My View

Appalling events have taken place in Brussels today. Some of you may know that the BMA has a European office in Brussels but I have had an e-mail from them saying none of the BMA employees or their families were affected. I have asked the BMA if they can give some words of condolences to the families of victims and some support to the know doubt large number of doctors and other healthcare workers involved with treating the survivors.

 

BMA News

BMA analysis on NHS funding and efficiency savings can be found at

http://www.bma.org.uk/-/media/files/pdfs/working%20for%20change/shaping%20healthcare/funding/nhs%20funding%20and%20efficiency%20briefing%20march%202016.pdf

 

British Medical Association response to Care Quality Commission strategy consultation

The British Medical Association (BMA) is a voluntary professional association and an independent trade union which represents doctors and medical students from all branches of medicine all over the UK. With a membership of over 170,000, we promote the medical and allied sciences, seek to maintain the honour and interests of the medical profession and promote the achievement of high quality healthcare. Our response is informed by consultation across the various branches of practice represented in the BMA and takes into account the results of a recent survey of GP practices that is attached with the response.

Consultation questions

1a Do you agree with the vision we have set out for regulation of the quality of health and adult social care services in 2021?

We cannot agree or disagree with the vision without knowing more about how the principles it seeks to promote would be implemented in practice.

1b What do you agree with, or not agree with, about the vision?

The principles of good regulation devised by the Better Regulation Task Force include proportionality and accountability. In our view the vision of the Care Quality Commission should place greater emphasis on these two principles.

 We believe that the main focus of the vision should be on addressing service quality without distorting the activities of the vast majority of organisations which are providing a good service. The time and effort that health professionals have to spend on preparation for inspections should be acknowledged. There should be explicit recognition of the fact that inspections can distract professionals from their primary responsibility for delivering services.

 We believe that the vision itself (i.e. not just the section on delivering the vision with reduced resources) should reflect the need for the Care Quality Commission to be accountable to the public and to demonstrate that it is making independent judgements. Also, although we have concerns about the recovery of costs from providers, if such recovery takes place, the Care Quality Commission should be taking account of the views of its funding bodies.

 The most important part of any regulatory regime is ensuring that proper clinical governance processes are in place. The regulator should ensure that in each organisation the board and practitioners are focused on working within a good clinical governance regime to promote high quality care.

 The purpose of any regulatory regime is to assure and improve the quality of service to patients. An essential part of the outcome of the regime, therefore, must be to identify the support that healthcare organisations need and how it will be provided.

2a Do you agree with our proposal to make greater use of data and information to better guide us in how we identify risk, and how we register and inspect services?

We cannot agree or disagree with the proposal without knowing more about how it would be implemented in practice.

2b What do you agree with, or not agree with, about greater use of data and information?

We would like to see better – rather than just greater – use of data and information. We therefore welcome the recognition of the need to balance the use of numerical data and non-numerical data with continued improvement in the analysis of qualitative information. We are concerned that the current inspection regime is distorted by overreliance on indicators that are numerical and/or readily available and that these indicators need to be tested against other information to see whether they truly reflect risks to patients and care users. We believe that any regulatory regime should implement a contextualised view of quality that is not necessarily rooted in readily available numbers.

 We are nevertheless concerned about the possibility that, if numerical and readily available indicators are to be complemented by information about the experiences of patients and care users, the latter information might include unsolicited comments. Any such comments would themselves need to be tested against other information and, in particular, tested to see whether they were representative of the views of the generality of patients or care users receiving the service.

 We continue to reject the emphasis on league tables. We are concerned that, whenever there is a change towards more focus on a narrative element in the inspection regime, the government seems to drag the regime back towards league tables.

3a Do you agree with our proposal for implementing a single shared view of quality?

 We cannot agree or disagree with the proposal without knowing more about how it would be implemented in practice.

 3b What do you agree with, or not agree with, about a single shared view of quality?

This principle seems attractive because it promotes a focus on outcome and experience without being specific to any particular organisation. In order to determine whether it can be meaningfully translated into practice, however, there needs to be further development, trialling and consultation. We note that views about quality reflect complex and continuously evolving sets of judgements.

 We believe a particularly important quality indicator is clinical governance. It is essential, for example, that inspections should ascertain whether boards are effectively discharging their particular responsibilities in relation to clinical standards. We therefore welcome the recognition that providers need to have in place their own systems for assessing quality.

 We would nevertheless emphasise two key principles in this context. Firstly, the extent to which explicit written evidence of processes can be expected has to take account of the size and administrative capacities of the organisation being inspected. Secondly, any regulatory inspection needs to determine whether the strategic lead of the organisation being inspected is able to create confidence that the organisation has good clinical governance mechanisms. This judgement will of necessity be based on differing sets of requirements depending on whether the organisation is a small practitioner-owned business or a large multi-thousand employee provider organisation.

