NHS Nottingham North and East CCG NHS Nottingham West CCG NHS Rushcliffe CCG

Primary Care Quality

Monitoring

Final Report

Internal Audit

September 2017 1718/NNECCG/03 1718/NWCCG/03 1718/RUSCCG/03

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Table of Contents

Heading Page

Executive Summary 1

Findings & Recommendations 4

Appendix A – Risk Matrix & Opinion Levels 10

Distribution

Name For Action For Information

Nichola Bramhall , Director of Nursing and Quality (South Nottinghamshire CCGs)

Esther Gaskill, Head of Quality, Patient Safety & Experience (South Nottinghamshire CCGs)

Sam Walters, Chief Officer (Nottingham North and East CCG)

Vicky Bailey, Chief Officer (Nottingham West and Rushcliffe CCGs)

Jonathan Bemrose, Chief Finance Officer (South Nottinghamshire CCGs)

Key Dates

Report Stage Date

Discussion Draft Issued: 22 August 2017

Exit Meeting: 29 August 2017

Final Draft Issued: 4 September 2017

Client Approval Received: 4 September 2017

Final Report Issued: 5 September 2017

Contact Information

Name / Role Contact details

Tim Thomas, Director, 360 Assurance tim.thomas1@nhs.net 0116 225 6114

Claire Page, Client Manager claire.page9@nhs.net 0115 883 5311

Kristina Dickinson, Assistant Specialist Services Manager – Clinical Quality

kristina.dickinson@nhs.net

07342 072951

Michelle Dixon, Audit Principal michelle.dixon3@nhs.net 01709 428714

Reports prepared by 360 Assurance and addressed to NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG directors or officers are prepared for the sole use of the NHS Nottingham North and East CCG, NHS

Nottingham West CCG and NHS Rushcliffe CCG, and no responsibility is taken by 360 Assurance or the auditors to any director or officer in their individual capacity. No responsibility to any third party is accepted as the report has not been prepared for, and is not

intended for, any other purpose and a person who is not a party to the agreement for the provision of Internal Audit between NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG and 360 Assurance dated 1

st April 2017

shall not have any rights under the Contracts (Rights of Third Parties) Act 1999. The appointment of 360 Assurance does not

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replace or limit NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG’s own responsibility

for putting in place proper arrangements to ensure that its operations are conducted in accordance with the law, guidance, good governance and any applicable standards, and that public money is safeguarded and properly accounted for, and used

economically, efficiently and effectively. The matters reported are only those which have come to our attention during the course of our work and that we believe need to be

brought to the attention of NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG. They are

not a comprehensive record of all matters arising and 360 Assurance is not responsible for reporting all risks or all internal control weaknesses to NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG.

This report has been prepared solely for your use in accordance with the terms of the aforementioned agreement (including the limitations of liability set out therein) and must not be quoted in whole or in part without the prior written consent of 360 Assurance.

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1

Executive Summary

Introduction

In April 2015 NHS England (NHSE) invited Clinical Commissioning Groups (CCGs) to take on an increased role in the commissioning of GP services through three different co-commissioning models:

Greater involvement – an invitation to CCGs to collaborate more closely with

their local NHS England teams in decisions about primary care services to ensure that healthcare services are strategically aligned across the local area;

Joint commissioning – enabling one or more CCGs to jointly commission general practice services with NHS England through a joint committee; and

Delegated commissioning – offering an opportunity for CCGs to assume full responsibility for the commissioning of general practice services.

Each CCG could choose its own approach or nothing at all, and the CCGs took on full delegation of commissioning of general practice services from April 2015.

Under fully delegated commissioning, CCGs have responsibility for the continuous improvement and assurance of quality and performance from primary medical services providers. However, NHS England does also still have a role in the monitoring of primary care.

This is still a new and developing area of responsibility for CCGs and, as such, systems and processes by which the quality of primary medical care is monitored and improved upon are not necessarily fully developed at a local level. Therefore, this review has

provided a baseline assessment/gap analysis of current arrangements and commentary on the direction of travel for planned and developing systems and processes.

Audit Objectives and Scope

The overall objective of our review was to provide independent assurance on the

systems and processes in place for the quality monitoring of primary care medical services (both national and local).

Specifically, our review focused on three key areas:

Strategy – Have the CCGs identified and documented their strategic aims in

relation to Primary Care Quality Monitoring? Does securing quality feature in the strategies and how is it monitored?

Controls - Do the CCGs have sufficient controls in place to ensure that they achieve their objectives in relation to Primary Care Quality Monitoring?

Governance - Do the governance structures, through the Primary Care Co-

Commissioning Committees, ensure:

o the right groups/committees receive appropriate information about the

quality of services provided by co-commissioned primary care? o appropriate responses in terms of improvement and action planning? o the Governing Bodies receive the necessary assurance that the systems

are functioning as expected and appropriate action is being taken to address any risks and ensure achievement of objectives?

