Try the all-new QuickBooks Online for FREE.  No credit card required.

Manchester City Council - Health

Document Sample
Manchester City Council - Health Powered By Docstoc

                      MANCHESTER CITY COUNCIL
                      REPORT FOR INFORMATION

Committee:          Health and Well Being Overview and Scrutiny

Date:               8 March 2007

Subject:            The Annual Health Check – A Guide for Scrutiny

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


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


Ged Devereux
Principal Programme Manager
Manchester Joint Health Unit
Room 4042
Town Hall Extension
Tel: 0161 234 3730
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
      •   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

   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
     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

     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

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

      •   Think about what matters most to the local community that uses the
      •   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
      •   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
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

                       Gareth Webb, Risk Manager
                       Manchester NHS Primary Care Trust
                       Tel: 0161 219 9464
                       Ged Devereux, Principal Programme Manager
                       Manchester Joint Health Unit
                       Tel: 0161 234 3391
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

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

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
   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).
                      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).
                      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).
                      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

                          Healthcare organisations ensure that clinicians participate in
                          regular clinical audit and reviews of clinical services.
                 C5d                                                                         Meeting       Declared compliant from January 06

                          Healthcare organisations apply the principles of sound
                          clinical and                                                                     The Clinical governance element which showed
                C7a&c     corporate governance and Healthcare organisations                  Meeting       insufficient assurance– was declared compliant from
                          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
                 C11a     aspects of the provision of healthcare are appropriately         assessment      assessment period (01/04/06 – 31/03/07)..
                          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.

Shared By:
Tags: domain, check