 We are concerned that in the current situation providers have to deal with multiple organisations with multiple views of quality generating disparate systems of quality measurement. This has led GPs, in particular, to lose confidence in the current inspections regime (see the results of a recent survey of GP practices that is attached with this response).

4a Do you agree with our proposal for targeting and tailoring our inspection activity, including reducing the frequency of some inspections so we target our resources on the greatest risk?

We cannot agree or disagree with the proposal without knowing more about how it would be implemented in practice.

4b What do you agree with, or not agree with, about targeting and tailoring our inspection activity?

We support the principle of targeting and tailoring inspection activity. We would like to be assured, in particular, that GP practices that are rated good or outstanding in the current round of inspections, which amount to over 80% of all practices, will not face a full inspection for at least another five years or at all if other indicators can be used.

 We also have concerns about the costs of inspections being recovered from providers. We do not support the principle of full cost recovery for providers but, if that principle is applied, any reduction in inspection activity should automatically lead to a reduction in costs for providers. This is particularly important for small practitioner-owned businesses, for example GP practices and consultants in private practice. We note that these businesses are paying not only the fees themselves but also the hidden costs of preparing for and participating in inspections. We also note that GP providers do not pay for practice inspections in some parts of the UK.

 In order for regulation and inspection to be proportionate it is essential that organisations being regulated and inspected should not be expected to fulfil requirements from multiple organisations looking at the same things. The Care Quality Commission must therefore work with other bodies that inspect healthcare organisations in order to reduce the burden of inspection to an optimum level.

5a Do you agree with our proposal for a more flexible approach to registration?

We cannot agree or disagree with the proposal without knowing more about how it would be implemented in practice.

5b What do you agree with, or not agree with, about a more flexible approach to registration?

Regulation has to be proportionate to the size and capacities of the provider and it is for the Care Quality Commission to work out how to apply a necessarily flexible approach in these circumstances. Rigid adherence to the same requirements for all providers would produce a uniformity that is not in line with government policy.

6a Do you agree with our proposal for assessing quality for populations and across local areas?

 We cannot agree or disagree with the proposal without knowing more about how it would be implemented in practice.

 6b What do you agree with, or not agree with, about assessing quality for populations and across local areas?

The most important principle is that organisations that regulate and inspect should have a shared vision of how to assess quality. We need to get away from the situation in which multiple organisations with multiple views of quality generate disparate systems of quality measurement. In the absence of more detail about the proposal for assessing quality for populations and across local areas it is hard to see how it can be the role of the Care Quality Commission to conduct this kind of assessment. The Care Quality Commission should be assessing the ability of a healthcare provider to work within a system.

7 What impact do you think our proposals will have on equality and human rights?

 We cannot assess this impact without knowing more about how the proposals would be implemented in practice. We recognise the potential for better analysis of patient equality monitoring information to contribute toward improving equity in service provision and clinical outcomes. We would urge the Care Quality Commission to make concrete proposals on how it will maximise the opportunities to promote equality and human rights as soon as possible.

 8 Are there any other points that you want to make about any of the proposals in this document?

The BMA would​​ be pleased to work with the Care Quality Commission on the development of an appropriate, proportionate, consistent, transparent and targeted system of inspection for GPs.

 

For further information please contact Mark Hope, Senior Policy Advisor, at mhope@bma.org.uk or on 020 7383 6251.

 BMA INFORMATION FROM LONDON REGION co Andrew Barton

  1. London sustainability and transformation plans (STP). The capital will have five STP footprints that are identical to the PCT cluster of 2012. A STP is the geographical boundary into which providers, commissioners and local authorities are being grouped to get along and plan care for their patients/residents. Specifically they will pool deficits and each one will be ruled by a triumvirate comprising one provider chief executive, one CCG lead and someone from a local authority. One of them will take overall responsibility for the area. For further information please refer to the NHS England document which I can send you if requested. The five London STPs are NW London, North Central London, NE London, SE London and SW London.
  2. Imperial reorganisation. This large trust has recently completed a consultation with staff on changes to its management structure that will see three clinical division directors report directly to the chief executive. The directors will be full members of the executive management team. This will obviate the need for a chief operating officer, and the trust’s COO of four years (and deputy chief executive of two years) Steve MacManus is leaving.
  3. Primary Care. You might be interested to have a look at this interactive map [http://heatmaps.bma.org.uk/ ] the BMA has produced that shows the numbers of GP practices on the verge of closing in areas across England. They illustrate the state of primary care. I thought it might help you in helping to reintroduce primary care in anticipation of more local engagement.
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