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2

Executive Summary

Limitations of scope:

The review considered systems and processes for quality monitoring of primary care

only. It did not include a review of GPs’ performance against the Quality Outcomes Framework (QOF) or the extent to which GPs evidence achievement of quality aspects of enhanced services.

Audit Opinion

Significant assurance - As a result of this audit engagement we have concluded that,

except for the specific weaknesses identified by our audit in the areas examined, the risk management activities and controls are suitably designed, and were operating with sufficient effectiveness, to provide reasonable assurance that the control environment was effectively managed during the period under review.

Our opinion is limited to the controls examined and samples tested as part of this review.

Summary Findings

Strategy

Whilst quality is a key aim of the Sustainability and Transformation Plan there is little in the way of national guidance on how best to monitor primary care quality. In response to

the need to monitor quality and drive improvement, the South Nottinghamshire CCGs have jointly agreed on the production of a primary care quality dashboard to record and monitor quality indicators.

The CCGs’ Quality Strategy shows a clear outline of quality priorities and provides a brief overview of performance monitoring including quality schedules and contracts. As

the Strategy was written prior to the changes in Primary Care Co-commissioning it was found that the Strategy does not fully align to the more recent ‘Transforming General Practice in Greater Nottingham’.

Controls

The CCGs have produced a ‘Primary Care Quality Assurance Improvement Framework’

to aid the quality monitoring process and provide guidance for escalation of concerns.

The dashboard is manually and electronically populated by CCG staff using a range of data collection methods with results being RAG rated to highlight outliers and provide a useful tool to compare practices.

Governance

Primary Care Commissioning Committees are delegated with the responsibility to oversee the work of the Primary Care Quality Group to ensure robust quality monitoring is in place.

As a result of concerns being raised at a practice we were able to confirm that the CCGs have an established and appropriate escalation procedure.

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3

Executive Summary

Summary of Recommendations

High Medium Low Total

Proposed Actions - - 1 1

Agreed - - 1 1

Follow-Up

A follow-up exercise will be undertaken during May 2018 to evaluate progress made in

respect of issues raised. This will include obtaining documentary evidence to demonstrate that actions agreed as part of this review have been implemented.

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Findings & Recommendations

The following sections of the report summarise the findings of our review. Each section highlights areas of good practice identified. Where relevant, any control weaknesses identified are outlined, including actions that have been agreed in order to address the associated risks. The matrix used for scoring risks is compliant with the ISO 31000 principles and generic guidelines on risk management. This risk matrix, along with definitions of different opinion levels, is provided at Appendix A.

1. Strategy

The South Nottinghamshire CCGs (Nottingham North and East CCG, Nottingham West CCG and Rushcliffe CCG) have taken the decision to collaborate on a range of areas including quality. They have identified and documented their strategic aims in relation to Primary Care Quality Monitoring within their 'Quality Counts' - Quality Strategy 2014 – 2019. The strategy clearly states the quality priorities and provides detail on how the CCGs will be monitoring quality of primary care delivery.

The CCGs have also produced a ‘Primary Care Quality Assurance Improvement Framework’. The aim of this is to provide a structure whereby the CCGs focus their review and compliance against clinical, safety and patient experience outcomes. Within South Nottinghamshire there is also a link to the quality aspects of the ‘Transforming General Practice in Greater Nottingham’ document which also covers Nottingham City CCG. For example, Nottingham West CCG stated objectives include ‘improve the quality of our local health services, particularly around health outcomes, patient safety, access and patient satisfaction.'

No. Findings Risk and Score

(Impact x Likelihood)

Agreed Action

1. We note from our review that the 'Quality Counts' - Quality Strategy 2014 – 2019 pre-dates delegated primary care co-commissioning. As a result of the changes in primary care there is a need for some realignment. Our review confirmed the ‘Transforming General Practice in Greater Nottingham’ document lists a different set of quality priorities to those within the quality strategy. For example, Strengthening the monitoring of patients on high risk medicines (particularly where shared care arrangements are in place) and Improving prescribing practice in relation to quinolones are not included in the CCGs’ quality strategy.

CCGs may not focus their resources on the correct quality priorities.

Low (2x3)

The Quality Strategy will be reviewed and refreshed taking account of the changes within the Greater Nottingham area.

Responsible officer: Nichola Bramhall, Director of Nursing and Quality

Implementation date: 30 April 2018

Management Response:

The CCGs were not aware of some issues relating to primary care at the time the quality strategy was written in 2014. These were subsequently identified through CQC inspections and by the implementation of the quality dashboard.

