Incidents, Seriously?

When something goes wrong, the NHS has a responsibility to learn from it and to prevent it from happening again. When this results in serious harm to anyone, the weight of responsibility to learn and improve is even greater. Within the NHS we call these Serious Incidents and each NHS organisation has a policy through which these are identified, investigated, lessons learnt and improvement made to reduce the risk of recurrence.

All local NHS organisations’ approach to managing Serious Incidents stems from the national Serious Incident Framework. This is ‘owned’ by NHS England and was originally established in March 2013 for a relatively new organisation to lead the process throughout the NHS in England. It is currently under review and it is recognised that a much greater focus is needed on the learning from serious incidents whilst also ensuring a consistent and proportionate approach to investigation and incident management. Key to this is to put the patient and/or family at the centre of the process and to ensure that they are involved as much or as little as they want to be in this.

This week I attended a meeting as part of the NHS England Patient Safety Team’s consultation with staff from commissioners and providers in our local area. This was to talk to us about the current review of the framework and get our feedback on the latest draft. It was a great opportunity for us locally to influence how this evolves nationally and for the national team to get a feel for how things work at the front-line and to ensure that the framework reflects practical realities. This was only one of a series of meetings that the national team were running to engage with staff who have good practical experience of managing serious incidents and the background evidence of what works and what doesn’t to improve outcomes for people.

Inevitably, the discussion about the proposed new framework got into some of the detail of what will change and what won’t, such as: Will or won’t commissioners require providers to submit update reports 72 hours after the incident is discovered? Will all Grade 3 pressure ulcers continue to be deemed as serious incidents? What will change on the list of Never Events, and will this form part of the framework or be kept separate? How will disputes be resolved where a commissioner and a provider don’t agree as to whether an incident is ‘Serious’ or not…

Personally, the most valuable part of the conversation was when we discussed the overarching values and principles that should form part of the Framework. If we try to legislate for every single minute detail or circumstance that may occur; firstly we’ll never see the revised Framework, as it will take a decade to write and secondly, it will be the size of several volumes of the Yellow Pages! However, if those principles and values that over-arch and underpin the framework are clearly stated and agreed by those operating within it, any issues not specifically detailed in an appendix or flow-chart should be easily resolvable.

Ultimately, I believe that the following two things are most important in this:

1. Ensuring that the person involved in the incident and/or family is at the forefront of the minds of anyone involved in investigating it to ensure they are treated with dignity and compassion throughout. The needs of the individual should come above protecting the reputation of any organisation; and

2. A rigorous focus on learning at all levels must be applied, to include those directly involved, local services, units, organisations, wider local stakeholders and feeding into a system to genuinely contribute to learning across the NHS to reduce risk in the future.

[EDIT]

SInce writing this post, I have become aware of a consultation by the Care Quality Commission on draft guidance on implementing the new regulations on 'Fundamental Standards'.  This includes a Fit & Proper Person Test for people sitting on providers' Boards.  The following is a section from the guidance that describes the requirements for a fit and proper person:

"In addition to the usual requirements of good character, health, qualifications, skills and experience, the regulation goes further by barring individuals who are prevented from holding the office (for example, under a directors' disqualification order) and significantly, excluding from office people who:

  "have been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity, or discharging any functions relating to any office or employment with a service provider".

This is a significant restriction. It will enable CQC to decide that a person is not fit to be a director on the basis of any previous misconduct or incompetence in a previous role for a service provider. This would be the case even if the individual was working in a more junior capacity at that time, or working outside England."

The full consultation details are here.  The relevance of this to my blog-post is that any person who has a history of covering up NHS failings may (should) find themselves barred from holding senior posts in the NHS in the future.  Interesting article in Telegraph online here.

They Came, They Saw, They Inspected

On Thursday last week I received notification that on Monday (this week) the Care Quality Commission were coming for a week to inspect Child Safeguarding and Looked After Children’s Health Services.  The CQC are the regulators for all health and adult social care services in England.  They have previously done these inspections jointly with Ofsted and therefore have included Local Authorities and Children’s’ Social Services in their scope; however, this inspection was just the CQC.  Therefore, whilst they did include health services that are commissioned by the Local Authority, their scope to make recommendations for these is limited.

The notification last week initiated a flurry of activity from my CCG colleagues and our providers to prepare for the inspection this week.  We needed to provide a range of documents as evidence in advance.  We also needed to identify a group of ‘cases’ that met certain criteria to enable the inspectors to see records of and speak to children and families who had used a specific range of services.

This week started with the inspectors meeting with me as the Executive Lead for Safeguarding within the CCG and with our Designated Nurses and Designated Doctor.  We agreed the programme for the week with the inspectors aiming to visit as many relevant services as possible to speak to staff, patients, families and to look at records.

The following are the services that they visited:

• Midwifery
• Health Visiting
• A&E
• School Nursing
• Child & Adolescent Mental Health
• Adult Mental Health
• Contraception & Sexual Health
• Drugs & Alcohol

Throughout the week our Designated Nurse for Safeguarding Children and I had regular briefings from the inspectors on what they have seen and heard.   As a normal part of the inspection process any major issues requiring immediate action are highlighted to commissioners.  Throughout the week there have been no major issues that have required immediate action.

Today we got some verbal feedback at the end of the inspection.  We will receive a draft report to correct any factual inaccuracies within a couple of weeks.  The final report, including any recommendations will then be publicly published.  The feedback today was generally positive and in particular, the inspectors were complimentary of the committed and passionate staff who they had met throughout the week.

