCs giving comments to trusts. However the Chair of the OSC is encouraged to ‘sign off’ any comments generated by the OSC before they are submitted to the Trust in response to their declaration. NHS Trusts should allow OSCs sufficient time to comment on their declarations before the deadline for submission to the Commission. The timetable for submission is as follows; • April 2007 – establish deadlines for submission of 3rd party comments to individual trusts • April 16th 2007 – NHS trusts can begin to submit declarations to the Healthcare Commission • May 1st 2007 – deadline for NHS trusts to submit declarations to the Healthcare Commission • May 18th 2007 – NHS trust declarations made public • October 2007 – results of the Annual Health Check published Each NHS trust should send a copy of their full declaration to relevant OSCs for comment before they have submitted it to the Healthcare Commission. The Healthcare Commission will use all 3rd party comments to assist in checking the trusts declaration. The Commission will also carry out follow up inspections with approximately 20% of trusts including those identified as being most at risk of not meeting core standards. If a Manchester trust is followed up the OSC will be contacted to discuss its comments. 4. Submitting Comments In order to ensure that OSC comments can add value to the process members are reminded of the following guidelines from the Healthcare Commission. • Think about what matters most to the local community that uses the services • Think about examples of good practice as well as problems and areas for improvements • Be familiar with the 24 core and 3 developmental standards and guidance relating to them. Aim to match the standards against your comments • Try to find facts and examples to back up comments, including notes of meetings, visits to trusts, results of local surveys or personal experiences The Healthcare Commission welcomes comments that include ‘items of intelligence’ that can be coded against 1 or more standard and carry sufficient weight. 5. Highlight Reports In order to start this process Manchester Primary Care Trust, Central Manchester and Manchester Children’s University Hospitals NHS Trust and South Manchester Universities Hospital NHS Foundation Trust have submitted highlight reports for initial consideration by the HWBOSC. These reports are not the full declarations of each respective trust but they do highlight the initial findings of the self-assessment process that each trust has carried out. These reports are attached as appendix 1, 2, 3 of this report. Appendix 1 Committee: Health and Well Being Overview and Scrutiny Date: 8th March 2007 Subject: Healthcare Commission’s Annual Health Check- Core Standards declaration Statement Report of: Manchester Primary Care Trust (PCT) (Gareth Webb, Risk Manager, Zoë Cohen, Director of Corporate Affairs) Purpose of report: To provide members with a highlight report of Manchester PCT’s Annual Health Check Core Standards Declaration and invite comments from the Health and Well Being Overview and Scrutiny Committee. Recommendations: The committee is asked to: i) Note the report ii) Provide a statement for the Manchester NHS Primary Care Trust’s Core Standards Declaration. Contact Officers: Zoe Cohen, Director Corporate Affairs Manchester NHS Primary Care Trust Tel: 0161 958 4136 Email: email@example.com Gareth Webb, Risk Manager Manchester NHS Primary Care Trust Tel: 0161 219 9464 Email: firstname.lastname@example.org Ged Devereux, Principal Programme Manager Manchester Joint Health Unit Tel: 0161 234 3391 Email: email@example.com 1. Introduction The Healthcare Commission is an independent body responsible for reviewing the quality of health care in England and Wales, which includes assessing and reporting on the performance of NHS organisations. In 2005/06, the Commission developed a new system of assessment, replacing the ‘star ratings’, called the Annual Health Check. Part of this assessment refers to the Standards for Better Health, published by the Department of Health. These are intended to assess quality improvement activity across the Manchester Primary Care Trust (the PCT). The Standards are divided into core standards which are the basic standards the PCT is expected to meet and developmental standards which the Government expects all PCTs and trusts to aspire to in order to improve the quality of care and treatment provided. The standards are divided into seven domains which are: • Safety; • Clinical and Cost Effectiveness; • Governance; • Patient Focus; • Accessible and Responsive Care; • Care Environment and Amenities; and • Public Health. The PCT Board is responsible for making a self-assessment and public declaration on the extent to which it has met the core standards for the period 1st April 2006 to the 31st March 2007; this includes the status of the PCTs predecessor organisations during this period. The final date for submission of the 2006/2007 declarations is Tuesday 1 May 2007. All PCTs and Trusts must publish their declarations to the public by Friday 18 May 2007. As part of the declaration process the PCT is required to invite comments, (although they can decline to comment) from the Northwest Strategic Health Authority, the Health and Well Being Overview and Scrutiny and the Patient and Public Involvement Forum, on whether the PCT is meeting the core standards. Their comments must be included verbatim in the declaration statement. 2. The PCT’s Declaration Process In order for a standard to be deemed compliant the PCT Board will have to make a decision as to whether there are sufficient assurances that the PCT has met with the Standards for the period 1st April 2006 and 31st March 2007 without ‘significant lapses’. Healthcare Commission guidance states that it is for the Board to make the decision whether a lapse is significant or not but that the Board should consider the extent of risk to patients, staff and the public and the duration and impact of any lapse. The guidance also states that the declaration is not intended as a medium for reporting isolated, trivial or purely technical lapses in respect of core standards. To ensure accuracy and probity, in January the Board approved the following four step validation procedure to produce its declaration. Step 1 The Project lead and individual leads for Standards assess the PCT against the standards and put forward their recommendations Step 2 The Executive Management Team (EMT) reviews those recommendations and puts forward further comments. Step 3 Governance Committee with Non Executive Director members’ involvement provides its comments Step 4 The PCT Board discusses and agrees final declaration Currently the PCT is in the process of finalising Step 1. As Council members are to go into recess without the PCT having fully gone through the validation process, the Chair has accepted the following highlight report, under the understanding that the position as presented may change over further assurance and discussion by the PCT. 3. Highlight Report The PCT in its declaration for the assessment period 1st April 2006 