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Findings & Recommendations

2. Controls

Quality objectives are communicated effectively to primary care providers

Within each primary care contract there is a schedule of quality requirements. Our review of the 2017/18 quality schedule confirmed inclusion of the following information:

Quality indicator (which align to the strategic aims of primary care quality as recorded in the Quality Strategy)

Required evidence for submission

Frequency

Consequences for breaching.

We were advised that there are a number of different contracts that are held within Primary Care but which all include a quality schedule:-

Main Practice contracts are either General Medical Services / Personal Medical Services / Alternative Provider Medical Services contracts, which are initiated through NHS England,

Direct Enhanced Services (DES) which are National specifications and cover items such as Frailty tool, Extended Access – these are managed through NHS England,

Local Enhanced Services (LES) – local contract and specification managed through public health such as Contraception services,

Local Enhanced Services (LES) - local contract and specification managed through the CCG and include services such as

Anticoagulation, Disease-modifying anti-rheumatic drugs (DMARD), Diabetes, Care Homes, Care & Quality etc.

We were advised that these agreements with the primary care providers are formally documented using the main NHS contracts standard contract (short version). Standard operating procedure

The CCGs have jointly implemented the Primary Care Quality Assurance Improvement Framework which describes how the South Nottinghamshire CCGs will monitor and ensure quality improvement in General Practice. In particular, the framework identifies that quality, as defined by Lord Darzi (High Quality Care for All, 2008), includes clinical effectiveness, safety and patient experience, and is the basis of all quality monitoring. We noted that quality performance is assessed, for example, through the use of infection prevention and control audits, patient record audits, patient and staff feedback, incidents, Quality Outcome Framework (QOF) and CQC reports.

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Findings & Recommendations

The Primary Care Quality Assurance Improvement Framework includes a quality rating methodology based on a RAG rating model to rate each quality domain. Based on the overall rating achieved we noted inclusion of prescribed subsequent action to support improvement and escalation to CCG committees and/or CQC or NHSE is identified. These include:

Discussing concerns with the practice and establishing an action plan (to be monitored through the Primary Care Quality Group)

Meeting with the practice to discuss concerns and agree an action plan and support (again to be monitored through the Primary Care Quality Group)

Meeting with the practice to agree an action plan and support required. Wider discussion with NHSE and CQC may also take place to determine any further support.

3. Governance

Quality Dashboard

The CCGs have set up a quality dashboard that covers all 44 GP practices within the locality. It was set up in 2016/17 to record the quality indicators of all practices. The dashboard covers a range of metrics, such as friends and family, vaccinations, health screening, and infection control, and provides a snapshot of current compliance rates. The choice of indicators is based upon requirements within the contract and any current themes identified within the NHS generally, as well as local initiatives. We met with the Head of Quality, Patient Safety and Experience who confirmed that it is the intention that indicators will be reviewed on an annual basis by the Primary Care Quality Group from 2017/18.

The dashboard is manually and electronically populated by CCG staff using a range of data collection methods; quarterly returns from GPs, clinical systems e.g. Systm One, and reviews of statistics from national reporting returns. We noted that where there is a ‘no return’ from the GP practice the process is to automatically rate the specific indicators as ‘red’ which results in the practice achieving an overall ‘Amber’ rating at best. This is then reviewed at the Primary Care Quality Group meeting and appropriate action taken as per the escalation process. However, we were advised that when there are mitigating circumstances for the ‘no return’, such as no practice manager, these are highlighted in grey with other indicators being judged as usual. All 44 GP Practices have access to the dashboard and can compare their performance with those of their peers. As the dashboard is relatively new it is too early to provide any evidence of improvement since its introduction. Although in itself the dashboard is not providing any additional information, the collation of the results into one place allows for targeted support. It also acts as a resource for Primary Care practices to review key quality indicators.

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Findings & Recommendations

Quality monitoring groups

Our review confirmed that each of the South Nottinghamshire CCGs has a quality monitoring group which is chaired by the Head of Quality, Patient Safety and Experience. This group is called the Primary Care Quality Group (PCQG). In addition to the Head of Quality, Patient Safety and Experience, the group consists of other individuals with professional qualifications and experience to suitably inform the review process:

Patient Experience Manager,

CCG’s Primary Care Lead,

Quality support officer and representatives from; o NHSE, o Patients, o Clinician / GP, o CCG Pharmacy, o Infection prevention and control , o Community nursing.

We were advised that each of the representatives above have a slot at each meeting to present and discuss their reports, papers etc. The group meets a minimum of eight times per year and reviews quality and, in particular, scrutinises the Primary Care quality dashboard and a range of other information, for example, infection control reports, patient record audits, CQC reports, and patient and staff feedback.