There were a number of areas highlighted by the inspectors that they will make recommendations on in their report.  None of these are issues that we weren’t previously aware of and already taking action of one sort or another on.  To follow-up the findings of the report we will ensure that there are robust plans in place to address all of the issues that were raised.

It is fair to say that the process of the inspection was challenging and hard work for a wide range of people across the NHS, the Local Authority and other services involved.  The result of this process will be for us to refocus our efforts in the areas identified by the findings of this inspection and to provide the public with assurance of how children are safeguarded and Looked After Children’s health is supported in Luton.

Competitive Dialogue

The technical detail of NHS procurement is not going to make the most inspiring blog for the majority, so it’s with trepidation that I write this post about what we’re doing in Luton at the moment.  Due to the specific procurement process I’m writing about still not being complete, I have to be careful about some of the detail, but I will either update this post in the future, or write again on the subject (unless there’s a significant ground-swell of opinion that I don’t!).  If you do want to read about some of the more technical details, the Procurement, Patient Choice and Competition Regulations are what you’re after.  These regulations implement Section 75 of the Health and Social Care Act 2012 and are updated by more recent European Regulations.

Clinical Commissioning Groups (CCGs) are clinically led local organisations that know the area in which they are working, and so are able to commission services that are specifically required by the population that they serve.  CCGs are responsible for commissioning the following services in their 'patch':

• Urgent and emergency care (for example, A&E);
• Elective hospital care (for example, outpatient services and elective surgery);
• Community health services (services that go beyond GP);
• Maternity and newborn; and
• Mental health and learning disabilities.

CCGs can commission services from a range of providers, including from the voluntary and private sectors.  Anybody that provides these services must be registered with a regulating body, such as the Care Quality Commission.  That’s a terribly brief description of CCGs adapted from NHS England’s Understanding the New NHS; more detail on the full commissioning cycle here.

When a CCG is ready to ‘procure’ (buy) services as part of its commissioning of services, there are a four possible procurement procedures used to award contracts under the legislation and regulations cited above, which are:

• ·     OPEN – The open procedure is suitable for simple procurements where the requirement is straightforward and the provider market is not very large. It is most commonly used in practice for the purchase of goods where the requirement can be clearly defined. As there is no "pre-qualification" of bidders, anyone can submit a tender and it is possible that a large number of provider will bid. The open procedure is more suited to a small provider market.
• ·     RESTRICTED – Consider the restricted procedure where you want to "prequalify" providers based on their financial standing and technical or professional capability so as to narrow the number of providers permitted to submit bids. Where the restricted procedure is appropriate, you should be able to specify your entire requirement now such that, based on your invitation to tender, bidders will be able to deliver a fully priced bid without the need for any negotiations following receipt of the bid.
• ·     NEGOTIATED – Following the Public Contracts Regulations 2006, the negotiated procedure can only be used in extremely limited circumstances, for example, where the contract is for a genuinely unique type of solution and there is only one capable provider in the market;
• ·         COMPETITIVE DIALOGUE – The competitive dialogue procedure can only be used in limited circumstances. It may be appropriate where: (1) the contracting authority is unable to produce a complete specification of requirements without discussing its needs in detail with providers (but iterative discussions with bidders should allow a detailed solution to be specified); and (2) where the solution is likely to be particularly complex and will require dialogue with bidders to conclude. The competitive dialogue procedure is generally used for very complex procurements.

If you’re still awake, congratulations, thank you and now keep reading...

The Luton CCG Board took a decision that in reprocuring our mental health and community services we would use the Competitive Dialogue process.  This decision was based on both the complexity of the services and our desire to work with potential providers to develop specifications for the services based on their expertise of what was innovative, possible and personalised to the needs of local people.  The way that this works is that rounds of dialogue are held with bidders, clarifying and honing ideas, until the best fit to achieve our required outcomes is arrived at.  This iterative approach represents best practice in procurement, as there is flexibility to shape services throughout the process, through patient and public engagement and through ideas from potential providers and commissioners, before finalising service specifications.

There are a range of ways in which you can approach this, but for us in practice this has meant that once the initial prequalification* stage was passed by potential providers we met with them one at a time to discuss what we wanted for our population and what they could potentially provide; formal written bids were then submitted, which were scored and any providers who didn’t meet a necessary minimum score dropped out.  The next round of ‘dialogue’ is currently in progress, but to a more detailed level, including providers sharing proposed service specifications.  Further formal written ‘bid’ documents will then be submitted and scored. Following a final executive-level panel meeting between bidders and commissioners, a proposal will be made to the Board to agree a preferred bidder and then contract negotiation starts.  We report regularly to our Board to update on progress with this procurement.  The latest Board paper summarising progress to date is here.

This whole process may all sound a bit complicated, and it is!  There is a lot at stake, with many tens of millions of pounds of public money involved in the potential contracts for these services and more importantly the potential benefit to the people of Luton and their health.  One significant thing that we have learned so far from the process is that it is definitely worth all the complexity and hard work.  We intend on getting really high quality services as a result, which are focussed on meeting the needs and achieving positive outcomes for our local population.  We have particularly valued the involvement of members of the public throughout the whole process and the contribution they are making to this being successful.  An element of the public involvement we have run was our ‘Big Conversation’.  The whole approach we’ve taken to involving the public in this procurement may be a subject I blog about in the future.

The procurement continues and I’ll provide an update in a future blog.

(*Preliminary stage in a bidding process where it is determined if a provider has the requisite resources and experience to provide the service as required.)