to 31st March 2007 has been required to take into account the compliance status against the Core Standards of it predecessor organisations. Out of 46 assessment criteria the PCT is currently indicating as compliant for the whole assessment period on 36. Of those 10 remaining the PCT is currently indicating as compliant on 8 but not for the whole assessment period. The remaining 2 are indicating as Insufficient Assurance, which means currently the PCT has insufficient assurance to state whether it has met those standards. Please refer to Appendix 1. The colour coding provides a visual representation of improvements, moving from red to amber and amber to green from the previous assessment period, against those standards which were previously showing non compliant. The comments column states the issues and what the PCT is doing to remedy them. 4. Recommendations i) Note the improvements made since the previous Annual Health Check assessment. ii) Provide a comment against the standards for the PCT declarations taking into account the transition from three PCTs to one. Highlight Report Appendix 1 Compliance statement against those standards which were either “Not Met” or “Insufficient Assurance” for the Column A assessment period – 1st April 05 – 31st March 06. This is the cumulative not compliant position in regards to North, Central and South Manchester PCTs Column B Core Standard reference numbers (There are 24 Standards in total some of which are further subdivided e.g. 4a,b&c) Column C Standard Description Column D Current status indication for Manchester PCT. Still to complete validation process. Column E Current status comments Column Column Column Column Column B A C D E Declared Projected 05/06 Ref. Standard 06/07 Comment RAG RAG Healthcare organisations protect children by following Not for whole national child protection guidelines within their own activities Currently indicating as compliant but not for the whole Not Met C2 assessment and in their dealings with other organisations. assessment period (01/04/06 – 31/03/07). period Healthcare organisations keep patients, staff and visitors As the three previous PCTs had variations in their safe by having systems to ensure that all risks associated purchasing and practices relating to Medical Devices with the acquisition and use of medical devices are the new PCT is carrying out an extensive audit of all minimised. its Medical Devices and is in the process of adopting a Manchester PCT Devices in Practice Policy. Until this audit is completed and an assessment is made against the Policy’s required practices, the PCT has Insufficient insufficient assurance against meeting this standard. Not Met C4b Assurance Once the audit has been completed and assessed the PCT Board will have further information and will make its declaration accordingly. This declaration will be made available to the public before the 18th May 2007, which will include any issues identified and the plans to rectify them. Column Column Column Column Column B A C D E Declared Projected 05/06 Ref. Standard 06/07 Comment RAG RAG Healthcare organisations keep patients, staff and visitors There are a number of standards and guides relating safe by having systems to ensure that all reusable medical to decontamination, the PCT has become aware that devices are properly decontaminated prior to use and that there are inconsistencies on interpretation of this Core the risks associated with decontamination facilities and Insufficient Standard. The Executive Team have been asked to Not Met C4c processes are well managed. Assurance review the evidence and assess potential levels of decontamination risk, working on the basis of an agreed standard. This includes a review of peers to identify those PCTs that are declaring compliant and on what basis. Healthcare organisations protect patients by following Not for whole Currently indicating as compliant but not for the whole Not Met C3 National Institute for Clinical Excellence (NICE) interventional assessment assessment period (01/04/06 – 31/03/07). procedures guidance. period Healthcare organisations ensure that they conform to National Institute for Clinical Excellence (NICE) technology Not for whole Currently indicating as compliant but not for the whole Not Met C5a appraisals and, where it is available, take into account assessment assessment period (01/04/06 – 31/03/07). nationally agreed guidance when planning and delivering period treatment and care. Healthcare organisations challenge discrimination, promote Not for whole Currently indicating as compliant but not for the whole Not Met C7e equality and respect human rights. assessment assessment period (01/04/06 – 31/03/07). period Healthcare organisations have a systematic and planned approach to the management of records to ensure that, from the moment a record is created until its ultimate disposal, the Not for whole Currently indicating as compliant but not for the whole Not Met C9 organisation maintains information so that it serves the assessment assessment period (01/04/06 – 31/03/07). purpose it was collected for and disposes of the period information appropriately when no longer required. Healthcare organisations have systems in place to ensure that appropriate consent is obtained when required, for all Not for whole Currently indicating as compliant but not for the whole Not Met C13b contacts with patients and for the use of any confidential assessment assessment period (01/04/06 – 31/03/07). patient information. period Healthcare organisations make information available to Not for whole patients and the public on their services, provide patients Currently indicating as compliant but not for the whole Not Met C16 assessment with suitable and accessible information on the care and assessment period (01/04/06 – 31/03/07). period treatment they receive and, where appropriate, inform Column Column Column Column Column B A C D E Declared Projected 05/06 Ref. Standard 06/07 Comment RAG RAG patients on what to expect during treatment, care and after care. Healthcare organisations ensure that clinicians participate in regular clinical audit and reviews of clinical services. Insufficient C5d Meeting Declared compliant from January 06 Assurance Healthcare organisations apply the principles of sound clinical and The Clinical governance element which showed Insufficient C7a&c corporate governance and Healthcare organisations Meeting insufficient assurance– was declared compliant from Assurance undertake systematic risk assessment and risk management. Oct 05 Healthcare organisations ensure that staff concerned with all Not for whole Currently indicating as compliant but not for the whole Insufficient C11a aspects of the provision of healthcare are appropriately assessment assessment period (01/04/06 – 31/03/07).. Assurance recruited, trained and qualified for the work they undertake. period Healthcare organisations ensure that staff concerned with all Insufficient aspects of the provision of healthcare participate in C11b Meeting Declared Compliant from the 1st April 2006 Assurance mandatory training programmes.