According to its terms of reference the Primary Care Quality Group has the following responsibilities: ‘ Act as a central information sharing point for concerns about quality of care…..areas of good practice and review of quality intelligence including:

o Patient experience o CQC inspection outcomes o Complaints o Incidents etc’

‘develop systems processes and working relationships to ensure quality monitoring is robust’ ‘Escalate concerns…..to quality in primary care both internally and externally to the Primary Care Commissioning Committee’ In addition, the terms of reference for the Primary Care Commissioning Committees for each CCG include reference to the Primary Care Quality Group. The role of the Group is to ‘ensure robust assurance processes are in place with regard to the quality of primary care delivered to patients by registered GP Practices of the CCG’.

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Findings & Recommendations

Reporting

We sought to identify if relevant data on how quality standards are being met is received and utilised at the CCGs. To address this the CCGs have implemented the Primary Care Quality Group assurance framework which states that 'The group…. agrees a response and ensures that concerns about quality and risks are escalated appropriately to the Primary Care Commissioning Committees and any serious concerns to the appropriate statutory body.' We were able to establish that an overall quality report is presented to each Governing Body which includes primary care practice information. Additionally, a highlight report from the Primary Care Quality Group (PCQG) is presented to the Primary Care Commissioning Committees (PCCC). The report includes a summary of the key discussions at the PCQG meeting, including the dashboard results, and CQC inspections update. Actions as a result of discussions are recorded within the minutes of the PCQG and are followed up at subsequent meetings. Special reports as a result of specific work completed by the PCQG, such as the Splenectomy report of July 2017, are also presented to the PCCCs. Reports are presented eight times each year to the PCCC to coincide with the timing of the quarterly returns and dashboard updates. The following table highlights the CCGs’ timetable for collation, review and subsequent monitoring of progress:

Action Quarter 1 Quarter 2 Quarter 3 Quarter 4

Quarterly return deadline

Date by which all returns from GPs are expected

End of June End of September End of December End of March

Lock down

Dashboard is closed to any further updates

Mid July Mid October Mid January Mid April

Review

Review of quarterly dashboard results and action planning

3rd week of July 3rd week of October 3rd week of January 3rd week of April

Monitoring

Monitoring of progress since quarterly review

3rd week of September 3rd week of December 3rd week of March 3rd week of June

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Findings & Recommendations

The two month gap between the review meeting and the progress monitoring meeting allows for any actions identified to be put in place. We note from our review of a sample of minutes between April and June 2017 that the PCCC and the PCQG are working as expected. Primary care providers meet the quality standards required in their contract

We sought to establish the processes that are in place to manage practices that do not meet acceptable quality standards. During 2016/17, action was taken by Nottingham North and East CCG as a result of issues at the Willows Medical Centre. We were able to confirm that the CCG had appropriately escalated its concerns to the CQC. We note adequate records including call logs have been maintained. As a result, a ‘lessons learnt’ report in December 2016 was compiled along with an action plan with subsequent updates (March 2017). We were not informed of any other issues at any other practices in the current financial year.

Interest in the dashboard has been expressed from other CCGs (Lincolnshire and Leicestershire). It is hoped that it can be rolled out to neighbouring CCGs in the near future.

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Appendix A – Risk Matrix & Opinion Levels

Risks contained within this report have been assessed using the standard 5x5 risk matrix below. The score has been determined by consideration of the impact the risk may have, and its likelihood of occurrence, in relation to the system’s objectives. The two scores have then been multiplied in order to identify the risk classification of high, medium or low.

Score Impact Likelihood Impact

1 Negligible Rare 1 2 3 4 5

2 Low Unlikely

Lik

eli

ho

od

1 L L L L L

3 Medium Possible 2 L L L M M

4 High Likely 3 L L M M H

5 Extreme Almost Certain 4 L M M H H

5 L M H H E

The audit opinion has been determined in relation to the objectives of the system being reviewed. It takes into consideration the volume and classification of the risks identified during the review.

Audit Engagement Opinions

Full Assurance

As a result of this audit engagement we have concluded that, in the areas examined, the risk management activities and controls are suitably designed, and were operating with sufficient effectiveness, to provide reasonable assurance that the control environment was effectively managed during the

period under review.

Significant Assurance

As a result of this audit engagement we have concluded that, except for the specific weaknesses identified by our audit in the areas examined, the risk management activities and controls are suitably designed, and were operating with sufficient effectiveness, to provide reasonable assurance that the control environment was effectively managed during the period under

review.

Limited Assurance

As a result of this audit engagement we have concluded that, in the areas examined, the risk management activities and controls are not suitably designed, or were not operating with sufficient effectiveness, to provide reasonable assurance that the control environment was effectively managed

during the period under review.

No Assurance

As a result of this audit engagement we have concluded that, in the areas examined, there are fundamental weaknesses in the design and operation of risk management activities and controls such that it is inadequate and likely

to fail.